In our previous modules, we've emphasize the word, diagnosis. We did an educational and behavioral diagnosis to find out why people became sick, what behaviors they did, seeking treatment or not seeking treatment, and why they did these thing. Was it something to do with their beliefs, attitudes, resources, skills, social support? We did a community diagnosis, where we tried to find out how social economic, political, cultural, and geographical forces influence the health of the community and influence the community or the human response to these health problems. We've recently talked about organizational diagnosis, where we try to find out what factors within the organization are functioning well and lead to a healthy organization or where there may be problems in terms of the human dynamics, the interaction with the environment, the technical gaps that may influence the functioning of the organization. At this point, we're in the process of making a diagnosis to determine how policies are made, who has a stake in these policies, and if we are going to influence the policy process, who should be involved, how can we involve them? Again, in the context of the ecological model, we are concerned with human behavior at all levels so policy makers can make decisions about drug distribution, make decisions about essential drug lists, make decisions about tariffs on bed nets, make decisions about who can attend school if they're pregnant or not. All of these kinds of policy decisions impact on the community and individuals. So we should be concerned about the behavior of policymakers and people who are trying to influence policy in the background, directly or indirectly. And this is where we enter the phase of stakeholder analysis. The example of HIV/AIDS control in developing countries will be used in this segment. The stakeholders in HIV/AIDS include activist groups, community-based support groups, government health departments at local, state, federal level, international donor agencies that are providing funds and programs, religious groups, and many others, including pharmacy manufacturers that make anti-retroviral drugs, condom manufacturers, professional and trade groups, from the point of view of professional groups, such as health workers and their concerns personally in terms of exposure and their concerns professionally to prevent the disease in the community, other kinds of trade groups and work groups, such as dockworkers and transporters who may be at risk. And, of course, the media has a stake in such a major health issue. The stakeholder analysis tries to, first, identify along six different variables, how much investment concern interest a particular stakeholder has in the issue. So in this slide, the chart shows these six different elements: involvement, interest, power, position, impact, and strategy. And two examples are given, the pharmaceutical companies and a national or state Ministry of Health. The nature or type or level of involvement of the pharmaceutical companies is there to protect their patents and promote sales. They certainly have a high interest in any policy that deals with HIV treatment. They have a lot of power because they do provide the lifeline to people. They are basically opposed to any efforts, any policies that would make treatment more universally accessible, low cost using generics made in other countries. Their ability to impact the condition, the situation through manufacture of the drugs through their court actions to prevent generics from entering the market because they have a lot of money to hire their lawyers is high. And the strategy that a group that wants to influence policy, and assuming that they want to influence policy in such a way that they guarantee treatment for even the poorest people in the community, would be to defend against the onslaught of the pharmaceutical company and their efforts to make drugs less accessible. On the other hand, the Ministry of Health, again, say that you're looking at this from the point of view of an AIDS activist group that you want to promote a policy that ensures people have access to care. The Health Department is quite concerned. Their involvement is influenced by the cost of care, how much they can afford, what their budgets are. Health departments have a high interest in the issue because there will be great demands made on their service. They want to respond. They have mandates to serve the public. Their power and actually influencing policy, most of them are civil servants, they generally don't speak out. They may, through some professional associations, make their views known. But as a Health Department, as a Ministry of Health, they usually are the recipients of policy directives and don't have a lot of power in influencing them. Sometimes they may be called on individually as experts to testify before legislative bodies that do make the decisions. Their position is that they would be strongly supportive, generally, of anything that would provide care to people at affordable price because the public sector is the major source of care, not necessary the best but the major source of care in many countries. They would have a high impact on the issue if they were able to treat all the people they needed to. Again, if you are the activist group trying to change policies, you would involve them, get them to contribute what they can to formulating better policies towards speaking out as experts. The next slide is based on news that came out of South Africa last year and shows another important stakeholder in the process. The Catholic bishops in South Africa spoke out officially, condemning the use of condoms. They were not concerned with the fact that it prevented AIDS because it was seen as a birth control measure. This was ironic because a few individual bishops a week before the conference were talking positively that community should be able to protect themselves. But as a whole group, the bishops came down specifically against, their position was opposed to the preventive side of AIDS control programs. In contrast, the level of involvement in donor agencies was actually to provide condoms. Many different agencies, U.S. government, British government, were providing condoms. Activist groups were supporting the provision of condoms. Ironically, pornographic movies made in Brazil were actually showing their movie stars as role models using condoms, and they had made that change over the years. They were actually forced in the media that were promoting condom use. So, again, when you have an issue, you have a number of stakeholders. You need to identify what is their position. Are they powerful, are they influential with which groups of people? It's important to classify the characteristics of these different stakeholders to see who are more powerful, who are on the side for certain policies, who are against certain policies. Want to rank their interest in the issue. Is it high? Is it moderate? Is it low? Is there a power or influence high, moderate, or low? Do they take a supportive position for the new policy? Are they opposed to it or they're not mobilized, they're disinterested, even though they might potentially have some impact? Again, looking at the example of the Catholic bishops in South Africa, they had a high-level of interest. They had moderate to low power though to make influence in the sense that it depends on the proportion of the population that would be Catholic or that would listen to them. They were be clearly opposed to the promotion of condoms and their impact though because of being quite vocal, because of media coverage of their event may actually be disproportionate, making people, policymakers, legislators more embarrassed or more uncomfortable in terms of taking a stand themselves. So, again, we need to be aware that some groups may have disproportionate influence and that may be because of other stakeholders such as the mass media. We need to look at policy even in a broader context. We have now the World Trade Organization functioning, and when we get to the areas of pharmaceuticals, they make policies that may be counterproductive to the policies that are made by WHO and international health agencies. Their concern about protecting copyright may make it difficult for AIDS patients to get cheap generic drugs. Recently, in South Africa, the government went to court, and fortunately, they were able to succeed in getting generic drugs accepted in their country. Countries like Brazil and India make their own drugs and are not dependent on the international pharmaceuticals. Again, having figured out who are stakeholders, what are their positions on the issue, what power and influence and potential impact they might have, the next question is then, what kind of strategy? What would your organization want to do? If their position, if the position of a stakeholder was supportive, it would be important to involve them, develop coalitions, where each organization, a member of the coalition can contribute, whether it's expertise, whether it's money, whether it's volunteer strength to go out in the community and canvass. If the position on the particular issue is mixed, maybe a particular group is in favor of preventing HIV/AIDS, but they're cautious about using condoms because of the family planning implications, it might be useful to collaborate with them until they can clarify their stand and maybe come around to your side. There may be some groups that are marginal. They're not directly concerned, maybe in terms of the drug issue. It may be the retail pharmaceuticals. They may not have as major a role, but eventually, they might take an interest. You'd want to monitor what they're doing. And again, the groups that are specifically opposed to the policy you're trying to promote, your group needs to come up with statements, expert testimony, information, influential groups that can defend your position. An important strategy that we'll talk about in the next section for promoting news policies and defending against opposition groups is the strategy of advocacy.
