Health Policy and Planning Advance Access originally published online on July 29, 2008
Health Policy and Planning 2008 23(5):291-293; doi:10.1093/heapol/czn025
This article appears in the following Health Policy and Planning issue: Future directions for health policy analysis: a tribute to the work of Professor Gill Walt [View the issue table of contents]
Future directions for health policy analysis: a tribute to the work of Professor Gill Walt
1 Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa.
2 Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, UK.
3 School of Public Health and Family Medicine, University of Cape Town, South Africa.
4 Overseas Development Institute, London, UK.
5 Division of Health and Social Care, King's College, London, UK.
6 HLSP Institute, London, UK.
* Corresponding author. School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, 7925, South Africa. E-mail: lucy.gilson{at}uct.ac.za
This edition of Health Policy and Planning comprises a set of seven papers that focus on the field of health policy analysis. Such analysis shares an understanding that policy making is a process of continuing interaction among institutions (the structures and rules which shape how decisions are made), interests (groups and individuals who stand to gain or lose from change) and ideas (including arguments and evidence) (John 1998
).
This area of multi-disciplinary inquiry is, in higher income countries, a recognized academic field of practical relevance, but in low and middle income settings it remains an under-developed area of work. Yet, in the year we celebrate the 30-year anniversary of the Alma Ata Declaration on Primary Health Care, it is clear that better understanding of the challenges to health policy implementation and renewed action to achieve the Millennium Development Goals are vital in these settings.
Health policy analysis is important to both tasks. It can help explain why certain health issues receive political attention, and others do not, such as by enabling identification of which stakeholders may support or resist policy reforms, and why. It can also identify the perverse and unintended consequences of policy decisions, as well as the obstacles that undermine policy implementation and so jeopardize national and global goals for improved health. In these ways, policy analysis supports more realistic expectations about the timeframes and nature of policy reform, can assist in enabling successful policy development and implementation, and can support the use of technical evidence in these processes (Buse et al. 2007).
The papers presented here derive from a workshop held in London in May 2007 which brought together 25 practicing health policy analysts from around the world.1 The workshop sought to take stock of the current state of health policy analysis inquiry in low and middle income countries (LMICs). Participants reflected not just on the content of this body of work but also, and equally importantly, on how this work is undertaken. The workshop specifically allowed an exchange of ideas about the use of theoretical and conceptual frameworks, and methods and approaches, in investigating and understanding policy processes; and it sought to identify how such analysis could be strengthened in the future.
The workshop and this set of papers pay tribute to the work of Gill Walt, a co-founder of this journal, Professor Emeritus in Health Policy at the London School of Hygiene and Tropical Medicine, and a key intellectual influence in the field of health policy analysis. Gill established Health Policy and Planning with Patrick Vaughan in 1986 and has played an important role in the journal's subsequent development. The hallmarks of their approach to health policy are reflected in the very first editorial [1(1): 3–4, 1986], which established that the journal would:
- have as its main focus the developing world, with the hope that most of its materials would be written by authors living in developing countries;
- seek to be of interest to people working in health services and organizations, as well as universities and donor organizations; and also to people working in fields such as social policy and community development;
- adopt a multi-disciplinary approach to health;
- present a balance between theoretical and practical approaches.
Health policy analysis is, in other words, not only of practical importance in public health, but also a legitimate area of academic inquiry. Professor Walt's own career has amply demonstrated these twin features. Her early analyses of primary health care, and community health workers, for example, are once again being drawn into international policy debates on health system strengthening. In addition her wide-ranging work on international agencies, including current work on Global Health Initiatives, continues to inform and influence trends in the global aid architecture. Her book, Health Policy: Process and Power (Walt 1994), remains a seminal text for students in this field, and the related policy analysis triangle framework (Walt and Gilson 1994) continues to grow in analytical influence. The simplicity of its approach enables even the novice analyst to explore the complex and chaotic reality of policy-making, as well as providing a tool for strategic policy management. Gill's infectious enthusiasm, moreover, continues to inspire and motivate others: as she confesses in the introduction to her book, it is the belief that policy analysis can lead to better health outcomes that ‘gets her out of bed in the morning’.
Given Gill Walt's role in the history and development of Health Policy and Planning, it is not surprising that it is one of the leading peer-reviewed international journals publishing work that falls within the field of health policy analysis in LMICs. It is therefore a natural home for this particular set of papers.
Reflecting the purpose of the May 2007 workshop discussions, the majority of these papers have a methodological and reflective slant, and two report empirical studies that demonstrate analytical approaches. The papers add to available texts in the field (e.g. Buse et al. 2005) by presenting practical methodological insights derived from the authors’ experience, offering pointers to bodies of theory that need to be more actively used in this field, and by providing new empirical analyses.
