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Received 26 August 2003; received in revised form 10 February 2004; accepted 23 March 2004
Available online 18 October 2004
KEYWORDS Summary Policy analysis is not an easy task. Its scope is broad and can include both the
Health policy; Policy analysis of policy process and the analysis of policy content. This paper is concerned
analysis; Health with the analysis of policy content and offers some practical guidance regarding how to
outcomes analyse health policy and link it to health outcomes. An eight-step framework for
policy analysis is proposed that public health policy makers and public health
practitioners may find especially useful due to its simplicity.
Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights
reserved.
0033-3506/$ - see front matter Q 2004 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2004.03.006
Health policy analysis: a simple tool for policy makers 193
study.2 The main concern of policy analysis is the iterative. Bardachs framework does not require
outcomes of health policies or the effects that the sophisticated methods of analysis; it is focused on
policy has on people. the policy issue and can be accomplished by policy
There are different methodologies for public makers in a relatively short period of time.
policy analysis. Dunn suggested that policy analysis
should incorporate five general procedures common
to most efforts at human problem solving: defi-
nition; prediction; prescription; description and
Health policy analysis
evaluation. Definition provides information about
the conditions that contribute to a policy problem. The different policy analysis methodologies above
Prediction provides information about future refer to general public policy analysis, but how does
consequences of acting on policy alternatives, one go about analysing health policies? At the
including doing nothing. Prescription provides outset, it is important to understand what is meant
information about the relative value of these future by health policy. The World Health Organization
consequences in solving the problem. Description (WHO) defined health policy as an agreement or
provides information about the present and past consensus on the health issues, goals and objectives
consequences of acting on policy alternatives. to be addressed, the priorities among those
Finally, evaluation provides information about the objectives, and the main directions for achieving
value or worth of these consequences in solving the them.7 The WHOs approach to public health policy
problem.3 puts health on the agenda of policymakers in all
Portney referred to the three approaches of sectors and at all levels, directing them to be aware
policy analysis: policy making; cause and conse- of the health consequences of their decisions and to
quence; and the policy prescription.4 accept their responsibilities for health.8 However,
The policy making approach to policy analysis health policy decisions are not always the result of a
defines public policy not as a product of govern- rational process of discussion and evaluation of how
ment action but as a political process. A proposal a particular objective should be met. The context in
must move through the following five stages to which the decisions are made is often highly
become a policy: problem formation; policy formu- politicalconcerning the degree of public provision
lation; policy adoption; policy implementation and of health care and who pays for it. Health policy
policy evaluation. decisions also depend on value judgements, which
The cause and consequence approach to policy in any society are implicit, but are very important
analysis is focused on intended or unintended to understand in order for policy to be
impacts of governmental decisions or non- implemented, for example, the value placed on
decisions. It uses terminology from system analysis, women and their health.9
such as inputs, outputs and outcomes. Walt differentiated policies by dividing them into
Policy prescription looks ahead. It attempts to high politics and low politics. High politics issues
use a variety of economic, mathematical, computer or macro-policies (such as major economic
science and operations research techniques to decisions or national security) involve the long-
answer the question: what should the government term objectives of the state and those in power, as
do in the future? opposed to low politics issues or micro-policies that
Pal offered a broader but brief definition of involve mainly sectoral interests. In health, many
policy analysis: the disciplined application of policies often fall into the category of low politics.
intellect to public problems.5 Since it focuses on However, as Walt stated, a low politics issue can
broad questions and on the future, policy analysis shift and become a high politics issue over time. A
is subject to considerable uncertainty. According to health policy maker needs to be aware of these
Bardach, policy analysis is more art than science. It constraints and develop a sense of what is urgent
draws on intuition as much as method. Bardach and feasible.10
proposed a practical framework for public policy Health policy analysis is a political as well as
analysis, which he referred to as the eight-fold social activity and could be very time consuming.
