The Process: Policy Development

Process Steps—Issues Framing, Agenda Setting, and Policy Formulation
Once a problem requiring a policy solution has been identified, the process of policy development includes how the problem is framed by various stakeholders (issues framing), which problems make it onto the policymaking agenda, and how the policy (or law) is formulated. Together, these steps, often not conducted in a linear fashion, determine whether a problem or policy proposal is acted on. Activities in policy development include advocacy and policy dialogue by stakeholders and data analysis to support each step of the process.

Issue framing
The way a problem is stated or an issue is framed influences the types of solutions that are proposed. Often, policy stakeholders take different sides of an issue, such as adolescent reproductive health or how to address the problem of teen pregnancy. Some policy stakeholders perceive that teen pregnancy should be addressed through abstinence-only education for young people, while others see the need for comprehensive sex and reproductive health education and access to means of protection against pregnancy and disease. Some might argue that teen pregnancy is not a problem or is a logical response to a given set of health and cultural conditions. Similarly, stakeholders have also taken various views on issues related to reducing maternal mortality. Debates have centered, for example, around the role traditional birth attendants can or cannot play in reducing maternal mortality and whether or not safe motherhood programs should focus primarily on providing emergency obstetric care or on wider components, such as antenatal care and nutrition (Gay et al., 2003).

The HIV/AIDS epidemic has sparked considerable policy debate, with various stakeholders holding different views on the appropriate policy responses. For example, when ARV treatment was becoming more affordable, even in developing countries, some stakeholders contended that prevention should remain the primary programmatic response and that introducing ARVs on a wide scale would not be feasible. Now, as the ARV drugs become more available in developing countries, the role of prevention programs is under debate. Some stakeholders take the view that prevention should focus on reaching those who are already infected, while others consider that working with people not yet infected is still important. Likewise, the policy debate on reducing HIV among intravenous drug users continues. Some stakeholders promote harm reduction strategies, including needle exchange programs, while others favor cracking down on drug users to stop the illegal activity.

Sometimes stakeholders take the same position on an issue, but for very different reasons. The views on China’s population policy are a case in point. Both conservatives and women’s health advocacy groups oppose China’s one-child policy—conservatives contend that the policy promotes abortion and women’s health advocacy groups contend that the policy infringes on women’s rights and choice (Kaufman, 2003).

Issue framing influences stakeholders’ ability of getting the issue on the policymakers’ agenda so that a problem is recognized and policy response is debated. Issue framing often sets the terms for policy debate. “The eventual fate of a policy proposal is also a function of how it is formulated in the first place—how it defines the problems to be attacked and what it offers in the way of policy solutions” (Porter, 1995: 15). Reich cites an example of how the framing of an issue can affect its chances of becoming policy.

[E]fforts to reform the health system in 1996 in the Dominican Republic were designed to transform the state’s role from direct service provider to financer and regulator. Similar approaches were adopted at the time in many Latin American countries, with financial support from the multilateral development banks. In the Dominican Republic, however, the press interpreted these efforts as “privatization” of health services, and the supporters of health reform were unable to create an alternative to public perception of the plan. This perception of the proposed policy created a strong reluctance among both politicians and bureaucrats to support the reform—especially when opposition arose from the powerful medical association and from NGOs active in the health field (Reich, 2002).

Agenda setting
Agenda setting refers to actually getting the “problem” on the formal policy agenda of issues to be addressed by presidents, cabinet members, Parliament, Congress, or ministers of health, finance, education, or other relevant ministries.

Stakeholders outside of government can suggest issues to be addressed by policymakers, but government policymakers must become engaged in the process for a problem to be formally addressed through policy. Government policymaking bodies “can only do so much in its available time period, such as the calendar day, the term of office, or the legislative session. The items which make it to the agenda pass through a competitive selection process, and not all problems will be addressed. Inevitably, some will be neglected, which means that some constituency will be denied. Among the potential agenda items are holdovers from the last time period or a reexamination of policies already implemented which may be failing” (Hayes, 2001).

At any given time, policymakers are paying serious attention to relatively few of all possible issues or problems facing them as national or subnational policymakers. In decentralized systems, sometimes issues are placed on the agenda of various levels of government simultaneously to coordinate policymaking. For example, “reproductive health is on the concurrent legislative list in Nigeria, and, therefore, the three tiers of government, including the states and local governments, are expected to formulate independent policies to guide their programs and service delivery” (POLICY, 2004a).

