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    Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy and Planning 2008;23:308–317
    ß The Author 2008; all rights reserved.
    ‘Doing’ health policy analysis: methodological
    and conceptual reflections and challenges
    Gill Walt,1* Jeremy Shiffman,2 Helen Schneider,3 Susan F Murray,4 Ruairi Brugha5
    and Lucy Gilson3,6,7
    22 June 2008
    The case for undertaking policy analysis has been made by a number of scholars
    and practitioners. However, there has been much less attention given to how to
    do policy analysis, what research designs, theories or methods best inform policy
    analysis. This paper begins by looking at the health policy environment, and
    some of the challenges to researching this highly complex phenomenon. It
    focuses on research in middle and low income countries, drawing on some of
    the frameworks and theories, methodologies and designs that can be used in
    health policy analysis, giving examples from recent studies. The implications of
    case studies and of temporality in research design are explored. Attention is
    drawn to the roles of the policy researcher and the importance of reflexivity and
    researcher positionality in the research process. The final section explores ways
    of advancing the field of health policy analysis with recommendations on theory,
    methodology and researcher reflexivity.
    Policy analysis, methodology, process, health policy
    Little guidance exists on how to do health policy analysis, concerning low and middle income countries. This paper
    explores ways of developing this field.
    To advance health policy analysis, researchers will need to use existing frameworks and theories of the public policy
    process more extensively, make research design an explicit concern in their studies, and pay greater attention to how
    their own power and positions influence the knowledge they generate.
    Health policy analysis is a multi-disciplinary approach to public
    policy that aims to explain the interaction between institutions,
    interests and ideas in the policy process. It is useful both
    Health Policy Unit, London School of Hygiene and Tropical Medicine, UK.
    Maxwell School of Citizenship and Public Affairs, Syracuse University,
    Syracuse, NY, USA.
    Centre for Health Policy, University of the Witwatersrand, Johannesburg,
    South Africa.
    King’s College London, UK.
    Department of Epidemiology, Royal College of Surgeons in Ireland, Dublin,
    Health Economics and Financing Programme, London School of Hygiene
    and Tropical Medicine, UK.
    School of Public Health and Family Medicine, University of Cape Town,
    South Africa.
    * Corresponding author. Health Policy Unit, London School of Hygiene and
    Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
    retrospectively and prospectively, to understand past policy
    failures and successes and to plan for future policy implementation. The case for undertaking policy analysis has been made
    by a number of scholars (Parsons 1995) and 15 years ago, in
    this journal, Walt and Gilson (1994) argued it was central to
    health reforms. However, there has been much less attention
    given to how to do policy analysis, what research designs,
    theories or methods best inform policy analysis. Reich and
    Cooper (1996) designed and have updated a software tool to
    help researchers and policy-makers analyse the political
    dimensions of public policies. Others, such as Varvasovszky
    and Brugha (2000), have designed guidelines for undertaking
    stakeholder analysis, as a part of health policy analysis. Bossert
    (1998) developed an approach to analyse choices for the
    decentralization of health sectors. Sabatier (1999, 2007) has
    explored different theoretical frameworks of the policy process
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    (although not focusing on health). However, it is rare to find
    any scholarly work that explicitly explores the methodological
    challenges for researchers studying the health policy process.
    This paper takes off from the conclusions drawn in the literature
    review by Gilson and Raphaely (2008, this issue), which identifies
    some of the gaps and weaknesses in the field of health policy
    analysis in low and middle income countries. The review notes the
    absence of explicit conceptual frameworks, little detail on
    research design and methodology, and a preponderance of
    single case studies on particular issues. It draws attention to the
    limited use of relevant theory to underpin analysis and the paucity
    of attempts to provide an explicit, explanatory focus. As the
    authors say, the main question is often ‘what happened’, to the
    neglect of ‘what explains what happened’. Researchers also rarely
    reflect on how their own positions shape their research
    interpretations and conclusions.
    In this paper, we tackle some of these issues, looking at some
    of the reasons for the above deficiencies identified in the Gilson
    and Raphaely review, and make some suggestions for advancing the field.
    First, to put the paper in context we begin by looking at the
    health policy environment, and some of the challenges to
    researching this highly complex phenomenon. Second, we argue
    for more attention to theory and frameworks and we consider the
    theoretical constructs often utilized in health policy studies. From
    there we move to methodology and study design, exploring the
    implications of case study research and temporality for health
    policy analysis; and then discuss the roles of the policy researcher,
    the importance of reflexivity and researcher positionality in the
    research process. The final section explores ways of advancing the
    field of health policy analysis.
