Introduction to Policy

Session Analysis, Stakeholder

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Analysis & Policy Briefs

Introduction
This first session of the module is divided into three parts:

 Session 1a: Policy Analysis

 Session 1b: Stakeholder Analysis

 Session 1c: Policy Briefs

Session 1a focuses on a theoretical understanding of the concepts relating to

policy analysis, while Session 1b is a more practical session, in which you will
do a stakeholder analysis based on a case study.

Session 1c is a short introduction to the topic of Policy Briefs, which will be

addressed in more detail in the session on Policy Briefs, leading into
Assignment 2 - the writing of a policy brief on a topic of your choice. The
concept of policy briefs is being introduced at the beginning of the module to
enable you to start thinking about and identifying your topic for the policy brief.

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 Introduction to Policy
Session
1a
Analysis

Introduction
Policy-making processes have been described as interactive and complex
processes of bargaining and accommodation of many different interests. Health
policy analysis is a growing field that includes multidisciplinary approaches that
aim to understand the policy process. It often includes attention to the influence
of people (actors in the health system), the contexts and processes within which
policy unfolds to better understand what health policy is, as well as how it is
developed and implemented.

This session is based on a course first developed at the Centre for Health
Policy, University of the Witwatersrand, and has been adapted and taught by
several academic institutions across Africa since, including the Understanding
and Analysing Health Policy course offered at the School of Public Health,
University of the Western Cape.

This session will introduce participants to the varied and complex nature of
‘policy’ and policy processes and how policy analysis can help to understand
what drives and influences these processes and their consequences. In this
session you will learn key principles such as definitions of policy, policy
processes and policy analysis. These concepts will become clearer as you
proceed through the session, and will also be applied in other sessions of the
module.

Session Contents
1. What is policy?
2. What is public policy?
3. What constitutes the policy process?
4. What is policy analysis?
5. Politics and policy
6. Session summary
7. References

Timing of this Session

There are three readings in this session and three additional (optional) readings
which you are encouraged to access for more information. There is also one
Activity for you to complete, two Reflection points, and a set of questions to

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frame your contribution to the Discussion Forum. The session is likely to take
you about three hours to complete.

Learning Outcomes of this Session

Public Health Outcomes Academic Learning

Skills
By the end of this session, you should be
able to: In the session, you will practise
 Identify different uses of the term these skills:
‘policy’ • Identifying specific information
 Distinguish between policy as intent in texts
and policy as understanding and
• Applying concepts to your
practice
own context
 Identify the role of public policy in
promoting public value • Reading information
presented in graphic form
 Identify key components and factors
facilitating and constraining policy and • Making notes to use in a
implementation processes discussion
 Understand how the study of policy
can help to explain the successes and
failures of current and past policies as
well as inform future policy
development and implementation.

Readings
Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy. Open University
Press. Maidenhead. Chapter 1 pages 4-14; 16-17. Add links

Walt, G. (1994). Health Policy: An Introduction to Process and Power.

Johannesburg. Witwatersrand University Press. Chapter 4: pages 59-61.Link

Walt, G. (1994). Health Policy: An Introduction to Process and Power.

Johannesburg. Witwatersrand University Press. Chapter 3: pages 40-44.Link

Additional readings

Walt, G. & Gilson, L. (1994) Reforming the health sector: the central role of
policy analysis. Health Policy and Planning, 9(4), pages 353-370. (p.353 –
Introduction, p.358 – What is policy analysis; p.362 - Focusing on actors)
https://academic-oup-com.ezproxy.uwc.ac.za/heapol/article/9/4/353/649125

Walt, G. et al. (2008). “Doing” health policy analysis : methodological and

conceptual reflections and challenges. Health Policy and Planning, 23, pages
308–317
http://academic-oup-com.ezproxy.uwc.ac.za/heapol/article/23/5/308/617219

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 1 What is policy?

To introduce you to the concepts of what policy is in the field of health and
pharmaceuticals, start by thinking about your home and how your family
function. Can anyone at home just do whatever they please? What influences
the behaviour of family members, or how things are done in the home? How do
you make decisions in the family on issues that affect the family as a whole?
These rules, practices, decisions can be considered ‘policies’, and in this
session we will explain why this is so.

So, think further:

 How do these policies come into existence? Who develops them? What
factors influence the types of policies that come into existence?
 How are these policies known? Are they ever written down (this is the
difference between informal and formal policies)?
 How are the policies communicated to children or visitors? And how are
they influenced by people’s values and beliefs?

Policy therefore exists everywhere:

 In households for example, think of how things are done in the home, i.e.
the time we set for children to be back home;
 Social groups such as Christian organisation groups where services are
set on a particular dates;
 Big organisations including for example the University with rules and
procedures about how teaching should be done or businesses which
have rules and guidelines for their day to day operations;
 Government with laws and policies;
 Society: so think about entering a bank and how people will line up
waiting to be served, it has almost become an unwritten rule for society.

Policy includes both the intention (the vision, goals, understandings, principles,
and plans that seek to e.g. guide activities, establish accountability &
responsibility) as well as the practice (routine decisions, activities,
understandings & actual achievements).