To provoke reflection on the nature of the field, the first paper (Gilson and Raphaely) provides an overview of the terrain of published English-language articles (1994–2007) that apply health policy analysis to LMIC settings. The paper maps the broad range of topics addressed in these articles, as well as considering the nature and adequacy of their analytical approaches. Highlighting the limited scope and methodological weaknesses of this body of work, it provides a basis for the other papers in the edition. Walt et al. then consider how to strengthen future analytic work. They note the changing challenges of conducting such work, including the much wider range of actors now involved in policy-making, and the growing influence of forces outside states, including the faster exchange of information and ideas. The paper then explores ways of advancing the field of health policy analysis with recommendations on theory, methodology and researcher reflexivity. Exworthy specifically reflects on the role of health policy analysis in supporting policy action on the social determinants of health, and how to conduct such analysis. This is timely given that the final report of the WHO Commission on Social Determinants is published this year, and there is a clear need to use policy analysis to support desperately needed public health action on these determinants.
The next two papers report empirical studies from different parts of the developing world. Tantivess and Walt investigate the HIV/AIDS policy response in Thailand, with specific reference to the processes by which the universal ART policy developed between 2001 and 2007. They consider the relevance of policy networks and the role of non-government actors in these processes, highlighting the value of network analysis in both understanding and supporting policy change. Crichton meanwhile addresses a common problem of policy implementation: the need to re-confirm a policy mandate even after the apparent prioritization of a policy issue in the agenda-setting phase. Examining recent experience of family planning policy in Kenya by applying the notion of policy space (Grindle and Thomas 1991), the paper shows the importance of advocacy work within the bureaucracy as a strand of the strategic management needed to move commitment to a policy agenda towards sustainable implementation.
Buse picks up the practical relevance of policy analysis by presenting a framework and guidance for prospective policy analysis, to be undertaken by advocacy groups, with support from national and international policy experts, in enabling and sustaining policy change. Finally, Erasmus and Gilson provide ideas about how to investigate power in the front-line organizational environments of health care provision, as a practical support for future implementation analysis.
The dominant methodological focus of these papers is, perhaps, an unusual orientation, but it is appropriate for our goal of building this field of work. We hope to encourage the application of analytical and intellectually rigorous inquiry to the challenge of strengthening policy processes and, ultimately, making a difference to people's and communities’ health.
Over a decade ago Gill Walt called for work that would integrate the study of politics, process and power with the study of health policies in LMICs. Her own body of published work is testimony to the importance of this analytical approach. However, there is still a need to do much more health policy analysis, as well as to deepen and extend the work done. The publication of this collection of papers is part of what we hope will be diverse and multiple responses to the 2007 workshop's recommendations for the future directions of health policy analysis work (Buse et al. 2007). These recommendations call for:
- A more explicit focus on the methods for doing policy analysis by:
- – Increasing the methodological diversity within policy analysis by drawing more extensively on experience from other fields whilst paying greater attention to the benefits and limitations of different methodological approaches;
- – Enhancing reflexivity in relation to both the relationships between researchers and policy actors and the manner in which the findings from policy analysis are used to engage with policy actors.
- – Enhancing reflexivity in relation to both the relationships between researchers and policy actors and the manner in which the findings from policy analysis are used to engage with policy actors.
- – Increasing the methodological diversity within policy analysis by drawing more extensively on experience from other fields whilst paying greater attention to the benefits and limitations of different methodological approaches;
- Better use of the existing, but often descriptive, body of policy analysis through:
- – Synthesis of existing case study material using theoretically robust and well-structured approaches to synthesis of findings;
- – Lesson learning from country case studies that have a common topic focus or common framework;
- – Lesson learning from all the health policy analysis studies carried out in a single country.
- – Lesson learning from country case studies that have a common topic focus or common framework;
- – Synthesis of existing case study material using theoretically robust and well-structured approaches to synthesis of findings;
- Future research on agenda setting and policy implementation to:
- – Place greater emphasis on comparative studies;
- – Increase the use of theoretical concepts and/or analytical frameworks that underpin analysis.
- – Increase the use of theoretical concepts and/or analytical frameworks that underpin analysis.
- – Place greater emphasis on comparative studies;
Implementing these recommendations will, however, require increased investment—to support the capacity development needed to strengthen analyses, to enable the development of a deeper and wider body of work, and to allow greater engagement with policy practitioners around analyses that are conducted. We call on research and other funders to recognize the value of health policy analysis by providing greater levels of dedicated funding for activities that strengthen this field.
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1 Organized by the Consortium for Research on Equitable Health Systems (CREHS), the HLSP Institute, King's College, London and the Overseas Development Institute; and funded by all these bodies, the UK Department for International Development and the British Academy. 
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Buse K, Mays N, Walt G. Making health policy. (2005) Milton Keynes, UK: Open University Press.
Buse K, Dickinson C, Gilson L, Murray SF. How can the analysis of process and power improve health outcomes? Moving the agenda forward. In: ODI Briefing Paper 26. (2007) London: Overseas Development Institute.
Grindle M, Thomas J. Public choices and policy change: the political economy of reform in developing countries. (1991) Baltimore and London: The Johns Hopkins Press.
John P. Analysing public policy. (1998) London: Cassell.
Walt G. Health policy: an introduction to process and power. (1994) London: Zed.
Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy and Planning (1994) 9:353–70.
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