Policy Formulation,

Implementation and Policy

Analysis

Prepared by: Dr. Fahad Mahmood, Lecturer, NIPSOM

What is “Policy”?

 Policy is a law, regulation, procedure, administrative action, incentive,

or voluntary practice of governments and other institutions.
 Health can be influenced by policies in many different sectors.
 For example, transportation policies can encourage physical activity
(pedestrian- and bicycle-friendly community design); policies in
schools can improve nutritional content of school meals.

Source:
https://www.cdc.gov/polaris/php/policy-resources-trainings/definition-of-policy.html
Many types of policy

 Laws  New programs or pilots

 Regulations Procedures
 Incentives
 Recommendations
 Resource allocation decisions
 Guidelines
 Administrative actions
Framing Questions

 What is the policy lever—is it legislative, administrative, regulatory,

other?
 What level of government or institution will implement?
 How does the policy work/operate?
 Is it mandatory?
 Will enforcement be necessary?
 How is it funded?
 Who is responsible for administering the policy?
 What are the objectives of the policy?
Framing Questions….cont.

 What is the legal landscape surrounding the policy (e.g., court rulings,
constitutionality)?
 What is the historical context (e.g., has the policy been debated
previously)?
 What are the experiences of other jurisdictions?
 What is the value-added of the policy?
 What are the expected short, intermediate, and long-term outcomes?
 What might be the unintended positive and negative consequences of
the policy?
Public Health Impact

 Potential for the policy to impact risk factors, quality of life, disparities,
morbidity and mortality.
 How does the policy address the problem or issue (e.g., increase access,
protect from exposure)?
 What are the magnitude, reach, and distribution of benefit and burden
(including impact on risk factor, quality of life, morbidity and mortality)?
 What population(s) will benefit? How much? When?
 What population(s) will be negatively impacted? How much? When?
 Will the policy impact health disparities / health equity? How?
 Are there gaps in the data/evidence-base?
Feasibility

Political
 What are the current political forces, including political history,
environment, and policy debate?
 Who are the stakeholders, including supporters and opponents? What
are their interests and values?
 What are the potential social, educational, and cultural perspectives
associated with the policy option (e.g., lack of knowledge, fear of
change, force of habit)?
 What are the potential impacts of the policy on other sectors and high
priority issues (e.g., sustainability, economic impact)?
Feasibility……cont.

Operational
 What are the resource, capacity, and technical needs developing,
enacting, and implementing the policy?
 How much time is needed for the policy to be implemented, and
enforced?
 How scalable, flexible, and transferable is the policy?
Economic and budgetary impacts

Budget
 What are the costs and benefits associated with the policy, from a
budgetary perspective?
 For public (federal, state, local) and private entities to enact,
implement, and enforce the policy?
Economic and budgetary impacts

Economic
 How do costs compare to benefits (e.g., cost-savings, cost-
effectiveness, cost-benefit analysis, etc.)?
 How are costs and benefits distributed (e.g., for individuals,
businesses, government)?
 What is the timeline for costs and benefits?
Policy analysis table (by CDC)

Criteria Public health Feasibility Feasibility Budgetary Economic

impact (political) (operational) impact impact

Policy 1

Policy 2

Policy 3

Consider gender and other dimensions of equity

Policy for low and middle income
countries

 Many governments in LMICs have identified UHC as a goal and

have named the three dimensions of UHC (i.e., coverage,
financial protection, and access) as ways to measure progress
toward UHC.
 As a result, governments are exploring policy mechanisms to
achieve UHC, with contributory health insurance, provider
payment reforms, and vouchers or fee exemptions taking center
stage in most countries

Reference:
Paul, E., Fecher, F., Meloni, R., & Van Lerberghe, W. (2018). Universal health coverage in Francophone Sub-Saharan Africa: Assessment of global health
experts confidence in policy options. Global Health: Science and Practice, 6(2), 260–271. https://doi.org/10.9745/GHSP-D-18-00001
 Policy for low and
middle income
countries

 To develop a list of common policy reforms

specific for Low- and MiddleIncome
Countries, Paul, Fecher, et al. (2018) for
example, highlighted 18 common reforms
—such as
 Fee exemptions, vouchers, public–private
partnerships, and separation of provider
and purchaser functions—that address
financial barriers to access, improve health
care funding, and improve the supply and
management of services.
Policy for low and middle income
countries