Also think about where policies are normally found. Policies are presented in
documents, regulations, laws, ministerial statements etc. and this is usually
what we think of when we hear the word policy. However, policies are
constructed and exist in what happens in practice and in the expectations,
principles, understandings that shape practice.

For example: The Pharmacy Law has a list of policies or guidelines found in the
compendium (an example of where policies are found). These guidelines are all
grounded in particular intentions that govern the Pharmacy profession (such as
health as a basic human right or access to safe, efficacious and cost-effective
medication). But they also provide the principles of how a Pharmacy should run.
However, even policies found in these laws (compendium) only become
constructed when practiced by Pharmacists and Pharmacist’s Assistants and so
the practice of these guidelines because the way policies are constructed.
And so,

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Different environments have different polices:
For example:
In a supermarket: a dress code; how to deal with customers’ demands
In an office: a procedure for booking leave; pay policy
In the home: the times children should be in bed; who helps with the household
chores.

Policy can be developed in different ways:

Polices may be negotiated as a way of resolving conflict: (For example due to
the high load HIV/AIDS patients, the prescription law was amended to allow
nurses to prescribe particular medications and start patients on anti-retrovirals)
They may developed through repetition and habit: (Pharmacist’s assistants
dispensing routine medicines especially in remote areas where there are no
pharmacies and eventually this has become like a policy).

There may be cultural practices or traditional ways of doing things, for example
in some health facilities especially local clinics, there may be particular days
designated for particular services for example Mondays for immunisations and
child care and Tuesdays for chronic care. Over time this becomes a policy as it
is viewed as the common way of doing things within that particular facility.

Policy can be implemented in different ways:

 Through decree (‘because Dad or the president says so’)
 Through convention (‘because that’s how it is done in this facility or this
hospital’)
 Through negotiation (‘if you do this you will get …or if you do this, you
will get that’)
 Through a shared understanding of an ethical code of conduct (for
example the implementation of a Patient’s Rights Charter may be
influenced by people’s expectations about how things should happen
even though the details may not be written down).

Activity 1: Respond to questions about your own experience of ‘policies’ in

your day-to-day work environment

1. Was your interaction with policy through decree, convention, or negotiation?

2. Have you ever been involved in any form of policy-making?
3. If so, what were some of the ways these policies were developed and
implemented - was it through decree, convention, or other means?

Feedback
Everybody interacts with policy on a day to day basis at home or work and
sometimes without realising that they are interacting with policies. Some may be
involved in roles that involve developing policies or implementation while others
could be operating within the boundaries of specific policies for example the
announcement of the budget speech by the minister of finance will affect the
cost of living which impacts all persons living in the country.

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Now read the following pages from a key text on health policy. This section
focuses on what health policy is, including types of policies, and how policy is
made. As you read, take note of the types of policies described and try to think
of examples of the different policy types.

Reading

Walt, G. (1994). Health Policy: An Introduction to Process and Power.

Johannesburg. Witwatersrand University Press. Chapter 3: pages 40-44.Link

2 What is public policy?

Formal public policy, as developed by governments, is intended to influence the

many actors working within a sector or system and the procedures and
processes built into it, in ways that guide them to work together to achieve
common goals and purposes. In general, public policies seek to generate
‘public value’; that is, they seek to produce outcomes of value to the public at
large in any country and to build public institutions, such as hospitals and
clinics, that operate in ways that the public judges as fair and accountable.
The notion of ‘public value’ is an important one for policy making in the health
sector: Think about policies such as immunization guidelines which not only
protect the individual but also have value for society as a whole.

And so public policies are those that influence:

 the direct provision of services or commissioning of services - such as

health services;
 the provision of information, education, advice - for example regarding
health of individuals or populations, or health service procedures;
 the establishment of laws, tax rules, penalties, and the policing of these -
such as laws underpinning the performance and financing of the health
system;
 the use of economic instruments, like taxes, subsidies, or social
benefits/grants - such as taxes to finance the health system or ‘sin’ taxes
intended to discourage people from smoking or alcohol use, or reduce
the sugar level in products;
 the regulation and behaviour of markets - such as legislation governing
tobacco advertising, or pharmaceutical production and advertising, or the
conditions under which new private health providers can start or continue
to operate in a country;
 procedures and rules concerning staffing
and operations of various government Public policy can be generally
agencies - such as the recruitment and understood as:
management of staff in state health a set of decisions (course of
organisations like national and provincial action), authorised by the state
health departments, and health facilities (parliament, courts, government
themselves; officials), and intended to create
 establishment of citizens’ rights - such as public value.
patients’ rights charters.
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However, policy can also result from what are called ‘non-decisions’. A ‘non-
decision’ occurs when a decision is deliberately made not to address an issue;
or when tackling an issue is simply avoided; or is a result of an oversight. In
these cases, the ‘non-decision’ may still influence the behaviour of actors and
the operation of the system it is intended to influence.