    The nature of the beast: the health
    policy environment
    It is important to contextualize the health policy environment
    in order to understand the challenges to methodology and
    theory. While drawing on ideas and concepts from general
    policy analysis, most of which is derived from studies on high
    income countries, this paper focuses on health policy, and on
    low and middle income countries. Much of the theory from policy
    analysis in high income countries has resonance for health and
    developing countries, and can usefully inform research in those
    areas. However, transferring such concepts needs to be undertaken with caution. It is generally fair to say that the health
    sector has specific characteristics which affect the policy
    environment (and that differentiate it from other social
    sectors). The state may be both provider and purchaser of
    services, but also is involved in regulation, research and
    training among other functions. In service provision, it may
    be in competition or partnership with a private sector that it is
    also regulating. In undertaking its health care purchasing and
    regulatory functions, the state is usually heavily reliant on—
    and may lack—essential information that can only be provided
    by the sectors it is over-seeing. Information asymmetry is often
    a bigger problem than with the other social sectors. Health
    issues are often high profile and demand public responses.
    Health interests, ranging from professionals to the pharmaceutical industry, have traditionally been perceived to influence the
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    policy process significantly. They are uniquely placed to do so
    because of their knowledge, technology, access to political
    processes and stake in life and death issues.
    However, while these characteristics are generally typical, all
    scholars point out that they have to be contextualized in both
    place and time. Health policy environments in middle and high
    income countries will therefore differ from those in low income
    countries, where, for example, there are weaker regulations,
    regulatory capacity and monitoring systems; lack of purchasing
    power as a leverage to influence types and quality of services
    delivered; more patronage in political systems, and more reliance
    on external donor funds, among many other differences.
    In spite of differences between high and low income countries,
    however, it is increasingly recognized that policy processes are
    changing everywhere. Initially policy analysis focused on the
    state—on the public or government sector—on politicians,
    bureaucrats and interest groups (Hogwood and Gunn 1984;
    Grindle and Thomas 1991). Over the past 10 years scholars have
    acknowledged a shift in the nature of policy and policy-making,
    which points to the involvement of a much larger array of actors in
    the policy process (Buse et al. 2005). The private sector, for
    example, including for-profit and not-for-profit organizations,
    large and small, has become an important player in health policy.
    Partnerships between public and private sectors have also
    changed the health policy environment. Furthermore, policy is
    increasingly shaped and influenced by forces (such as global civil
    society) outside state boundaries (Keck and Sikkink 1998). The
    growing literature around issues of globalization which emphasize changing spatial, temporal and cognitive dimensions (Lee
    et al. 2002) reflects the extent to which the world is perceived to
    have altered. There is less geographical distance between regions,
    exchanges have become faster, ideas and perceptions spread
    rapidly through global communications and culture.
    This means that the policy environment is increasingly
    populated by complex cross-border, inter-organizational and
    network relationships, with policies influenced by global decisions as well as by domestic actions. The technological revolution
    has facilitated communications and relationships, both between
    governments and their advisers as well as between many different
    networks of actors outside of government. While government and
    its hierarchical institutions remain important, all policy analysis
    must also take into account a range of open-ended, more ad hoc
    arrangements which increasingly affect decision-making. Hajer
    and Wagenaar (2003, p. 8) talk about ‘new spaces of politics’
    where there are ‘concrete challenges to the practices of policymaking and politics coming from below’. In their view, policy
    analysis has to become more deliberative: less top-down, involving
    expanded networks, and more interpretative, taking into account
    people’s stories, their understandings, values and beliefs as
    expressed through language and behaviour.
    Challenges for ‘doing’ health policy
    These changes in the policy environment make the analysis of
    policy even more complex but there are conceptual and practical
    problems that are specific to ‘doing’ health policy analysis.
    The first challenge is that ‘policy’ can itself be defined
    in many different ways, with consequent implications for
    its study. It can be useful to think of health policy as embracing
    ‘courses of action (and inaction) that affect the set of
    institutions, organizations, services and funding arrangements
    of the health system’ (Buse et al. 2005, p. 6). Such policy may
    therefore be made within government, by non-government
    actors, and by organizations external to the health system.
    However, such processes of ‘making’ policy are not necessarily
    overt or clearly bounded. The ways in which decisions ‘emerge’
    rather than taking place at a single point in time, and which
    are often unobservable to the researcher, can be particularly
    difficult to unpack and explain (Exworthy 2007). On the
    practical level, there are often many hurdles to accessing the
    many different, geographically widespread, actors, individuals,
    groups and networks involved in policy processes. Decisionmaking processes are often opaque, and obtaining relevant
    documents and papers can be problematic. Or, in contrast, an
    excess of information—where background documentation such
    as large volumes of email exchanges become available—can be
    burdensome and difficult to analyse. Participant observation
    can be difficult in practice.