Altman and Petkus (1994: 42) note that “as problems become salient issues, and as individuals or groups begin to take action, legislators place the problems on the policy agenda.” Starting in the 1950s, it took many years for population issues to reach the policy agenda in many countries; likewise, safe motherhood and HIV have taken time to be accorded space on the policy agenda around the world (UN, 2003; Stover and Johnston, 1999; Starrs, 1998). But with clear issue framing and strong evidence to substantiate the problem, stakeholders have been able to set the critical issue on the policy agenda.

Policy formulation
Policy formulation is the part of the process by which proposed actions are articulated, debated, and drafted into language for a law or policy. Written policies and laws go through many drafts before they are final. Wording that is not acceptable to policymakers key to passing laws or policies is revised. For example, a policy in Jamaica to support providers to serve minors (under the age of consent) went through numerous drafts over a period of two years before it was passed in 2003. The final version of the policy contained more references to promoting abstinence than did the first version. International conference declarations and programs of action also go through iterations during formulation. Leading up to the 1994 ICPD in Cairo, the draft Program of Action contained “bracketed” text that required negotiation and policy dialogue among stakeholders from around the world in order for the final document to be ratified.

Policy formulation includes setting goals and outcomes of the policy or policies (Isaacs and Irvin, 1991; Health Canada, 2003). The goals and objectives may be general or narrow but should articulate the relevant activities and indicators by which they will be achieved and measured. The goals of a policy could include, for example, the creation of greater employment opportunities, improved health status, or increased access to reproductive health services. Policy outcomes could include ensuring access to ARV treatment for HIV in the workplace or access to emergency obstetric care for pregnant women. Goals and outcomes can be assessed through a number of lenses, including gender and equity considerations. Activities Related to the Process—Advocacy, Policy Dialogue, and Data Analysis While issues framing, agenda setting, and policy formulation are stages that policies go through, each of these stages can include a number of activities, namely advocacy, policy dialogue, and analysis of evidence related to the problem and policy responses.

Advocacy and policy dialogue.
Preferably drawing on the participation by a range of stakeholders, advocacy and policy dialogue are used to convince policymakers to address a problem, debate various solutions, and decide on specific policy actions. Advocacy is more likely to succeed if networks of organizations and individuals join forces to address issues that require policy action and organize advocacy campaigns. Networking for Policy Change (POLICY, 1999), an advocacy training manual, provides details about the role of networks and advocacy in bringing about change. Stories from people and organizations involved in advocacy for HIV (e.g., women’s groups, PLHAs, and faith-based organizations) highlight some key advocacy successes in HIV/AIDS in Africa, Latin America, and Asia (POLICY Project, 2003).

The media can also play an influential role in advocacy and policy dialogue by highlighting issues that need to be addressed or bringing public discourse to issues already on the agenda (Altman and Petkus, 1994). The media often provides symbolic understandings of policy issues and also serve as gatekeepers, deciding which issues will receive public attention and which will not (Porter, 1995).

Both advocacy and policy dialogue are important for policy. In advocacy, stakeholders promote issues and their positions on the issues. Policy dialogue involves discussions among stakeholders to raise issues, share perspectives, find common ground, and to reach agreement or consensus, if possible, on policy solutions. Policy dialogue takes place among policymakers, advocates, other nongovernmental stakeholders, other politicians, and beneficiaries (see VSI, 2002, for a code of good practice on policy dialogue between the government and civil society).

Data analysis
Data analysis in the process component of the Policy Circle is more complex than in problem identification because policymakers weigh their decisions on a number of criteria. Data analysis expands from the technical aspects of an issue and focuses on the political costs and benefits of policy reform. Thomas and Grindle (1994) posit that policymakers tend to make their decisions based on a number of criteria, including: 1) the technical merits of the issue; 2) the potential affects of the policy on political relationships within the bureaucracy and between groups in government and their beneficiaries; 3) the potential impact of the policy change on the regime’s stability and support; 4) the perceived severity of the problem and whether or not the government is in crisis; and 5) pressure, support, or opposition from international aid agencies.