Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine Health Policy

cy and Planning 2012;27:i64–i76

ß The Author 2012; all rights reserved. doi:10.1093/heapol/czs007

Using stakeholder analysis to support moves

towards universal coverage: lessons from
the SHIELD project
Lucy Gilson,1,2* Ermin Erasmus,3 Jo Borghi,2 Janet Macha,4 Peter Kamuzora5 and Gemini Mtei4
1
School of Public Health and Family Medicine, University of Cape Town, South Africa, 2Department of Global Health and Development,

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London School of Hygiene and Tropical Medicine, UK, 3Independent consultant, South Africa, 4Ifakara Health Institute, Tanzania and
5
Institute of Development Studies, University of Dar es Salaam, Tanzania
*Corresponding author. School of Public Health and Family Medicine, University of Cape Town, Health Sciences Faculty, Anzio Road,
Observatory, 7925, South Africa. E-mail: [email protected]

Accepted 11 January 2012

Stakeholder analysis is widely recommended as a tool for gathering insights on

policy actor interests in, positions on, and power to influence, health policy
issues. Such information is recognized to be critical in developing viable health
policy proposals, and is particularly important for new health care financing
proposals that aim to secure universal coverage (UC).

However, there remain surprisingly few published accounts of the use of

stakeholder analysis in health policy development generally, and health
financing specifically, and even fewer that draw lessons from experience about
how to do and how to use such analysis. This paper, therefore, aims to support
those developing or researching UC reforms to think both about how to conduct
stakeholder analysis, and how to use it to support evidence-informed pro-poor
health policy development. It presents practical lessons and ideas drawn from
experience of doing stakeholder analysis around UC reforms in South Africa and
Tanzania, combined with insights from other relevant material. The paper has
two parts. The first presents lessons of experience for conducting a stakeholder
analysis, and the second, ideas about how to use the analysis to support policy
design and the development of actor and broader political management
strategies.
Comparison of experience across South Africa and Tanzania shows that there are
some commonalities concerning which stakeholders have general interests in UC
reform. However, differences in context and in reform proposals generate
differences in the particular interests of stakeholders and their likely positioning
on reform proposals, as well as in their relative balance of power. It is, therefore,
difficult to draw cross-national policy comparisons around these specific issues.
Nonetheless, the paper shows that cross-national policy learning is possible
around the approach to analysis, the factors influencing judgements and the
implications for, and possible approaches to, management of policy processes.
Such learning does not entail generalization about which UC reform package
offers most gain in any setting, but rather about how to manage the reform
process within a particular context.
Keywords Universal coverage, insurance reform, stakeholder analysis, political manage-
ment, political viability

i64
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i65

KEY MESSAGES
 Stakeholder analysis is an important approach to apply in order to enhance the political viability of universal coverage
proposals.

 Doing stakeholder analysis requires patience and careful judgement, and particular attention to the contextual influences
shaping policy actors’ interests, positions on new policy proposals and relative power.

 Given the dynamic nature of policy change, repeated stakeholder analyses are likely to offer clearer insights to support
policy change than a single analysis representing experience at only one time.

 Stakeholder analyses can be used both to think through the political viability of new policy proposals and to develop

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broader political management strategies to support policy change.