    There is also often a tension between the long-term nature of
    policy development and implementation and the short-term
    nature both of funding for policy research and of policy-makers’
    demands for quick answers and remedies. Box 1 provides an
    example of some of these tensions. Hunter (2003) has called
    this the ‘curse of the temporal challenge’. Much health policy
    research is motivated (and attracts funding) by practical
    concerns such as the evaluation of existing programmes, and
    policy analysts are expected to deliver easily implementable
    recommendations within relatively short time horizons. The
    imperatives of quick policy ‘fixes’ may lead to reductionism.
    There are also many other conceptual challenges to ‘doing’
    policy analysis. For example, capturing and measuring levels of
    resources, values, beliefs and power of diverse actors is difficult;
    also, the notion of ‘power’—fundamental to policy analysis—is
    a highly contested concept. Yet it is often used as if there were
    little difficulty in agreeing what power is, where it lies, and
    how it is exercised. It can also be difficult to ‘tell the story’,
    without getting immersed in detail. Researchers have to find
    ways of organizing their analysis so that it provides a lens that
    represents but also explains a highly complex environment. As
    Gilson and Raphaely (2007) have shown, most health policy
    analysis is relatively intuitive, ad hoc, and the assumptions on
    which it is based are seldom identified.
    In this paper we argue that the field of health policy analysis
    would be advanced if researchers approached it more systematically, developing clear and testable propositions about the issue
    they are studying, within explicit frameworks. Scholars have
    proposed a number of different theoretical frameworks to help
    researchers organize and focus their efforts to analyse the policymaking process. In the next section we look at some of these.
    Approaches to health policy analysis:
    frameworks and theories
    There are a number of widely used frameworks and theories of
    the public policy process.1 We discuss some of the more
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    enduring examples; those which have been utilized most in the
    published public policy literature (Gilson and Raphaely 2007).
    Frameworks organize inquiry by identifying elements and
    relationships among elements that need to be considered for
    theory generation (Ostrom 2007). They do not, of themselves,
    explain or predict behaviour and outcomes (Schlager 2007). The
    best known public policy framework is the stages heuristic
    (Lasswell 1956; Brewer and deLeon 1983). It divides the public
    policy process into four stages: agenda setting, formulation,
    implementation, and evaluation. Agenda setting is the issue
    sorting stage during which a small number of the many
    problems societies face rise to the attention of decision-makers.
    In the formulation stage, legislatures and other decisionmaking bodies design and enact policies. In the implementation
    stage, governments carry out these policies, and in the
    evaluation stage impact is assessed. Analysts have criticized
    the stages heuristic for presuming a linearity to the public
    policy process that does not exist in reality, for postulating neat
    demarcations between stages that are blurred in practice, and
    for offering no propositions on causality (Sabatier 2007).
    Nevertheless, the heuristic offers a useful and simple way of
    thinking about the entire public policy process, and helps
    researchers situate their research within a wider framework.
    Walt and Gilson (1994) developed a policy analysis framework specifically for health, although its relevance extends
    beyond this sector. They noted that health policy research
    focused largely on the content of policy, neglecting actors,
    context and processes. Their policy triangle framework is
    grounded in a political economy perspective, and considers how
    all four of these elements interact to shape policy-making. The
    framework has influenced health policy research in a diverse
    array of countries, and has been used to analyse a large number
    of health issues, including mental health, health sector reform,
    tuberculosis, reproductive health and antenatal syphilis control
    (Gilson and Raphaely 2007).
    As the number of actors involved in policy processes has
    expanded, so has interest in network frameworks. Seen
    largely as a tool for describing systems of interactions and
    interconnectedness between groups of actors, network analysis
    is a contested area, and there are many definitions of what a
    network is (Thatcher 1998). Most agree, however, that networks are clusters of actors linked together, who may be closely
    connected or loosely structured but are still capable of engaging
    in collective action. Policy networks are clusters of actors with
    interests in a given policy sector, and the capacity to help
    determine policy success or failure (Marsh 1998). There are
    many different ways of classifying networks. Marsh and
    Rhodes (1992) treat policy networks as a generic term, with
    policy communities at one end of a continuum and issue
    networks at the other. Policy communities are tight-knit
    networks with few participants who share basic values and
    share resources. There may be a strong inner or dominant core
    of actors, surrounded by a number of other, more peripheral
    members, all of whom make up a policy community. An issue
    network, on the other hand, brings together many different
    groups and individuals for a common purpose or cause, and
    may have little continuity in values or participation. Network
    analysis reflects the phenomenon of shared decision-making
    and exchange of resources to achieve their goals.
    Box 1 Applying health policy analysis in a fast moving policy environment
    Brugha et al. (2002, 2004) have conducted a number of studies on global health initiatives such as the GAVI Alliance and the
    Global Fund to Fight AIDS, Tuberculosis and Malaria. Designed to gather and report the views of national-level stakeholders
    at very early stages in their implementation, the studies were sensitive. For the Global Fund, in particular, the research was
    perceived as premature, enabling country stakeholders to articulate criticisms, which it feared would have a deleterious affect
    on the need to raise significantly greater funds globally. The Global Fund Secretariat in Geneva requested that the scope of
    the study be widened to report its perspective, which was beyond the capacity and resources available to the researchers. In
    both studies, under pressure from funding agencies, the researchers reported findings within 9 months. The researchers
    resisted pressure from the Global Fund Secretariat to report interim findings to the Fund in late 2003, in advance of
    reporting back to country stakeholders.