Non-decision making is also sometimes an expression of actor power – when

one actor works to ensure that an issue is simply not put on the decision-
making agenda, perhaps to protect their own interests. Think of a committee
situation, where the secretary or chair or other powerful person works to keep
an issue in which they have a personal interest off the committee’s agenda so
that precedents and rules about the issue are never developed. For example,
for many years the global tobacco industry worked very hard within and across
countries to prevent evidence about the links between smoking and cancer
being taken seriously by policy makers, thus limiting the possibilities of anti-
tobacco legislation being developed.

Policy actors are defined as any individual or group that is directly or indirectly,
formally or informally, affiliated with or affected by the policy process at any stage.
They can include governments, businesses, NGOs, civil society organizations and
communities as well as individuals.

Reflection

Can you think of examples where non decision making has

occurred in your contexts?

Feedback
One of the most common non-decisions that exist currently in Sub-Saharan
African countries is the lack of or limited regulation guidelines regarding
traditional, complementary and alternative medicines (TCAMs). It has been
shown that the general population uses traditional and complementary
therapies alone or combined with conventional medicines (James et al. 2017).
The lack of any concrete regulations or policies to provide guidelines for the use
and distribution of TCAMs can be considered a non-decision by most
governments. By failing to make any policies or any decisions, this in itself
becomes a policy.

The reading below, which you should now undertake, is one of the key texts in
health policy literature, and provides an overview of what policy is, and more
definitions regarding public policy. Pages 5-10 provide definitions regarding
policy and public policy which will complement sections 1 and 2 of these notes.
Think about the following questions as you go through the text:
 Why is health policy important?
 What are the different ways of defining policy?

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Reading

Buse, et al. (2005) Making Health Policy. Chapter 1; pages 4-14.Link

The next reading is from Gill Walt. She is among the founding scholars of health
policies in Low and Middle Income Countries. In her book entitled ‘An
Introduction to process and power’ she describes non decision making as a
form of policy in her chapter on agenda setting. Read Chapter 4, page 59-61,
for an extensive example on how non-decision making in itself becomes a
policy.

Reading

Walt, G. (1994). Health Policy: An Introduction to Process and Power.

Chapter 4; pages 59-61. Link

3 What constitutes the policy process?

The overarching process of making and implementing policy is called the policy
process, indicating that the changes which make up and are part of the policy
process occur during both development and implementation. At the heart of this
process are the many and complex sets of decisions and actions entailed in
developing policy and putting policy into effect. These decisions are sometimes
understood as a set of steps that follow one another as in the ‘stages’ model in
Figure 1 below.

Figure 1: The Stages Model

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Source: Sabatier P and Jenkins-Smith H (1993). Policy Change and Learning. Boulder, CO:
Westview Press

The ‘stages’ model suggests that the four main stages of any policy process
are:

1. Agenda setting – which entails the identification of problems or recognition of

issues, and setting priorities for what needs to be addressed. What does, and
does not, get onto the policy-making agenda determines what policies are
formulated and is influenced by policy actors’ interests and concerns.

2. Policy formulation – which entails actors with formal policy authority making
decisions about the details of policy content, using various decision-making
strategies, and perhaps involving other policy actors.

3. Policy implementation – which entails implementation of the policy content

through various strategies and by various structures and people, including the
adaptation or non-implementation of the policy by these policy actors.

4. Policy evaluation – which entails assessing the success of the policy, either
during its development and implementation (sometimes with a view to
influencing this process), or after these periods, as a basis for further policy
action.

However, experience of policy making and planning shows that, in reality, the
ways in which problems are identified for policy attention and in which policies
are formulated, negotiated and implemented do not entail a simple process in
which there is a clear and almost automatic decision to move from one stage to
the next. Instead, the processes of policy making and implementation take
place over many years, sometimes moving forward across the stages above,
sometimes moving in stops and starts, and sometimes moving forwards, and
backwards and sideways. In addition, policy making does not always begin in
agenda setting, policies can be re-formulated after implementation failure or
may not even get to implementation.

4 What is policy analysis?

Policy analysis is the systematic study of all factors, people, processes that
affect the way in which a policy is developed, formulated and implemented.
Experience shows that even where policy documents are technically sound in
presenting new approaches to addressing problems, this is often not enough to
bring about the real changes in the operations in the health system such that it
can be said that a policy has really been implemented and taken effect. There is
often a gap between the intentions of policy - represented in formal documents
and statements - and the reality of what people on the ground in the health
system do, be they doctors, nurses, pharmacists, managers or patients and
citizens.

Reflection

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 Is what a policy intends to do the same as what happens in practice?
Can you think of any examples in your own experience – either as a
professional or as a citizen in your country?

Feedback: One example is of the unintended consequences of the removal

of user fees for maternal and child services in South Africa in 1994, which
was the increase in the number of patients attending facilities for curative
services. Although the intention of the policy was to improve access to
services especially the most vulnerable, increasing numbers of patients may
result in a loss of other services in the effort to cope with the demand of
patients such as preventative services.

The policy process is about who makes what decisions and why, and how and
when they are made in the course of developing and implementing policies.
Studying the policy process or policy analysis therefore considers the influences
on whether, and how, policies:
• are designed;
• are implemented;
• are seen as solutions to problems;
• influence practice; and
• generate specific outputs and outcomes.
The Policy Analysis Triangle (Figure 2) is a simple model for understanding the
various sets of factors that are at work within any policy process. It emphasises
the central role of policy actors, but also highlights the links between actors and
three other factors that influence decision-making: context, content and
process. So while the figure may look simple, the complexity of the policy
process results from the interaction between the factors. Actors are rarely a
homogenous group, they can have different interests, positions, and values
which can affect policy processes and will be covered later in stakeholder
analysis.