 Policy in LMICs has a significant impact on the trajectory of

development, influencing everything from economic growth to
healthcare, education, governance, and environmental sustainability.
 The right policies can help overcome structural challenges, promote
resilience, and foster a more equitable society.
 However, poorly designed policies or political instability can exacerbate
inequalities and stagnate development.
 Therefore, the formulation and implementation of effective, inclusive,
and forward-thinking policies are crucial for long-term progress in
LMICs.
Policy for low and middle income
countries

 Economic Growth: Effective policies drive economic growth, reduce

poverty, and support SMEs and infrastructure development
 Healthcare: Health policies improve access to care, reduce diseases, and
enhance maternal and child health outcomes.
 Education: Policies that increase access to quality education build human
capital and improve workforce skills.
 Social Protection: Policies like cash transfers reduce inequality and protect
vulnerable populations.
 Gender Equality: Laws addressing gender discrimination empower women
and improve societal well-being.
Policy for low and middle income
countries

 Environmental Sustainability: Climate change adaptation and

natural resource management policies are crucial for long-term
survival.
 Governance: Strong institutions, anti-corruption policies, and
inclusive governance promote political stability.
 Infrastructure: Policies improving transport and energy access boost
economic opportunities and quality of life.
 Urbanization: Affordable housing and smart city policies address
urban growth and improve living conditions.
Lasswell (1956) assumed public policy-
making ought to perform to identify five Policy Cycle
(sometimes six) stages of the policy
process:
(1) agenda setting, which recognises the
problem;
(2) policy formulation, where a solution
is proposed;
(3) decision-making, where the solution
is chosen and legitimised;
(4) implementation, in which the solution
is put into action;
(5) evaluation, or the monitoring of the
results; and in some cases
(6) the choice to either maintain, replace
or terminate the policy.
Stage 1 – agenda setting

Policy cycle
Agenda setting

 Agenda setting is the first in both logical and chronological order: the
government can pass no policy if a problem is not identified in the
first place.
 Agenda setting is concerned with the way policy problems emerge
and how they gain the government’s attention
 Agenda-setting scholars identify three ways through which items can
reach the government’s agenda.
 Firstly, society can learn about problems through objective
indicators.
 Examples are the rate of unemployment, inflation, pollution levels or
criminality.
Agenda setting…..cont.

 These measures may indicate that things are getting worse, and that
action is needed, thus making the issue gain considerable attention.
 Secondly, focusing events – sudden, relatively rare events that
spark media and public attention– are another way to gain policy-
makers’ attention.
 Examples are natural calamities, wars, or scandals. In the wake of
such events, policy-makers may be pushed to provide an immediate
solution, which requires giving heightened attention to the issue.
Agenda setting…..cont.

 Finally, since attention is scarce compared to the number of potential issues, agenda
setting is fundamentally a competition to exercise power and define policy issues to
establish their severity and causes
 Agenda priorities thus create political winners and losers by their very nature.
 As such, for a problem to gain attention, it is important to create compelling stories
that help policy-makers focus their attention to that particular issue (Peterson & Jones,
2016; Stone, 2012).

Reference:
Peterson, H. L., & Jones, M. D. (2016). Making sense of complexity: the narrative policy framework and agenda setting. In Handbook of Public Policy
Agenda Setting. Zahariadis, N. (Ed.). Cheltenham, UK and Northampton, MA: Edward Elgar Publishing, pp. 106-131.
Stages of agenda setting

 Conduct robust situational analysis

 Facilitate ideas and feedback from key stakeholders to
policymakers
 Develop clearly defined problem statements
 Facilitate policymaker access to resources with current
evidence
 Conduct stakeholder analyses
Reference:
Lane, J., Andrews, G., Orange, E., Brezak, A., Tanna, G., Lebese, L., Carter, T., Naidoo, E., Levendal, E. and Katz, A., 2020. Strengthening health
policy development and management systems in low-and middle-income countries: South Africa's approach. Health Policy OPEN, 1, p.100010.
Conduct robust situational analysis

 The goal of a situational analysis is to develop a common

understanding of contextual factors affecting a public health problem.
 These contextual factors can include economic, social, racial,
historical, cultural, political, gender, technological, and institutional
considerations.
 Situational analyses can include both qualitative and quantitative
data.
 The time frame for the situation analysis should examine the current
context and sufficient historical context to identify relevant trends.
 Facilitate ideas and feedback from key
stakeholders to policymakers

 Stakeholders can and should include a wide range of perspectives,

such as health care providers, public health practitioners, patients,
community members, advocates, and researchers.
 Methods could include open consultative forums, surveys, and
interviews.
 This proactive engagement can help improve the diversity of
perspective reflected in the situation analysis and policy formulation.
Develop clearly defined problem
statements