    The policy environment was very fluid, and the researchers found they were tracking a moving target—one where the
    Global Fund itself was responding to difficulties, changing guidelines, and proving to be a ‘learning organization’. Despite
    what the researchers viewed as rapid feedback of findings, given the need for rigour, the study funders and the Global Fund
    responded that the findings only confirmed what they had already learned through their own channels; and that these
    findings were being superseded by events. The study also found that the donor landscape had become even more complex by
    the time of the second phase of data collection (2004), because of the negotiation or establishment of other new HIV/AIDS
    financing instruments at the country level, such as the World Bank Multicountry AIDS Program and the US President’s
    Emergency Plan for AIDS Relief (PEPFAR). New sources of funds were being negotiated sequentially or in parallel, which
    was distracting countries from implementation.
    The dynamic nature of the policy environment made data collection and analysis difficult, and created sensitivities
    between the global initiatives, research funders and the researchers. One lesson was that maintaining a balance between
    independence and engagement with the entity being studied is difficult but key; building trust is essential if findings are to
    be taken on board.
    There is a debate among scholars as to whether the concept of
    networks is merely descriptive, or whether it has explanatory
    value, whether it is largely a Western concept, developed
    by looking at policy-making in the US and UK, and whether it
    has legitimacy for developing countries (Thatcher 1998). For
    some the network approach is not really a new analytical
    perspective, but signals rather a change in the policy environment and the political system. There are only a few empirical
    studies in health in developing countries which use network
    analysis as a lens (Schneider 2006; Tantivess and Walt 2008).
    Explicit attention to theory development could benefit public
    policy practice by deepening our understanding of causality,
    and by bringing coherence to a fragmented body of knowledge.
    This does not imply a positivist approach to analysis, but a
    more thoughtful conceptualization of the policy process, that
    goes beyond ‘telling the story’.
    Influential theories of the public policy process include
    multiple-streams (Kingdon 1984), punctuated-equilibrium
    (Baumgartner and Jones 1993) and top-down and bottom-up
    implementation (Sabatier 1999). Theories are more specific
    than frameworks, and postulate precise relationships among
    variables that can be tested or evaluated empirically. Kingdon
    (1984), whose multiple-streams theory is concerned with
    agenda setting, argues that the public policy process has a
    random character, with problems, policies and politics flowing
    along in independent streams. The problems stream contains
    the broad problems and conditions facing societies, some of
    which become identified as issues that require public attention.
    The policy stream refers to the set of policy alternatives that
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    researchers and others propose to address national problems.
    This stream contains ideas and technical proposals on how
    problems may be solved. Political transitions, national mood
    and social pressure are among the constituent elements of the
    politics stream. At particular junctures the streams merge, and
    in their confluence windows of opportunity emerge and
    governments decide to act.
    Several health policy scholars have adapted ideas from
    Kingdon’s theory to explain how particular health issues have
    emerged on policy agendas. Reich (1995) identified additional
    elements that fed into the politics stream—organizational,
    symbolic, economic, scientific and politician politics—all of
    which favoured child over adult health through the 1990s,
    explaining the higher position of the former on the international health agenda. Ogden et al. (2003) also drew on
    Kingdon’s ideas in their research on tuberculosis. They
    demonstrated that the emergence of the HIV/AIDS epidemic
    contributed to the opening of global policy windows, facilitating
    advocacy networks to promote DOTS (directly observed
    treatment, short-course) as a treatment of choice for
    Baumgartner and Jones’ (1993) punctuated equilibrium
    theory postulates that the policy-making process is characterized by periods of stability with minimal or incremental policy
    change, disrupted by bursts of rapid transformation. Central to
    their theory are the concepts of the policy image and the policy
    venue. The policy image is the way in which a given problem
    and set of solutions are conceptualized. One image may
    predominate over a long period of time, but may be challenged
    at particular moments as new understandings of the problem
    and alternatives come to the fore. The policy venue is the set
    of actors or institutions that make decisions concerning
    a particular set of issues. These actors may hold monopoly
    power but will eventually face competition as new actors
    with alternative policy images gain prominence. When a
    particular policy venue and image hold sway over an extended
    period of time, the policy process will be stable and
    incremental. When new actors and images emerge, rapid
    bursts of change are possible. Thus, the policy process is
    constituted both by stability and change, rather than one or the
    other alone
    Shiffman et al. (2002) examined the emergence of global
    political attention for the control of tuberculosis, malaria and
    polio, finding that patterns conformed to punctuated rather
    than rational or incremental models of the policy process.