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Figure 2: The policy analysis triangle
Source: Walt, G. & Gilson, L. (1994). Reforming the health sector in developing countries: the
central role of policy analysis. Health Policy and Planning, 9(4): 353-370.

In the next readings from Buse, et al. (2005) give a detailed explanation of the
role of the policy analysis triangle in policy analysis and its emphasis on the
content of policy, the processes of policy making and how power is used in
health policy. Read pages 8-10 to get a more detailed explanation of the policy
analysis triangle and consider the emphasis on the central role of actors who
make policy as you read the text.

Reading
Buse, et al. (2005). Making Health Policy, Chapter 1; pages 8-10 and 16-17
for more explanations regarding the policy analysis triangle. Links

Policy analysis helps us to better understand the interactions between the

different factors (such as actors, context, content and process) impacting on
policy process resulting in either a success or failure and to think about
strategies to manage the process. In every policy process, the four factors of
the Policy Analysis Triangle interrelate and affect one another. So if, for
instance, a new health minister is appointed who supports a policy which has
long been side-lined, the context will shift and the policy process will be altered.
Or if many babies and old people die for a third year in a row following annual
cholera epidemics, discussions about the content of policy action to address
cholera may shift to include more forcefully the ‘upstream’ issue of the right to
clean water.

Sometimes what a policy intends to achieve does not happen in practice.

Unintended consequences happen! Policies often don’t achieve what was
intended because of power & processes. Gill Walt defines process and power
in the following way:
“Health policy is about process and power … it is concerned with who
influences whom in the making of policy, and how that happens.” (Walt,
1994)
So, policy analysis encompasses attention to, and investigation of, the formal,
deliberate decisions people make to do things differently, as well as their failure
to take action or to change the routines and practices that are experienced as
the reality of health systems. This form of policy analysis might be seen as
something that academics do. However, we argue here that policy analysis can
(and should) be conducted by practitioners (leaders and managers) who
develop or engage with policies – to understand better why certain policies are
not being implemented as intended and/or have unintended outcomes; or to
think prospectively through the different aspects of and factors which might
influence a policy process.

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Policy analysis is included at the start of this module to introduce you to
concepts such as the role and influence of actors, power, politics, context and
processes that shape the development of all health policies. Understanding the
concepts and the role of policy analysis provides a good foundation that will
enable you to better engage with the upcoming sessions.
Policy analysis can be undertaken during a policy process, with the intent of
intervening to support that process, or it can be undertaken to learn lessons
from the past about policy change. Policy analysis is therefore commonly
understood to comprise of two different approaches:
 Analysis of policy – Analysis of policy tends to be retrospective and
descriptive. This involves looking back at how a policy was developed or
its content and whether it achieved its intended outcomes. For example if
one was to analyse the development of National Health Insurance
schemes in countries such as Ghana to examine the impact on
availability, affordability and quality of medicines. This would be a form of
retrospective analysis of policy.
 Analysis for policy – This is usually prospective in order to inform the
formulation of a policy as it is ongoing or to anticipate how a policy might
unfold when it is introduced (e.g. how other actors might respond to the
proposed changes). An example could be of examining an ongoing
policy development or implementation process such as the scale up of
mobile phone technology for health-related purposes (m-health). Another
example of analysis for policy would be any analysis done to inform the
ongoing policy process or to predict the effects of implementation.

5 Politics and Policy

How does politics affect health and pharmaceutical policies?

The state plays a key role in any national health system. This is because the
political system determines the participation of people in policy-making, thereby
determining people’s potential to influence public policy. Politics or political
systems determine who can be involved, how decisions are taken and ways in
which citizens are able to influence policy i.e. if citizens can vote for political
representatives who support their views. The extent to which people can
participate in the political system either directly or indirectly is partially a function
of the culture and nature of the political system. Different systems exist in a
dynamic state and are classified according to how open the system is to
deliberation of alternatives (how liberal or authoritarian). The five systems are
outlined in the box below:

a. Liberal-democratic: This category is marked by governments that

operate with relatively stable political institutions with considerable
opportunities for participation through a diverse number of mechanisms