Describe how the problem occurs, how serious it is, and its outcomes
and impacts. Doing this can also help you identify any gaps in the data
you have gathered. The problem statement you develop might include:
Literature Review
 An examination of the current body of research about your policy
problem that can include possible policy options.
 This kind of review may help you identify what is known about the
policy options as well as gaps in the current research.
Develop clearly defined problem
statements

Environmental Scan
 A proactive, systematic collection of information about events,
trends, and expectations of what you might encounter during
the policy process.
 Who is affected?
 How big is the problem?
 What contributes to the problem?
 When and where the problem is most likely to occur?
Example of Problem statement (in a
para)

 Although fewer teens are drinking and driving, this risky behavior is
still a major public health problem in this community. Drinking and
driving among U.S. teens decreased by 50% from 1991-2012.
However, high school teens often still drive after drinking—about 2.4
million times per month. In 2010, 1 in 5 teen drivers involved in fatal
crashes had some alcohol in their systems. Of those drivers, most of
them—about 4 in 5—had blood alcohol concentrations higher than the
legal limit for adults. National, state, and local data show that risk
factors for teen drinking and driving include lower socioeconomic
status (which is associated with not having access to a car), lower
driver education levels, and less access to alcohol.
 Facilitate policymaker access to resources
with current evidence

 These resources could include access to online libraries or systematic

linkages to experts (e.g., researchers, think tanks, or policy research
units within ministries or departments of health).
 Conduct stakeholder analyses

 Ongoing stakeholder analyses are important to identify key interests

at stake, their views of the policy issue and its importance, how
optional policy interventions might align or conflict with those
interests, and whether certain groups may be disproportionately
burdened or benefited by the policy proposal, which may affect the
relative equity of each proposal.
 As policy proposals become increasingly detailed and evolve,
stakeholder analyses often need to be updated.
Stage 2: Policy Formulation
Policy Formulation

 Once the problem has been identified and put on the decision agenda,
the next question to ask is: what is the plan for dealing with the
problem?
 This stage is essentially a matter of policy design: it is about setting
objectives, choosing which course of action to take among the various
options available, and which tools can be employed to address the
problem
 The main job of policy formulation is then to ‘narrow down the range
of all possible options to those that are available and that decision-
makers might accept’
Policy Formulation…..cont.

 At this stage, policy-makers may avail themselves of the opinion of

epistemic communities, stakeholders and interest groups, thus
engaging in what is known as ‘evidence-based policy-making’
 For example, if your policy involves writing a new policy, your
stakeholders will know—usually from past experience—the best
contacts and partners who can help guide your policy through the
appropriate process.
 Because they previously traveled to the same destination and
successfully navigated the same route, you might learn a lot from them.
Stakeholders might also be able to help with timing of the policy.
Stage 3: Decision-making
Decision-making

 Often ministries of health develop a range of different types of policies

with different purposes, including guidelines, strategies, frameworks,
and standard operating procedures.
 Often the content and objectives of these different policy types overlap,
but developing standard definitions will be important for standardizing
structure and review procedures for different policy types
 Although ideally the decision to be made would be optimal and the
result of an ‘evidence-based’ and informed choice, most often decision-
making is a satisficing process, depending on institutional constraints
and political calculations
N.B. Satisficing is a decision-making strategy that aims for a satisfactory or adequate
result, rather than the optimal solution.
 Stage 4: Policy
Implementation
Translate the enacted policy into action, monitor uptake, and ensure full implementation.

 Translate policy into operational practice and define implementation standards

 Implement regulations, guidelines, recommendations, directives and organizational
policies
 Identify indicators and metrics to evaluate implementation and impact of the policy
 Coordinate resources and build capacity of personnel to implement policy
 Assess implementation and ensure compliance with policy
 Support post-implementation sustainability of policy
 Determination of Three levels to
implementation implement policy

 What type of policy is being

proposed? Organizational
 What organization has the
authority to enact that policy? Community
 Who will implement the policy?
 How will the policy be
National/
operationalized?
government
 What is the history behind this
policy?
Political feasibility: Will your policy be
supported?

 What are the current political forces?

 Who are the stakeholders, including those most affected by the
policy?
 What are the potential social, educational, and cultural
perspectives that should be included in policy development?
 What are the potential impacts of the policy on other high-
priority issues?
 Operational feasibility
Can your policy be implemented?

 Who will be involved in developing, enacting and implementing

the policy?
 What resources are needed?
 How much time is needed?
 How scalable, flexible and transferable is the policy?
 When and how to engage the public and community members?
Budgetary impact: Is your policy
affordable?