    Baumgartner and Jones themselves apply the theory to a health
    concern. They show that little changed in US tobacco policy
    in the first half of the 20th century, as the subject generated
    little coverage in the US media, government supported
    the industry through agricultural subsidies, and the product
    was seen positively as an important engine for economic
    growth. Beginning in the 1960s, however, health officials
    mobilized, health warnings came to dominate media coverage,
    and the industry was unable to counter a rapid shift in the
    policy image that focused on the adverse effects of tobacco on
    Multiple implementation theories have been dominated by
    a discourse as to whether decision-making is top-down or
    bottom-up, or a synthesis of the two (Sabatier 1999). For
    example, Dye (2001) argues that even in a democracy like the
    United States, public policy is made from the top down, not
    from the bottom up. In his view, public policy reflects the
    values, interests and preferences of the governing elite. Dye
    separates policy development from implementation, admitting
    that bureaucrats may affect policy in implementation, but
    suggesting that all decisions are monitored to ensure they are
    not altered significantly. Lipsky (1980), on the other hand,
    describes implementation of policy as highly influenced by
    ‘street level bureaucrats’—front-line staff who can change
    policies significantly—and others have developed this approach
    (e.g. Hjern and Porter 1981). Much of the literature focuses on
    the gap or deficit between policy objectives and actual
    implementation (Hill and Hupe 2002). Saetren (2005) reviewed
    all implementation literature published and concluded that
    while most of the studies focused on health and education,
    they were predominantly of high income, Western countries.
    There are a few notable exceptions (Kaler and Watkins 2001;
    Kamuzora and Gilson 2007).
    Researchers have also applied a range of social science theory
    from outside of policy studies to health policy analysis, drawing
    these from disciplines such as sociology, anthropology and
    organizational management (Gilson and Raphaely 2007).
    Murray (2007), for instance, in the example given in Box 2
    draws on sociological theory concerning consumption to
    understand the impact of private medical service financing
    mechanisms on maternity care in Chile. Others have used social
    construction theories to explore why public policies sometimes
    fail in their objectives. Ingram et al. (2007), for example, focus
    on how public policy-makers may construct target populations
    positively or negatively, leading to unfair distribution of
    resources that perpetuate health inequalities.
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    Designing health policy studies:
    Few health policy analyses on low and middle income countries
    explicitly discuss research design, and the field would benefit
    from more reflection on the range of approaches that could be
    used, and their relative benefits. Most investigations are case
    studies, whether or not researchers identify them as such
    (Gilson and Raphaely 2007). Policy decisions often have their
    roots in longer term processes and the choice of time frames for
    research is an important factor. Temporal issues thus also affect
    research design. Addressing these factors is an important aspect
    of research design.
    Research design: case studies
    Case studies are in-depth investigations of a single instance of a
    phenomenon in its real-life context (Yin 1994). They are to be
    distinguished from other research designs, such as controlled
    comparisons, formal modelling, quantitative analyses and
    randomized-controlled experiments. A substantial body of
    work offers guidance on case study methodology (Yin 1994;
    Brady and Collier 2004; George and Bennett 2004; McKeown
    2004; Yin 2004).
    Case study methodologists argue that asking just a few basic
    questions about the case can improve the value of the study
    considerably. First, what is it a case of (George and Bennett
    2004)? Is it, say, an example of health policy implementation
    failure, of effective transfer of a health policy from one country
    to another, of health policy network influence on agenda
    setting, of the influence of political factors on health policy
    evaluation? Sometimes cases may be clearly identifiable by the
    researcher at the start of the study, sometimes they may be
    constructed or re-constructed during the course of the research
    as the analysis reveals their defining characteristics (Ragin and
    Becker 1992). The process of clarifying ‘the case’ enables the
    researcher to specify a body of knowledge to which he or she
    may make a contribution. Second, why is this case a useful one
    to study (George and Bennett 2004)? Does it offer the
    possibility of comparing the explanatory value of alternative
    theories? Is it an unusual example of policy effectiveness,
    potentially offering insight into factors that facilitate policy
    impact? It is consideration of these issues that help the
    researcher to select the tools and theories that might frame a
    study, and to determine which methods will be used.
    A study on the global availability of praziquantel, a drug for the
    tropical disease schistosomiasis, offers clear answers to both
    questions (Reich and Govindaraj 1998). The researchers document how the discovery of this effective drug did not automatically result in it reaching the poor in developing countries.
    They identify this as a case of the gap between drug development
    and drug availability for the poor—an issue of concern for many
    tropical disease pharmaceuticals—and highlight the usefulness of
    this case in revealing the influence of political and economic
    factors on this gap. Their careful case selection and classification
    enable them to suggest a set of policy prescriptions on
    surmounting the drug development–availability gap, recommendations that apply well beyond the case itself.