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 and groups: elections, political parties, interest groups, and ‘free media’. It
includes the countries of North America, Western Europe as well as
countries such as India and Israel.
b. Egalitarian-authoritarian: Characterized by a closed ruling elite,
authoritarian bureaucracies and state-managed popular participation (i.e.
participation regimented and less a democratic opportunity than an
exercise in social control). Close links often exist between single political
parties and the state and its bureaucracies. During the 1970s, the Soviet
Union, China, Vietnam, Angola, Mozambique and Cuba might have been
included. These countries had well-developed social security systems and
health care was financed and delivered almost exclusively by the state
(private practice was banned in some cases) and treated as a
fundamental human right. Few egalitarian-authoritarian political systems
now exist.
c. Traditional - inegalitarian: These systems feature rule by traditional
monarchs which provide few opportunities for participation. Saudi Arabia
and Swaziland provide an example of this increasingly rare system.
Health policy relies heavily on the private sector with the elite using
facilities in advanced countries as the need arises.
d. Populist: These are based upon single or dominant political parties,
highly nationalist and leadership tends to be personalized. Participation is
highly regimented through mass movements controlled by the state or
political party. Elites may have some influence on the government either
through kinship with the leader or membership of the political party – as
long as they support the nationalist and populist causes. Many newly
independent states of Africa and South America began with populist
political systems. While the colonial health services had only been
available to the ruling elite, populists attempted to provide health for all as
a basic right.
e. Authoritatian – inegalitarian: These political systems have often
occurred in reaction to populist and liberal democratic regimes. They are
often associated with military governments and involve varying degrees of
repression. In the mid-1980s, over half the governments in Sub-Saharan
Africa were military – and many were marked by autocratic personal rule.
Health policy reflected the interests of a narrow elite: a state-funded
service for the military while others had to rely heavily on the private
sector.

Source: Buse, et al. (2005). Making Health Policy. Chapter 2, page 37)

These five political systems are vastly different. One of the most important
features is the extent to which they encourage or stifle participation. This in turn
has major implications for how health policy is made and whose interests health
policies serve.

Discussion Forum

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 Think about the following questions and make notes to use in the Discussion
Forum:
Which political system are you currently living in and what impact does it have
on access to healthcare? How are health policies developed within the
particular political system? And whose interests are served with those
policies?
You will be informed when the Discussion Forum will take place so you can
plan your participation.

6 Session summary
These are the take-home messages you should have got from this session. We
hope you are clear about these points.
 The term policy has a wide range of different meanings
 Governments, organizations and even households have policies
 Public policy is government policy for the public good or for public value,
including, importantly, relating to health, especially public health, and
including medicines.
 Policy can be formal and informal, and can include non-decisions
 Policy arises from a process and policy problems are often generated by
failings in that process
 Politics matters and impacts policy development at every stage of
development and implementation
 Policy analysis can be used to understand policy processes

7 References

James, P.B., Wardle, J., Steel, A. and Adams, J. (2018). Traditional,

complementary and alternative medicine use in Sub-Saharan Africa: a
systematic review. BMJ global health.

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 Stakeholder
Session
1b Analysis

Introduction
This session will introduce the central role of actors in the policy process, which
applies to medicines policy as well as to other health policies, and the impact of
their interest, values and beliefs on policy processes. Stakeholder analysis as
an approach will be discussed including its benefits and limitations. The session
will then use a case of a policy development process and unpack how
stakeholder analysis tools were used to map out the stakeholders and their
impact on the policy process.

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A stakeholder is a person who has something to gain or lose through the
outcomes of a policy process. In the health policy analysis field, most
frameworks and tools identify the importance of actors and stakeholders, who
can be individuals, organizations or networks. Actors influence policy processes
in various ways including formulating policy content and implementation. Given
their key position in policy processes, it is usually important to find out who they
are, what drives them, what roles they play in the policy process, from where
they derive their power and how they exercise that power.

Stakeholder analysis is an approach or tool that allows a researcher to generate

knowledge about actors’ behaviors, intentions and interests. It is used to assess
the influence and resources they bring which affects the overall policy process.
Stakeholder analysis can therefore be used to both analyse the past experience
of a policy to understand how policies are developed and the influence of
actors, as well as to support the management of actors for an ongoing or future
policy change process. To conduct a stakeholder analysis there is a need to
consider how actors, content, context and processes interact.

Session contents
1. Stakeholder Analysis – what is it?
2. The purpose of stakeholder analysis
3. Conducting a stakeholder analysis
4. Session summary

Timing of the session

The main activity in this session is a stakeholder analysis based on a case
study. In addition you are referred to 3 short readings. The session should take
you about 3 hours to complete.

Learning Outcomes of this Session

Public Health Outcomes Academic Learning Skills

By the end of this session, you In the session, you will practise these
should be able to: skills:
 Identify the role of actors in
• Identifying specific information in texts
policy processes
 Understand the purpose and • Using forms to record information from
a case study
approach of stakeholder
analysis • Analysing information
 Assess the strengths and • Presenting information in graphic form

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 weaknesses of stakeholder
• Summarising information
analysis as a management tool

Readings
Buse K., Mays, N., & Walt, G. (2005). Making Health Policy. Maidenhead: Open
University Press, Chapter 10 pages 179-184. Add link - Mod resources

Gilson, L. et al. (2012). Using stakeholder analysis to support moves towards

universal coverage: lessons from the SHIELD project. Health Policy and
Planning, 27 Suppl 1, pages i64–76. https://academic-oup-
com.ezproxy.uwc.ac.za/heapol/article/27/suppl_1/i64/602445