Introduction Lessons of experience 1: Doing SHA

There is long-standing recognition that health system reform The key steps in a SHA
has both technical and political dimensions (Reich 1995). Data SHA can be conducted either as a formal research exercise,
on stakeholder perceptions of policy problems and options are involving data gathering through document review, media
seen as an important input for evidence-based policy making analysis and in-depth interviews (Schmeer 1999), or through
(Lavis 2009), and viability, defined as ‘consumer acceptability, brainstorming amongst knowledgeable participants (Bryson
acceptability to professional organisations and political accept- 2004). In either case, it is important to prepare for the SHA
ability’ (WHO 1993: 8), is a recognized criterion for assessing by clearly identifying the policy issue of focus (Schmeer 1999)
financing policy. The political stewardship needed to move and the purpose (e.g. rapid situational analysis vs comprehen-
towards universal coverage (UC) must, therefore, take account sive analysis: Hyder et al. 2010).
of diverse societal preferences (Carrin et al. 2008). Three key steps follow (Roberts et al. 2008):
The most commonly recommended analytical tool for gather-
ing information on these issues is stakeholder analysis (SHA): (1) Identifying the groups and individuals (the stakeholders)
‘an approach, tool or set of tools for generating knowledge relevant to the policy issue of focus;
about actors - individuals or organisations - so as to understand (2) Determining the current position (in terms of support or
their behaviour, intentions, inter-relations and interests; and opposition) of each stakeholder on the issue;
for assessing the influence and resources they bring to bear on (3) Determining the relative power of each stakeholder over
decision-making or implementation processes’ (Varvasovszky the issue.
and Brugha 2000: 338).
The analysis of this information can then be presented
However, the few available empirical studies reporting SHAs
visually to allow understanding of who the key stakeholders are
undertaken on health policy issues rarely report on the details,
around the policy issue, what positions they take on it and
challenges and usefulness of this tool in understanding and
what power they have to influence decisions around it. Analysts
informing policy change.
must also recognize how their own positions and resources,
This paper, therefore, aims to support those developing or
and contextual understandings, influence their interpretive
researching UC reforms, specifically, to think both about how to
judgements.
conduct stakeholder analysis, and how to use it to support
evidence-informed pro-poor health policy development (Buse
2008). It presents practical lessons and ideas drawn from
experience within the SHIELD project which has supported Determining purpose and focus
such reform in Ghana, South Africa and Tanzania (Strategies Following Hogwood and Gunn (1984), SHA might be con-
for Health Insurance for Equity in Less Developed countries: ducted retrospectively (Gonzales Rossetti and Bossert 2000;
http://web.uct.ac.za/depts/heu/SHIELD/about.htm). The project Gilson et al. 2003) to generate knowledge of policy and the
encompassed financing and benefit incidence analyses, model- policy process, or prospectively (Mathauer et al. 2007; Mathauer
ling future policy options for expanding coverage and, in South et al. 2008; Lalta 2009; Hyder et al. 2010; Surjadjaja and
Africa and Tanzania, stakeholder analysis to support policy Mayhew 2010) to generate knowledge in the policy process and
formulation. Analysis of the Ghanaian experience of health so support policy change (Glassman et al. 1999). Retrospective
insurance policy formulation is already available (Rajkotia analysis is primarily to understand how policy actors’ position-
2007; Agyepong and Adjei 2008). Drawing on the SHIELD ing and relative power influenced the process of policy change.
experience in Tanzania and South Africa, and wider literature, Prospective analysis more directly informs the process of policy
the paper is structured in two main sections. In the first, change, for example by generating ideas about how to change
guidance on how to conduct an SHA in relation to UC reforms policy design in ways that address critical actor concerns or the
is presented; and in the second, ideas are presented about how likely areas of contestation that will need to be negotiated or
to use an SHA in managing policy change, for those seeking to deliberately managed. It might also be used in such negotiation,
manage or influence the process of policy change (policy to draw out reasons for differences and provide a basis for
drivers). addressing them.
i66 HEALTH POLICY AND PLANNING

However, simply deciding the focus and purpose of an SHA in whilst Ministries of Finance are often circumspect about any
relation to UC can itself be a challenge. The fluidity of the policy with clear fiscal implications. Ministries of Health,
broader policy environment in South Africa and Tanzania, and meanwhile, include not only the political head, the Minister,
the absence of clear proposals for financing reform, were, for and the most senior civil servants, but also other groups—both
example, difficulties faced at the start of the SHIELD work those driving reform (e.g. in Tanzania, the Health Policy and
(2006). By 2010 (the time of writing this paper), comprehensive Planning Department of the Ministry of Health and Social
policy proposals were still not available in either country. Welfare), and those who may be concerned about the impact of
Nonetheless, a 2009 policy decision resulted in the Tanzanian UC reforms on their role and positions [e.g. if new insurance
Community Health Fund (CHF/TIKA, the largest voluntary organizations are established, officials within national minis-
scheme covering the informal sector) being taken over by the tries of health may lose power (Tangcharoensathien and
largest mandatory formal sector scheme, the National Health Jongudomsuk 2004)]. Other stakeholders include individuals
Insurance Fund (NHIF); whilst in South Africa, political playing important roles in resisting reform implementation and

