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The Health Policy Triangle

In this lecture, Anna Kalbarczyk explains the Health Policy Triangle. (Step 3.5)
ANNA KALBARCZYK: Welcome back. In this section, I will describe the health policy triangle, a framework that outlines key considerations for good health policy making and the different factors that may affect policies. Most often, emphasis is placed largely on the content of policies for health care programs, which is shown here on the bottom left of the triangle. The health policy triangle also draws attention to the actors involved in policy reform at the international, national, and subnational levels, in addition to the processes in which policies are initiated, developed or formulated, negotiated, communicated, implemented, and evaluated, and the context within which policy is developed. These aspects together allow for more effective implementation than just considering the content itself.
The triangle promotes a better understanding of the interface between context, process, and content, power relations among actors, potential alliances, and conflicts among stakeholders, and also provides the foundation for planning stakeholder engagement. Now this, of course, is a highly-simplified model of an extremely complex set of interrelationships. In reality, each of these components are influenced by each other. For example, actors are influenced by the context within which they live and work at both the macro government level and the micro institutional level. Context is affected by factors such as instability created by changes in political regime. And the process of policy making in turn is affected by actors, including the actor’s position, power structure, and their own values and expectations.
Let’s first look at actors or stakeholders. From your experience, can you think of a list of key stakeholders to involve as part of policy engagement? Consider a program you’re working on now or a health issue that you think should be a priority in your country. What stakeholders would you need to engage to move forward your program or agenda? In this health policy triangle, actors are central because they have the power to influence and be influenced by content, context, and processes. Stakeholders may be defined as individuals, groups, and organizations that can collectively and individually support the development of a strong constructive policy formulation process which must have strong ownership as well.
The key questions regarding who, why, what, how, and when to engage with stakeholders is crucial. Understanding the breadth and depth of stakeholder engagement at each stage of the policy cycle, what decisions need to be made throughout policy engagement, and what form is very important. These are all aspects that should be considered when planning engagement with policymakers. Who might you engage first and why? Are there gatekeepers who need to be brought on board early or else they might later serve as a barrier? Stakeholders may be directly or indirectly affected by the policy.
The range of potential stakeholders is diverse and can include target beneficiary groups, locally-affected communities or individuals, national and local government authorities, civil society actors including nongovernmental organizations, Indigenous peoples, politicians, religious leaders, the academic community, private sector entities, worker organizations, UN agencies and donors, and other special interest groups. Importantly, stakeholders may include groups that are opposed to your proposed interventions. This stake that each of these different groups has in the policy will vary. That is, not only are they for or against the policy, but to what degree?
The range of potential stakeholders is diverse as I mentioned earlier and as is outlined on this slide. And the identification of key actors is a critical step in understanding how you create buy-in and from whom it must be obtained to align the various actors within the organizational framework. Understanding the role of each actor in the broader environment allows the program to start thinking through the various ways key actors will be engaged, consented, and interacted with throughout the course of the program. Multiple mechanisms may be needed to obtain commitment ranging from formal legal arrangements and informed consent to memorandums of understanding and other nonlegally-binding commitments.
Two aspects of an effective engagement strategy are understanding the overlap of vital interests and creating a shared sense of local impact. Effective stakeholder engagement enhances policy acceptance and ownership and strengthens the social and environmental sustainability and benefits of supported interventions. It is both a goal in and of itself as well as an effective means for achieving policy outcomes, including those related to democratic governments, protecting the environment, promoting respect for human rights, and preventing and resolving conflict.
Take a moment to watch this video, a series of interviews with Global Polio Eradication staff on engaging with local leaders across different contexts. As you watch, take notes. What are some key takeaways from this video? And how might you incorporate them into your own work moving forward?
The video you just watched provided some tips on engaging with different policy makers and highlighted the importance of listening and respecting people who work within the country. In my mind, this speaks a bit to the different roles that people have within policy engagement. Let’s use polio eradication as an example and consider the role of leaders at the national level. Government provides a unifying policy framework for prevention and control and establishes linkages with formal institutions for leveraging commitment, dialogue, resource mobilization, and technical support. Development partners can play a complementary role to support national efforts, including providing technical assistance and some of the others that I just mentioned. At the subnational level, policy stakeholders implement and monitor program activity.
Here there is often decentralized decision making and accountability. Again, local non-government organizations can complement activities by creating demand, mobilizing communities, and identifying implementation gaps at the community level. Stakeholders at the community level may be community leaders or religious leaders or also members of the community itself who may experience impacts from the health policy or program. Community members can empower families, individuals, and decision making and form bonding relationships within the community to improve readiness for implementation. Community-based organizations may be able to facilitate reaching harder-to-reach populations, including the socioeconomically disadvantaged, and can also help bridge relationships with other communities to address inequities. We will now discuss both the content and process components of the triangle.