Varvasovszky, Z. & Brugha, R. (2000). How to do (or not to do) a stakeholder

analysis. Health Policy and Planning, 15(3), pages 338–345.
http://dess.fmp.ueh.edu.ht/pdf/
Zsuzsa_Varvasovsky_2000_stakeholder_analysis.pdf#http://dess.fmp.ueh.edu.ht/pdf/
Zsuzsa_Varvasovsky_2000_stakeholder_analysis.pdf

Additional readings
Brugha, R. & Varvasovszky, Z. (2000). Stakeholder analysis: a review. Health
Policy and Planning, 15(3), pages 239–246. https://academic-oup-
com.ezproxy.uwc.ac.za/heapol/article/15/3/239/573296

1 Stakeholder analysis – What is it?

Stakeholders are all those who have something to gain or lose through the
outcomes of a policy process. They are also actors in the policy process, but
are particularly those whose interests are at stake in some way or another, as
opposed to those actors who merely play a role in the process, but will not
necessarily be affected by the outcome. The role of stakeholders is therefore
important to understand when planning or evaluating a policy development.
Remember from the first session that actors have their own understandings and
perceptions of problems and policies, based on their own values and beliefs.
They make their own calculations of risk and gain around policies, based on
their interests (self-interest vs public interest). This influences how they
understand policy problems and likely impacts on them of policy content.
Stakeholder analysis is therefore an approach, tool or set of tools for generating
knowledge about key actors (both individuals and organizations) so as to
understand their behaviour, intentions, inter-relations and interests; and for
assessing the influence and resources they bring to bear on decision-making or
implementation processes.

2 The purpose of stakeholder analysis

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There are two purposes of stakeholder analysis:
 The first is to analyse past experience in order to understand how polices
have developed, and how actors have influenced that process. For
example when doing an analysis OF a past policy such as the
introduction of multi-drug resistant TB guidelines we can use stakeholder
analysis to analyse how the guidelines were developed and how actors
influenced the process.
 The second purpose is as a strategic management tool: to assess the
feasibility of future policy directions; to facilitate the project
implementation; to develop strategies for stakeholders. This is crucial
particularly when doing and analysis FOR policy, where one wants to
influence the ongoing process and so a stakeholder analysis is done in
this case in order to identify stakeholder positions and develop strategies
to ensure they will act in favourable ways to ensure policy success.

Stakeholder analysis can help you to understand actors; to determine, for

example, stakeholders’ concerns about an issue, their level of interest and
power, how much they know about the issue, whether or not they are likely to
support or oppose the policy.
However, stakeholder analysis is limited in that:
- It reflects experience at only one point in time: actors concerns and
perceptions about an issue could change over time and so an analysis
only reflects a moment in time;
- It may be difficult to make judgements and reconcile different
interpretations. Stakeholder analysis relies on one’s interpretations, as
you will note during the activity, and so analysts become stakeholders
themselves.
- It focuses on actors’ interests, but these are not the only influences over
policy change.

Some of these limitations can be offset. For example, it is good practice to

conduct stakeholder analyses at different time periods, and to examine changes
in actors’ positions and power over time. It is also possible to conduct such
analyses in ways that draw on various views and perspectives, or develop a
collective judgement through brainstorming in a group on issues like, for
example, actors’ positions and power.

Varvasovszky and Brugha have published an article that outlines all the key
steps on how to conduct a stakeholder analysis as well as how to navigate
some of the limitations. Before conducting the stakeholder exercise in section 3
below, to enable you to get an overview of stakeholder analysis, read the article
and pay particular attention to pages 338-340 of the article. Think about the role
of the analyst during the process of stakeholder analysis as you read the paper.

Reading

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 Varvasovszky, Z. & Brugha, R. (2000). How to do (or not to do) a stakeholder
analysis. Health Policy and Planning, 15(3), pages 338 – 345.

3 Conducting a stakeholder analysis

In this section you will be introduced to and asked to perform a stakeholder
analysis. The readings and questions provided should prepare you for this task.

For an example of how stakeholder analysis becomes vital in developing

managing strategies for various actors see Gilson, et al. (2012). Refer
particularly to pages i64-i76 on ‘Using stakeholder analysis to support moves
towards universal coverage: lessons from the SHIELD project’.
(https://academic-oup-com.ezproxy.uwc.ac.za/heapol/article/27/suppl_1/
i64/602445 ) Look for and note the particular strategies suggested for building
support and offsetting the opposition after conducting a stakeholder analysis.

Also read Buse et al (Chapter 10, pages 179-184) in which they too briefly
discuss strategies one can consider after conducting a stakeholder analysis
including distributing power resources and changing perceptions.

Readings
Gilson, L. et al. (2012). Using stakeholder analysis to support moves towards
universal coverage: lessons from the SHIELD project. Pages i64–76.
https://academic-oup-com.ezproxy.uwc.ac.za/heapol/article/27/suppl_1/
i64/602445

Buse K., Mays, N., & Walt, G. (2005). Making Health Policy. Chapter 10;
pages 179-184.

There are various toolkits available for stakeholder analysis. As part of this
session, we will introduce you to one set of tools and guide you through the
process of conducting a stakeholder analysis.
As the first step in this activity, familiarise yourself with the case study below,
which describes the policy process of separating drug prescribing and
dispensing in South Korea in the late 1990s.