    Another means of facilitating generalization is increasing the
    number of cases. Doing so is not always easy, since
    Box 2 Applying theory from the sociology of consumption in a longer term retrospective policy analysis to maternity care in
    Chile in the 1980s and 1990s (Murray and Elston 2005; Murray 2007)
    This study was initiated after the Chilean Minister for Women’s Health Services expressed concerns over rising national rates
    of caesarean section delivery (37% of births in the mid-1990s), and a preliminary analysis of health fund statistics revealed
    that caesarean section rates were twice as high in women who had private health insurance plans than in women who were
    receiving delivery care financed through the National Health Fund (59%:28.8% in 1994; Murray and Serani 1997).
    In order to understand this problem, the study examined healthcare financing decisions in the 1980s through to experience
    of care up to the present. The analysis was informed by theory from the sociology of consumption. Healthcare services for
    pregnancy were conceptualized as a complex good that is produced and consumed in a production/consumption ‘cycle’ (Edgell et al.
    1996). The cycle has four dimensions: mode of provision, the conditions of access, the manner of delivery and the experience of
    consumption. Implicit to such an approach is an emphasis on social processes situated in time and place. Data to inform the
    analysis included documentation relating to national policy change, trends data from health services and insurance funds,
    and interviews with policy-makers and administrators. In-depth interviews with health practitioners and service users
    investigated patients’ and practitioners’ perspectives on the structure, process, delivery and consumption of maternity care. A
    postnatal questionnaire and medical notes review provided quantifiable detail on medical care practices and on women’s
    perceptions of them. In an approach similar to that employed in framework analysis (Pope et al. 2000), a series of general
    and then increasingly more specific questions were elaborated, enabling testing of alternative explanations of phenomena.
    The findings traced how neoliberal financial reforms initiated at the beginning of the 1980s under a military dictatorship
    which aimed to reduce fiscal support for health care had led to the roll out of private health insurance organizations and new
    patterns of organization of medical care. These ultimately resulted in changes in service delivery and the experience of
    consumption (including the programming of births so that obstetricians could manage fragmented work schedules, and users
    could avoid payment of unsocial hours fees) which led to high rates of caesarean delivery. Using the consumption cycle
    framework helped to understand the interface between macro, meso and micro levels over time, and the relationship
    between the policy and its healthcare outcomes.
    investigating even a single case is a time and resource intensive
    process that requires careful consideration of historical and
    contextual influences. Comparative case studies may introduce
    the further challenges of working across multiple languages
    and cultures. It can also be difficult to find sufficient funds for
    undertaking such research. Yet there are several strong
    examples in the health policy field.
    Lee et al. (1998) used matched country comparisons to
    investigate factors influencing the development of strong national
    family planning programmes. They conducted four country
    comparisons: Bangladesh/Pakistan, Tunisia/Algeria, Zimbabwe/
    Zambia and Thailand/Philippines. Each pair was matched on
    socio-economic characteristics, but differed on the strength of the
    family planning programme. The comparisons enabled the
    researchers to point to three factors that shaped the development
    of effective programmes: the formation of coalitions among policy
    elites, the spread of policy risk, and the country’s financial and
    institutional stability. Walt et al. (1999) considered individual
    cases of donor aid coordination in the aid-dependent countries of
    Bangladesh, Cambodia, Mozambique, South Africa and Zambia to
    develop generalizations concerning the origins and effectiveness
    of aid coordination mechanisms. Shiffman (2007) explored
    agenda-setting for maternal mortality reduction in five countries:
    Guatemala, Honduras, India, Indonesia and Nigeria. He identified
    nine factors that shaped the degree to which this issue emerged as
    a political priority. He found that while international donors
    played a role, even more critical were efforts by national
    Collectively, these different examples highlight the value of
    cross-country comparative study approaches, where comparisons
    between similar (and different) country contexts can help
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    disentangle generalizable from country context-specific effects
    in policy adaptation, evolution and implementation. Comparisons
    can be incorporated into study design, ad-hoc, as in the case of Lee
    et al. (1998) above; researchers can select as case studies several
    countries with a shared feature (Brugha et al. 2005), see Box 1; or
    comparison can be made post-hoc, as in the case of Walt et al.
    (1999). Clearly, multi-country studies are more time and resource
    Research design: temporal issues
    The extent to which policy analyses are focused on contemporary
    policy, or are retrospective and take a longer view of policy
    development, will have implications for methods and for the
    questions that are asked. Short horizon approaches are sometimes
    appropriate and necessary for responsiveness in some fast moving
    political circumstances; for example, work on the global health
    funds that was conducted early in their implementation (see
    Box 1). Concurrent or ‘prospective’ analysis of policy processes
    may be utilized in order to support and manage policy change, and
    this approach is explored in some detail in a companion paper
    (Buse 2008, this issue). Stakeholder analyses that focus on
    position, power, players and perception (Roberts et al. 2004) are
    often central to this type of work.
