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Community of stakeholders

In any country, a wide range of stakeholders have an interest in health policy making. Engaging and involving these stakeholders is a fundamental first step in the process. The stakeholders are the participants in the national policy dialogue -- the people and organizations who influence and decide the content of health policy. Stakeholders will differ from country to country, but broadly they will include:

• Public - Ministry of Health, levels of MOH (regions), other Ministries (Civil Service, Social Security, Finance, Education, Labor, Defense), decentralised levels of government, like states and districts
• Private for-profit - Companies, Private practitioners, Insurers
• Donors -- multilateral, bilateral, international NGOs
• UN system -- WHO, other health and non health agencies
• Providers -- (unions, medical associations, nursing associations)
• Citizens - Patient organizations, citizens' organization
• Nonprofit -- nongovernmental organizations (NGOs), foundations, faith-based organizations
• Political organizations -- political parties, parliament or other representative houses

Ideally, stakeholders are consistently engaged throughout the policy process in dialogue and consultation. Stakeholder collaboration throughout the process is critical to ensure:

• There is a common vision of the goals and objectives
• Funding sources can be secured
• Implementing partners adhere to a common workplan and align their mandates
• There is a common vision of the goals and objectives
• Decisions made are communicated

The Country Health Policy Portal allows the community of stakeholders to be visible to one another and to participate via the site in the policy dialogue.

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Situation analysis

The Situation Analysis phase of the policy process involves evaluating the current health situation and state of the health system. A situation analysis requires the Community of Stakeholders to consider data and information about the health system and reach conclusions about key problems and opportunities.

The Community of Stakeholders carryout the situation analysis through the following activities:

1. Reviewing reliable quantitative and qualitative information about the health system, population health status and progress towards health goals.
2. Conducting participatory, transparent policy discussions to agree on current problems and propose next steps.

1. Review reliable quantitative and qualitative information

   In order to proceed with the review, we ideally need:

   • Robust data (routine & survey)
   • Analytical capacities in various disciplines such as epidemiology, demography, economics, sociology, political science, anthropology, statistics, medicine, etc.
   • Competent institutions able to generate specific data or analysis, etc.
   • Ability to share information in a useful format with all stakeholders

   In the country's health policy portal, evidence is collated in a structured and logical way.

2. Transparent Participatory Process

   It requires:

   • Bringing together all actors
   • Broad consultation
   • Facilitation of an inclusive discussion
   • Consensus on key problems and opportunities (situation analysis)
   • Mechanism for recording discussions and agreements (The CHPP can be used for this)
   • Use of this process to inform sector reviews and propose next steps.

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Priority setting

The Priority Setting phase of the Policy Process is carried out by the Community of Stakeholders based on the Situation Analysis and also on information about the relative cost of different options and their expected results. The process begins with a debate among stakeholders about the major weaknesses and options for solving those. It continues with the development of several scenarios which can be compared regarding results and needed investments.

Priority setting is about choosing among options, given limited resources.

It is performed including the following activities:

1. Compile the summary strengths, weaknesses and recommendations for each area of the Situation Analysis
2. Use the recommendations to develop a set of activities and interventions that will result in the desired outcomes over a fixed time frame. Estimate the cost of this set of activities.
3. Then adjust the content of the set of activities, keeping in mind the recommendations, but changing the amount or content of the component activities. Estimate the cost and the expected outcomes of this new set of activities and compare to the previous one. Continue this modeling exercise until several sets of options exist.
4. Have all stakeholders discuss and debate the sets of options in a transparent and participatory manner and select one option as the basis for the plan.

In summary, priority setting involves

• Describing the strengths, weaknesses and recommendations for each area of the situation analysis.
• Reviewing the recommendations and identifying critical interventions
• Developing a set of scenarios involving different combinations of actions
• Costing the different scenarios and comparing them on cost and results
• Reviewing the cost implications of the scenarios with real budget options
• Developing recommendations for programmes and resources to generate the most additional health benefit.

The expected results should be measurable and can be different types of outcomes, such as changes in morbidity or mortality rates or changes in utility such as quality adjusted life years.