Case study: Separating prescribing and dispensing of medicines in South

Korea
Policy issue
In all countries, expenditure on pharmaceuticals (drugs) impacts on the total cost of
providing health care. The high and increasing cost of medicines puts pressure on
national health budgets and often makes health care unaffordable for poorer groups.
In South Korea as early as the 1980s, prescription practice was identified as the key

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factor influencing what was considered to be an unsustainably high level of
pharmaceutical expenditure. This over-consumption resulted in an increased level of
resistance to antibiotics.These medicine prescription problems were linked to:
a. the activities of two groups of actors: physicians and pharmacists, who both
prescribed and dispensed medicines (which was traditional practice in oriental
medicine);
and
b. Pharmaceutical companies, who attempted to influence which medicines were
being prescribed and dispensed.
To encourage providers to prescribe ‘their’ medicines, pharmaceutical companies
sold medicines directly to providers at prices that were less than government
reimbursement levels. (In this way they increased sales.) Therefore, medicine
providers could generate a maximum profit by prescribing the medicines that cost
them least to buy (relative to the government-set reimbursement level) and by
prescribing more medicines than were necessary. As a result of this financial
incentive, pharmaceutical companies and medicine providers would often work
together in illegal and unfair ways to sustain their own profit levels.
The patients’ lack of knowledge was also seen as a factor affecting medicine
prescribing practice. Lack of knowledge limited patients’ ability to challenge provider
practices. In addition, patients’ preference for some form of medication, reflecting
oriental medicine practice, encouraged providers to over-prescribe medicines.
Policy change
On July 1st 2000 the Korean government introduced a new health policy to prevent
physicians and pharmacists from both prescribing and dispensing medicines. Under
the new policy (in relation to those medicines categorised as prescription medicines)
physicians would only be able to prescribe, and pharmacists to dispense. This new
policy also allowed physicians to prescribe either the brand name or the generic
medicine. However, when dispensing, pharmacists could substitute a generic for a
brand name medicine if an equally effective generic medicine (as verified by a
bioequivalence test) was available.
Chronology and experience of implementing pharmaceutical reform
Since 1963 attempts to amend the law in order to separate prescribing and
dispensing of medicines had been made. However, these had been unsuccessful
due to opposition from physicians and pharmacists, whose strong professional
associations actively lobbied against the proposed changes. The 1994 amendment
to the Pharmacy Law specified that the separation of prescribing and dispensing
would occur by 1999. A new president came to power in 1998, determined to
implement this reform as it had been one of the key elements of his presidential
election campaign.
In May 1998 the Ministry of Health and Welfare established a steering committee to
prepare for the separation. To facilitate implementation, the committee made a
revised proposal for the reform and classified medicines as either prescription or
non-prescription. The civil servants made no special efforts to negotiate these
proposals with the affected stakeholders. Apparently they believed that they could

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implement policy by instruction, as under earlier authoritarian regimes.
Reaction from civil society
The democratisation of South Korean society provided more opportunities for interest
groups to shape policy processes, and increased their bargaining power relative to
the state. In November and December 1998, the medical and pharmaceutical
associations appealed to Congress to defer the reform. They also appealed to the
public for support by emphasising that:
• the new system would make it very inconvenient for consumers to obtain
medicines; and
• it would not lead to reduced costs or other benefits.
Their activities were opposed by civic groups, mainly progressive academics and
political activists, who had previously opposed military rule and who were aligned
with the new President. These groups made pharmaceutical reform a major social
issue, and deliberately revealed the huge hidden profits made by physicians.
This information initially caught public attention and mobilised support. It led
Congress to reject the medical and pharmaceutical associations’ appeal. However,
neither the civic groups nor the government put much effort into persuading
consumers to support the reform. Little publicity was given to the reason for the
reform, and its potential benefits to consumers; and little effort was made to address
the providers’ claim that it would make consumer access to medicines more difficult.
The civic groups also apparently did not take account of the possibility that revealing
physician profit levels to the public would strengthen the physicians’ resistance to the
new policy.
Implementation of a ‘no-margin’ policy
In November 1999, the government implemented the ‘no-margin’ policy. This policy
cut the medicine reimbursement fee that government paid medicine providers close
to the price that providers actually paid to the pharmaceutical companies. This
strategy was intended to remove the physician’s financial incentive to dispense
medicines and so encourage their compliance with the separation reform. It was put
through with little consultation or negotiation.
The ‘no-margin’ policy showed the physicians how great an impact the separation
policy would have on their profit margins. They decided to go back on the attack. In
February 2000 about 40,000 physicians demonstrated against the reform. This was
followed by a series of other strikes (on April 4-6, June 20-26 and August 11-17). In
the second strike more than 90% of general practitioner-type physicians went on
strike. In addition, strikes by resident doctors in teaching hospitals (the vast majority
of doctors in those hospitals) began in July and lasted for three months.
The Korean health system is extremely vulnerable to strikes by private sector
physicians. It is heavily dependent on general and teaching hospitals for both
inpatient and outpatient care. Only 7% of acute hospital beds are owned by the
government. Therefore, the government not only agreed to raise the physicians’
general reimbursement rates by up to 44%, but also to exempt many injectable
medicines from the mandatory separation (although the latter was ostensibly to avoid
patient inconvenience). At the same time, in order to offset the threat of further
strikes, they increased dispensing rates for pharmacists.