    Policy evaluation requires a longer timeframe than political
    exigencies often allow. Sabatier suggests that ‘a decade or more’ is
    the minimum duration of most policy cycles, from emergence of
    the problem through sufficient experience with implementation
    to render a ‘reasonably fair evaluation’ of impact (Sabatier 2007,
    p. 3). A long span of study of the policy process may well be needed
    to identify unintended and unexpected consequences of policy.
    For example, a study may be triggered by concern over a
    controversial health care outcome, or an observed inequity of
    delivery or access, and not by a particular ‘policy event’ itself.
    Longer-term analysis or ‘backward working’ from a trigger
    statistic or social phenomenon may be necessary to reconstruct
    a policy implementation trajectory. This will entail mapping out
    its social and historical context, and how the policy unfolded over
    time in order to understand its eventual impact.
    Such longer-term retrospective studies throw up particular
    challenges for data collection and analysis, including recall bias.
    In the case outlined in Box 2, the legislation introducing private
    health insurance structure to Chile was passed in 1981, the
    primary data collection interviews with practitioners and users
    took place 14 to 16 years later and trends analysis continued for
    some years after that. There is no simple way of knowing when
    is the ‘best’ time to initiate such work. In this particular case
    the impetus was a concern over rising caesarean section rates
    within the Ministry of Health, which in turn had been
    influenced by international debates. Multiple corroborative
    sources of different kinds (qualitative and quantitative)
    become particularly important, including different generational
    perspectives from interviews.
    Positionality and health policy analysis
    One of the issues facing health policy analysts is how they are
    viewed or ‘situated’ as researchers, their institutional base,
    perceived legitimacy, and prior involvement in policy communities. This is critical to their ability to access the policy
    environment and conduct meaningful research, especially in
    policy analyses that require engaging with policy elites
    (Shiffman 2007), and when investigating sensitive issues of
    ‘high politics’ (Box 1). Yet in contrast to other disciplines in the
    social sciences (e.g. Lincoln 1995; Rose 1997), the policy
    analysis literature seldom explicitly discusses researcher ‘positionality’ and its possible impact on the research process.
    With respect to positionality, the classic distinction often
    made is between ‘insiders’ and ‘outsiders’, where insiders may
    be both participants and researchers (participant-observers) of
    the policy process, or alternatively, country-based rather than
    foreign researchers. Class, caste, gender, age, ethnicity and
    profession may also be highly relevant to insider/outsider status
    in some health policy research contexts. In seeking to unravel
    complex policy dynamics, insiders may see things quite
    differently to outsiders, with implications for the data collected
    and the interpretation of research findings. As explained by
    Merriam et al. (2001, p. 411), ‘. . . being an insider means easy
    access, the ability to ask more meaningful questions and read
    non-verbal cues, and most importantly, to be able to project a
    more truthful, authentic understanding of the culture under
    study. On the other hand, insiders have been accused of being
    inherently biased . . . the outsider’s advantage lies in curiosity
    with the unfamiliar, the ability to ask taboo questions, and
    being seen as non-aligned with sub-groups.’ In the study cited
    in Box 2, an ‘outsider’ interviewer was found to be particularly
    useful for persuading the interviewees to give fuller explanations than they might otherwise have felt necessary.
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    Policy research teams that combine both insiders and outsiders
    and that engage all team members in active discussions of
    findings during data collection and analysis may therefore yield
    the richest and most comprehensive understanding of the policy
    process (as proposed by Buse 2008, this issue). However,
    implementation of such a model is not easy. While policy research
    designs may recognize the value of this team approach, the reality
    is that policy analysis is only emerging and has yet to establish its
    legitimacy as a field within developing countries, ‘insider’ policy
    researchers are hard to recruit and ‘outsider’ researchers may be
    expensive and time-constrained.
    Researcher positionality has implications not only for access to
    data but also for knowledge construction. Research may be based
    on externally imposed categories and constructs. Parkhurst
    (2002), for example, argues that explanations of the decline in
    HIV prevalence in Uganda were driven at first by the need to hold
    up a success story on HIV in Africa, leading to an overly simplified
    analysis of both the extent and the ingredients of this success by
    UN and donor agencies. Short timeframe policy research initiated
    in response to external political imperatives runs a real risk of
    superficial and decontextualized analyses of the policy process
    that reveal only part of the picture.
    ‘Position’ can influence the issues that researchers focus on and
    therefore the research agendas created and the research questions asked. Scholars have noted that positionality is tied to
    questions of power and resistance, and in the context of health
    policy research the North/South dynamics need to be acknowledged. Tensions can occur between northern researchers who
    have the funds, and southern researchers who have insider
    knowledge and understanding. As Staeheli and Lawson (1995,
    p. 332) point out, ‘. . . researchers cannot escape the power
    relations even when they wish to do so. Western researchers are
    in a position of power by virtue of being able to name the
    categories, control information about the research agenda, define
    interventions and come and go as research scientists.’