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Planning

The Planning Phase of the Health Policy Cycle is carried out by the Community of Stakeholders and builds on the Situation Analysis and Priority Setting phases.

A plan should say who will do what at what cost with which funds by when and with what expected result. The purpose of writing a plan is to make the agreed actions explicit to all stakeholders. A written plan allows everyone to see clearly what is what is supposed to happen.

Countries may have national health sector plans, as well as state, regional and district health sector plans. Facility plans, for hospitals and clinics, are also often developed. Each may have a specific budget as well.

In many countries, a 3-year rolling plan and budget is developed. Called the Medium-Term Expenditure Framework (MTEF), this brings together the financing and the health specialists to agree on budget allocations to health.

Each Country´s Health Policy Process portal contains a document library which links to all of the documents used in the policy process. This is the place to find the current, past and future health sector plans, budgets etc. In many cases, this document library is the one and only place where all country health sector documents are accessible.

On this page of its portal, a country should put copies of:

• the national health plan
• state or regional health plans
• district health plans
• facility plans
• MTEFs
• budgets

Posting national, regional, district and facility plans on this page of its portal, allows stakeholders in different parts of the country and at different levels of the health sector to share plans and learn from one another. It also makes it easier to follow.

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Implementation

The Implementation phase of the Policy Cycle is carried out by the Community of Stakeholders and involves the actual execution of the plans set in the Planning phase.

The implementation phase involves many activities for which records need to be kept. For example, during implementation, health sectors personnel may be involved in:

• hiring
• training
• supervision
• purchasing
• accounting
• etc.

Using the Health Policy Portal, the country Community of Stakeholders can communicate progress on many of these implementation procedures as well as benefit from improved access to the documents, reports and accounts underpinning the implementation.

Additionally, the current activities page provides the possibility for the Community of Stakeholders to plan meetings and share agendas, minutes and keep up to date on the latest activities.

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Monitoring & evaluation

The term M&E is used to describe the full process of monitoring and review of results, as well as evaluation and learning.

In this phase of the Health Policy Process, the Community of Stakeholders can use their Country Portal to measure the outcomes and impacts of the Implementation of the health plans. This information is then fed back into the cycle in the Situation Analysis, Priority setting and Planning processes.

Sound M&E systems are built on inclusive policy dialogue and regular evidence-based assessments that inform progress and performance reviews and result in remedial action and mutual accountability among all stakeholders. This should form the basis for resource allocation, policy making and effective management of programmes.

Most countries already have some sort of monitoring, evaluation and review mechanism in place that allows systematic monitoring of progress and review in the context of NHS.

The Health Policy Portal provides a platform for the stakeholders to build upon and strengthen existing country mechanisms. It can be used in conjunction with the IHP+ work on Joint Assessment of National Health Strategies and Plans (JANS) and can be considered as an effort to strengthen the fifth component of the JANS - monitoring, evaluation and review mechanisms.

The way M&E is done will be unique to each country. This guidance is deliberately generic, setting out the essential attributes and characteristics for four areas, considered to be the foundation of a sound monitoring, evaluation and review platform for a national health strategy:

I. National health strategy as the basis for information & accountability: Monitoring, evaluation and review is an integral component of a comprehensive national health strategy, established through inclusive policy dialogue, and with support and alignment of country and development partners.

II. Institutional capacity: The roles and responsibilities of in-country institutions to support regular monitoring, review and (remedial) action are specified and supported by adequate capacity and resources.

III. Monitoring and evaluation: Monitoring and evaluation includes a comprehensive framework that addresses indicator selection, related data sources, analysis and synthesis practices, including quality assessment, performance review, communication and use.

The IHP+ common M&E Framework (Figure below) provides a logical and results chain representation of the key components of the M&E component of a NHS. It comprises four major indicator domains: system inputs and processes, outputs, outcomes, and impact. For each indicator domain, preferred and alternative data sources are recommended.

Community of specialists in research and evaluation work to improve the availability, quality and use of the data needed to inform country health progress and performance reviews (eg, situation analysis, M&E of health plans).

IV. Country mechanisms for review and action: This implies the existence of well-established, transparent processes at country level, involving multiple stakeholders to ensure quality of data and independence.