path. The following eight steps form the bases of However, in todays fast-paced environment,
the path: (1) define the problem; (2) assemble the health policy makers may face a daunting reality
evidence; (3) construct the alternatives; (4) select of having to make important decisions in a very
the criteria; (5) project the outcomes; (6) confront short period of time. Most frameworks proposed in
the trade offs; (7) decide; and (8) tell your story.6 It the health policy literature use particular concepts
is worth noting that going through these steps is not and models in order to explain health policies in
necessarily a linear process. Often, it can be abstract, theoretical terms and focus mainly on
194 T. Collins
sufficient to complete the analysis. Secondary if we refer to the HIV/AIDS example again, in a
data indicates not only published academic country with a low HIV/AIDS epidemic, the
sources, but important policy documents and policy might be focused on prevention of HIV/AIDS
unpublished reports that could be made available through public education about individual pro-
through ministries of health or other public insti- tection. However, with a rising incidence of
tutions of a given country. Some information can be HIV/AIDS, the government might consider adding
found through the Internet as well, although the treatment to the prevention.
validity and reliability of web data is sometimes
suspected.
Surveys of best practices could also be a useful Step 5. Project the outcomes
tool to collect valuable information. The chances
are that the health problem under study is not An important point to keep in mind is that when
unique to a given country; other countries may have considering the alternatives, we are mainly con-
already dealt with it successfully. Finding where the cerned with the outcomes of the proposed alterna-
problem has already been addressed could lead to tive interventions. For example, if we arrive at the
solutions that can be extrapolated to the situation conclusion that alternative A will lead to a desirable
under study. outcome OA, which we consider to be better than
If more evidence is needed after exhausting the outcome OB (the result of alternative B), we
secondary sources, it is time to move to more will decide to choose alternative A as the best
expensive primary data collection. For less- possible policy option.6 If we use the previous
explored problems, qualitative tools are more example of HIV/AIDS policy, the alternatives could
appropriate. This can be done through face-to- be treatment vs prevention. Although attractive in
face interviews or through focus groups that give an theory, treatment of HIV/AIDS (where there is no
analyst very rich qualitative data and a depth of cure and sometimes benefits are uncertain, while
understanding of the problem. costs are high) benefits a relatively small number of
individuals, while preventive strategies have the
Step 4. Consider different policy options potential of reaching out to the whole population
and could be more feasible.
Upon compilation of evidence, it is time to think
about constructing the alternatives for alleviating
the problem. Alternatives indicates policy Step 6. Apply evaluative criteria
options, alternative courses of action or alternative
strategies of intervention. We often think about
In order to evaluate interventions, we need
alternative approaches to the problem as possible
standards; criteria against which we measure the
interventions in the system that hold the problem in
projected outcomes. It is important to stress again
place or keep it going.6
that criteria apply to judging the outcomes of
When it comes to options analysis, the policy
alternative interventions, not the alternatives
linkages to contextual factors are imperative. Some
themselves. The choice of criteria depends on the
options are often ignored even before any kind of
problem under study.
option appraisal is attempted. For example, in
Rodriguez-Garcia2 proposed five criteria that
examining the available options for HIV/AIDS
policy, a sexually explicit public education cam- should be applied to the evaluation of interven-
paign may not be considered in a given country. In tions:
other cases, epidemiological, clinical and economic
aspects of interventions need to be considered if 1. Relevance: does the intervention contribute to
the policy is to be implemented. The options should the health needs of the target population? Is it
also reflect the ethnic specificity and experience of consistent with policies and priorities?
the nation and be scientifically justified and based 2. Progress: how do actual results compare with
on international experience. projected or scheduled results?
Weighing different alternatives does not necess- 3. Efficiency: what are the results in relation to
arily mean that the policy options are mutually resource expenditure of the intervention?
exclusive. Sometimes choosing one alternative 4. Effectiveness: to what degree does this particu-
implies forgoing another, and sometimes it means lar intervention attain its objectives?
simply adding one more policy action that might 5. Impact: what is the effect of the activity on
solve or mitigate the health problem, perhaps in overall health and related socio-economic devel-
conjunction with other alternatives.6 For instance, opment?
196 T. Collins