    National policy researchers, for their part, tend to be invested in
    their policy environments in some way, even if they operate from
    an independent research base or are not involved in the specific
    policy process under investigation. Researchers linked to particular policy environments will naturally be inclined to focus on
    specific and contemporary features of the particular policy space,
    rather than more universal themes that cut across policy or
    country contexts. They may also be more concerned with developing policy relevant conclusions than new theoretical or methodological understanding. Over time, such researchers will
    typically move in and out of various policy networks: sometimes
    directly implicated in policy communities, other times more
    loosely as part of issue networks or epistemic communities (Haas
    1992) that provide public commentary on policy developments.
    Increasingly, funders are mandating researchers to engage in
    research translation, forcing them to become policy actors. Being
    an interested actor may have both advantages and disadvantages
    for generating new policy knowledge. Maintaining a degree of
    legitimacy amongst a wide range of actors may be crucial to the
    ability to conduct future research. In highly contested policy
    spaces this may involve complicated balancing acts that limit the
    ability to ask certain questions. The intense polarization that has
    characterized HIV/AIDS in South Africa is one such example
    (Fassin and Schneider 2003). Or where researchers take strong
    activist stands, they may become ideologically positioned in ways
    that may both open and close doors in the research process
    (Narayan 2007).
    Conclusions: advancing health policy
    Schlager (1997, p. 14) observed that the field of policy studies is
    characterized by ‘mountain islands of theoretical structure,
    intermingled with and occasionally attached together by foothills of shared methods and concepts, and empirical work, all of
    which is surrounded by oceans of descriptive work not attached
    to any mountain of theory’ (cited in Sabatier 2007, p. 323). We
    think this statement accurately characterizes the field of health
    policy analysis as well. Through this discussion of theory,
    methodology and positionality in health policy analysis, it is
    clear that there are a number of ways research in this field
    could be strengthened:
    On theory
    (1) More critical application of existing frameworks and
    theories of the public policy process to guide and
    inform health policy inquiry, while recognizing the need
    and potential to contribute to theory development as a
    goal of health policy analysis, with consequent benefits
    for practice.
    (2) Greater use of social science theories (for example,
    of organizations or street level bureaucrats) that come
    from outside of policy studies to inform health policy
    On positionality
    (9) Greater reflexivity on the part of researchers, that involves
    an analysis of their own institutional power, resources
    and positions (in much the same way they would analyse
    actors in the policy process) and their role in defining
    research agendas and generating knowledge (rather
    than assuming themselves to be ‘objective’ and
    (10) Greater attention to policy research team composition and
    roles, including insiders and outsiders, which can relate to
    nationality but also to multiple roles. Researcher positionality may need to be negotiated and also reflected upon,
    considering how it may influence data collection and
    (11) Long-term approaches to building policy analytic capacity.
    This would include acknowledging and providing space
    for different policy research agendas arising from different researcher positionalities, and building a critical mass
    of policy analytic capacity to enable this.
    In conclusion, we argue that if those who conduct, teach,
    commission, fund or publish public health policy research take
    on board some of these points, there will be a significant
    improvement in research approaches to health policy analysis,
    especially in relation to low and middle income country
    settings. If applied, these recommendations will also provide
    lessons on the evolution of policy implementation successes and
    failures as well as tools to assist policy-makers in evaluating
    and planning current and future policies.
    On methodology
    (3) Making research design an explicit concern in all health
    policy analyses, and identifying and justifying the type of
    design in published articles.
    (4) Drawing on the growing body of work on case study
    research methods in order to enhance the quality of case
    study inquiry in the field.
    (5) Clearly identifying the type of ‘case’ and the unit of analysis,
    and considering the need for multiple cases and
    (6) Making assumptions and propositions explicit, logical and
    interrelated, and open to being tested empirically, so as to
    explain general sets of phenomena.
    (7) Making the case to funding agencies to support more
    comparative work in health policy analysis in order to
    expand the generalizability of results and develop greater
    certainty concerning causality. This case will be strengthened by the willingness of researchers to collaborate
    across institutions, countries and regions.
    (8) Exploring other approaches to synthesis (e.g. through
    large sample studies which employ quantitative and
    qualitative methods) as well as retrospective studies
    which draw on research from different disciplines in
    one policy domain or set of countries.
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    In addition to those discussed here, other frameworks and theories
    widely used in public policy analysis include institutional rational
    choice and advocacy coalitions among others. However, few
    examples of these have been applied in the health policy literature
    referring to low and middle income countries. For an overview of
    frameworks and theories of the public policy process, see the
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