Content again is the substance of a particular policy which details the subjects and topics covered. And process is the way in which policies are initiated, developed, negotiated, communicated, implemented, and evaluated. Kingdon’s model, which I’ll describe in a moment, highlights the three streams of this policy process. The problem stream captures the attention of the public, government, and health officials and is considered a very first step in formulating a policy or a change in strategy to address a problem. So this is really the perception of a problem as a public matter requiring government action. The second stream is the policy stream, which encourages debate and discussion and further analysis of the problem and the proposed solutions.
This stream also helps in narrowing down the problem and the possible solutions which are doable within a given timeframe and are acceptable to the public. The final and the third stream is to feel the pulse of the political leadership’s interest, the nation’s mood, changes in government, and the priorities of interest groups. And this is described as the political stream. It’s by aligning these three streams that the policy process can move forward. The three streams often remain as separate streams. And advocacy efforts or strategies are needed to merge them and to identify this policy window. That is an ideal opportunity for advocates to bring attention to their issues and to craft and implement solutions.
Finally, let’s discuss context. It is important to take into account contextual opportunities and constraints to policy change or those factors including situational, structural, cultural, et cetera that are unique to a specific setting and time. And these condition the limits of policy change or influence, which is that policy window that I described previously. Policies are implemented in complex, multifaceted, and dynamic environments, which arguably means that the same policy intervention would rarely work in the same way in different contexts or even in the same location but at different times. So we need structured and comprehensive conceptualization and assessment of context within the implementation of policy interventions.
Context is not so much a backdrop for implementation but rather interacts, influences, modifies, and facilitates or constrains the intervention and the implementation effort. The PESTLE framework captures contextual factors that influence implementation of programs and are in turn influenced by the implementation of programs. There are six core dimensions of this framework. And I’ll provide some examples of contextual factors within the polio eradication initiative that influenced the program at each level. At the political level, we could think about instability, geopolitical shifts, and variable commitment and program ownership by different groups. Economically, there were a lack of finances sometimes to support the initiative or to support emerging needs. At the social level, we sometimes saw misinformation or competing priorities for the community.
We’ve also seen the role of gender norms both within communities and polio eradication organizations that needed to be accounted for for implementation. Legally, we could consider a legal or policy recourse. And at the technological level, there were so many innovations such as mobile and tablet-based data collection and GIS mapping that emerged in response to needs to the polio program. And finally, environmentally, we could think about population density and geographical access to areas, which can make some populations harder to reach. Also, of course, political priorities are based on many factors like I’ve just described. And sometimes, unfortunately they’re not driven by public health research evidence but rather by other factors as well or instead of.
I’d like to end by describing two examples of a similar strategy that was used in polio eradication but in two different contexts both dealing with conflict. Nigeria and Afghanistan are two countries that have struggled with conflict, which has made many populations harder to reach by the polio program. In both settings, different approaches to community and political engagement helped the program access some turbulent regions. One GPEI staff member at the global level described this in Nigeria and said, “If you take Nigeria, for example, where we had a case I think in August 2016 in the Northeast, which is Borno, they were dealing with this Boko Haram factor. We were unable to access I think around 600,000 children in those areas.
And then the program came up again with a number of innovative strategies. There was engagement of military. And participation of imams was requested. There was a high political commitment that it was supporting.”
In conflict areas, militant or religious groups are important stakeholders to consider. In this next example, Taliban, who are Muslim fundamentalists, released fatwas denouncing vaccination as an American ploy to sterilize Muslim populations. So here high-profile endorsement by political, international, and military figures in Afghanistan might actually be counterproductive in nonsecure areas as anti-government elements would likely oppose high-priority government programs. Therefore, different stakeholders had to be considered to access populations living in these conflict areas. These two examples showcase why careful planning and consideration of context is so important. One strategy, even in terms of engagement, is not likely to be successful in all places.
As you move forward and think about the importance of policy engagement, remember, when done successfully, it can yield buy-in, provide access to resources, and facilitate implementation in diverse and complex contexts.

Anna Kalbarczyk, DrPH, MPH
Bloomberg School of Public Health, Johns Hopkins University, USA

The lecturer invites you to watch the video Working with Local Leaders. It is a series of interviews with Global Polio Eradication staff on engaging local leaders across different contexts. As you watch, consider the question:

Consider a program you’re working on now or a health issue that you think should be a priority in your country. What stakeholders would you need to engage to move forward your program or agenda?

We invite you to share your thoughts in the discussion.

Please also take a moment to review the reading How can the analysis of power and process in policy-making improve health outcomes?

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