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The policy of separating medicine prescribing and dispensing was, nonetheless,
eventually implemented in July 2001.
In summary, three points can be noted as emerging from this medicines policy case:
a. The increases in reimbursement rates won by health care providers will limit the
impact of the policy on total health expenditure levels, and may raise total costs for
consumers.
b. Consumers will also have to bear the impact of reduced access, and this has
already led to consumer complaints about the policy.
c. Physicians (in particular) have clearly demonstrated their power to influence the
Korean health policy process – suggesting that the battle to contain the costs
resulting from their practices is not yet over.

Activity 2: Conduct a stakeholder analysis of a pharmaceutical

reform policy
Using the above scenario which details the implementation of pharmaceutical policy
reform in South Korea to separate prescribing and dispensing of medicines as a
strategy to decrease/control expenditure on pharmaceuticals, follow the steps below
to conduct a stakeholder analysis of the policy.
1. Identify four key actors in the case study (people, groups, organisations),
2. Consider the questions below for each actor. Using the questions below fill in the
information for each actor in Form 1 which you will find in your Module Resources
folder in iKamva.
• What are the actor’s interests and values relating to the policy issue?
• How is the actor likely to see the impact of the policy action?
• Is the actor likely to support or oppose the policy action?
• What power resources does the actor have?
• What capacity does the actor have to mobilise resources?
• What is the overall power level of actor?
It is important to attempt to determine each stakeholder’s real interests, position and
level of commitment for a proposed policy. This knowledge will play an important part
in designing political strategies to affect change.
3. Prepare a force-field map that predicts actor positions and power levels around
the issue (complete Form 2 in the Module Resources folder). This allows you to
judge what level of power the actors are likely to have around the particular policy
issue (‘very high to very low’); as well as whether the actor would see the impact of
the policy on them as strongly positive, strongly negative or somewhere in between.
It is a way to summarise the stakeholder analysis and predict which actors should
possibly be targeted for future interventions such as mobilisation activities.
4. Drawing on the information in the more detailed stakeholder analysis which you

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 have already done, and from Form 2, locate the actors on the force field chart (Form
3) so that their location shows their relative support for the issue at hand and their
relative power in relation to other actors and the issue.
A forcefield map allows you to graphically show the extent to which you think actors
may help or hinder the policy process, and what level of power they have to do so. It
ultimately helps you assess the political feasibility of policy action around the issue
and provides a basis for developing an actor management strategy to support the
process of policy change.
A forcefield map is a chart with two axes: the vertical axis indicates the actor’s power
in relation to the policy (from ‘very high’ to ‘very low’); and the horizontal the extent to
which they support the policy or not (‘high support’ to ‘high opposition’). Once the
actors are plotted on the force-field map, one can then devise strategies to move
them from for example high opposition to supportive of the policy process.
Remember that each position map will look different depending on the policy content,
actors and context.
To guide you into completing this activity, one actor has been filled (physicians) for
you and placed on the forcefield map.
Submit your stakeholder analysis (Form 1) and force field map (Form 2) in
iKamva, after which you will receive general feedback.

4 Session Summary
In this session you saw, in the pharmaceutical policy case study, how
conducting a stakeholder analysis and a force field analysis enables you to:
o draw together your understandings of how actors (particularly
stakeholders), content, context and processes interact within any
policy process
o assess the political feasibility of a policy and its implementation
o identify key potential allies and opponents relating to a policy
process
o clarify the resources and power of key actors in the process; and
identify the basis for developing strategies for managing actors

These analyses should be repeated at various times, as actors’ positions and

power change over time and the assumptions made can become invalid. In
addition, drawing on various views and perspectives, or developing collective
judgement through consulting others can overcome some of the limitations in
these tools.

The stakeholder analysis also forms the first step in developing policy briefs as
one can identify which actors need to be mobilised or engaged with. One of the
ways of engaging with actors in order to change their positions on various policy

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issues is through the development of a policy brief, which will be introduced in
Session 1c.

Introduction to Policy
Session
1c
Briefs

Introduction
What is a policy brief?
A policy brief presents a concise summary of information that can help readers
understand, and likely make decisions about, for example, government policies.
A policy brief may give objective summaries of relevant research, suggest
possible policy options, or go even further and argue for particular courses of

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action. A policy brief may also act as a vehicle for providing policy advice or
recommendations.

A policy brief is usually a short, concise document that can be written for a
variety of policy actors. Exactly who a policy brief is written for depends on the
aim of the specific policy brief and the level of its application, for example, local,
national, regional or private. Finding the right policy actor to target is crucial to
ensuring that it will be read and to determine the language and information that
should be included in the policy brief.

Policy briefs will be covered more details in the session on Policy Briefs, and at
the end of the module you will be expected to critique a given policy brief and
also develop a policy brief based on a particular issue. As you go through the
next sessions, it would be a good idea to start identifying potential policy topics
that you could analyse and use to develop your policy brief at the end of the
module.

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