 How much does it cost?

 Who will bear the costs?
 Are costs distributed equitably?
 Will there be any revenue generated?
Economic impact: Do the outcomes justify
the costs?

 How do costs compare to benefits?

 How are costs and benefits distributed?
 What are the implications for equity and other health sector or social
goals?
 What is the timeline for costs and benefits?
 Are there potential unintended consequences?
Policy analysis table (by CDC)

Criteria Public health Feasibility Feasibility Budgetary Economic

impact (political) (operational) impact impact

Policy 1

Policy 2

Policy 3

Consider gender and other dimensions of equity

Example: Syphilis (by CDC)

Status quo (no services)

 Operational (high)—uses current infrastructure
 Political (high)—no change proposed
 Budgetary (high)—no increase in budget needed
 Economic (low)—current results are poor
Example: Syphilis (by CDC)

Expand availability of Rapid Plasma Reagin testing (RPR;

current method)
 Operational (low)—requires skilled staff, logistics (testing,
notification) and improved follow-up
 Political (low)—budget is a concern to MOH decision-makers
 Budgetary (low)—expensive to upgrade
 Economic (medium)—shown to be less cost effective than Rapid
Syphilis Test (RST)
Example: Syphilis (by CDC)

Use Rapid Syphilis Test

 Operational (medium)—best option based upon many studies;
staff and pregnant women prefer RST over RPR
 Political(high)—growing interest among health workers and
decision-makers
 Budgetary (medium)—cheap relative to RPR
 Economic (high)—has been shown to be effective
Example: Syphilis (by CDC)

Increase treatment completion

 Operational (medium)—testing first, improve follow-up (three doses
better than one), or just treat all without testing (one dose)
 Political (high)—desire to treat people; (low)—treat all
 Budgetary (medium to high)—may require more resources (drugs
and the ability to follow up)
 Economic (medium)—the benefit may not be worth the effort
Example: Syphilis (by CDC)

Improved syphilis test characteristics in clinics

 Operational (high)—know the quality of tests
 Political (high)—growing interest
 Budgetary (medium)—increase quality, increase cost?
 Economic (high)—find more positive, treat fewer negatives
Policy evaluation
Policy evaluation

 Policy evaluation is about assessing the extent to which a policy was

successful
 It is the last and most contentious stage of the policy process for two
reasons.
 First, it is very difficult to answer the question ‘to what degree was the
policy successful?’ since it requires knowing
 whose success is being measured (the government’s? the stakeholders’?
the lobbyists’?),
 what kind of success policy-makers should care (the effect on their
popularity? the completion of their agenda? the long-term impacts?)
Policy evaluation

 Secondly, what is significant at this stage is not so much the success or

failure of the policy, but the ‘lesson-drawing’ aspect for policy-makers.
 Evaluation should be an opportunity for policy-makers to shed light on the
experience of the policies on the ground to understand whether or not the
intended results were achieved and what can be learned for future policies
 At the end of this process, and some time after the policy is enacted,
legislators must decide whether to maintain, replace or terminate it.
 A policy, for instance, may be terminated either because it has achieved its
goals, or because it has been proven to be ineffective
Four Types of Policy Evaluation

 Process Evaluation
 Outcome Evaluation
 Impact Evaluation
 Cost-Benefit Evaluation
Process Evaluation

 Purpose: To assess whether project activities are implemented as

planned.
 When to Use: During the implementation phase of a project.
 Key Characteristics: Focuses on the operational aspects of the
project. Identifies any challenges or deviations from the plan.
 Examples of Use: Used in healthcare programs to ensure that
services are delivered efficiently and consistently.
Outcome Evaluation

 Purpose: To measure the immediate results and effects of the project.

 When to Use: Toward the end or just after project completion
 Key Characteristics: Focuses on short-term changes, such as
behavior or knowledge improvements.
 Examples of Use: Used in social programs to assess improvements in
education, health, or income following a specific intervention.
Impact Evaluation

 Purpose: To assess the long-term effects and changes brought about

by the project.
 When to Use: After a project has been completed (may take years).
 Key Characteristics: Examines causal relationships and the lasting
impacts of the project on participants or the environment.
 Examples of Use: Used in development programs to measure
changes in poverty levels or health outcomes.
Cost-benefit Evaluation

 Purpose: To determine if the outcomes justify the costs of the project.

 When to Use: During or after project completion.
 Key Characteristics: Compares the costs involved with the benefits
achieved.
 Examples of Use: Used by donors or governments to decide whether
to scale up interventions based on their efficiency and impact.