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momentum around National Health Insurance (NHI) was moving it forward; both political champions of reform and
building. Dynamism is a common feature of policy change, individuals who get their ear—as in South Africa in the late
particularly around ‘high politics’ issues (Walt 1994) such as 1990s (Gilson et al. 2003).
UC, which impact directly on the general public as well as Comparison of South African and Tanzanian experience
powerful policy actors, involve wide-ranging changes in various around UC reforms (Table 1) shows, moreover, that:
health system elements, and may have been an area of political
 Some stakeholders are common across countries, e.g. polit-
debate and contestation over many years. Indeed, Varvasovszky
ical parties in government and opposition, officials from the
and Brugha (2000) suggest that, with such reforms, SHA
national Ministries of Health and Finance, commercial
should be an ongoing process rather than a once off activity, to
companies and a range of social sector stakeholders; at the
allow for change in actors’ positioning.
same time, the general public is not an obvious or vocal
In both South Africa and Tanzania, therefore, we conducted
stakeholder in either country, although civil society organ-
an initial SHA in 2007–08 with the primary objective of
izations are on the fringes of the debates.
providing a sense of stakeholder concerns and interests
 Differences in relevant stakeholders between countries are
concerning the broad policy direction of reforms that would
likely due to:
promote health system equity, as an input into our future work
[15 key informant interviews in Tanzania and, building on  Their broader political and governance systems (e.g. one
earlier work (Gilson et al. 2003), 12 in South Africa]. Only Trade Union federation is an important political grouping
limited further work was possible in South Africa given the lack in South Africa because of its political alliance with the
of clarity around policy proposals and political sensitivity party in government; and provincial stakeholders are also
around the issues (two group brainstorms and a media important because of the quasi-federal governance struc-
review in 2009–10). In Tanzania, however, a second round of ture of the country);
13 interviews in 2010 allowed consideration of stakeholder  Differences in the nature of the health system itself (e.g.
views on different options for expanding insurance and around the much stronger private sector in South Africa than
one particular policy action (the 2009 take-over of the CHF/ Tanzania brings a wider array of private health stake-
TIKA by the NHIF). In total six stakeholder groups were holders into play in UC debates);
considered in Tanzania (Ministry of Health, politicians, donors,  The level of economic development (the role of interna-
researchers, civil society groups, insurance schemes) and five in tional actors is much stronger in Tanzania than in South
South Africa (government officials, private health insurers, Africa, given its higher level of aid dependency).
professional groups, trade unions and independent analysts).

The media is not identified in Table 1 but did influence

Identifying stakeholders the ways in which NHI was spoken about and understood in
For any policy issue, stakeholders can be identified by South Africa. In 2009–10, for example, media reports, com-
considering both who has formal bureaucratic and political monly portrayed NHI as a threat to the health system and an
authority to make relevant decisions and who has interests in inappropriate policy option for the country (often presenting
the outcome of a decision (Moore 1995). A large array of the perspectives of particular individuals).
stakeholders from political, governmental, health system, busi- Given the large numbers of policy actors interested in UC
ness and social sectors are, therefore, likely to have interests in reform in any setting, it is useful to try to prioritize which
UC reforms in any setting. In addition, it is important to actors to consider in an SHA, recognizing that every policy
consider those whose rights may be affected, that is the public process is unpredictable. Perhaps the least risky approach is to
at large (patients and citizens), whatever their level of power identify an initial set of influential stakeholders based on
(Bryson 2004; Mayers 2005). in-depth knowledge of the particular context, including inter-
Stakeholders include not only whole organizations, but also actions with some policy actors. A ‘snowball approach’ could be
different units or groups within them, which may themselves used, for example, where initial informants are asked ‘who has
hold different positions on the same policy issue. Governments, influence in current policy debates around issue xx?’ (adapted
for example, may comprise groups championing the reforms from Lewis 2006), to identify those actors commonly seen as
(such as Ministries of Health) and other ministries champion- important. However, it is always important also to consider the
ing competing reforms (such as social security expansion); potential role of less visible or powerful actors, who might
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i67

Table 1 Examples of key stakeholders in health insurance reform from different sectors (2007–10)

Stakeholder group South Africa Tanzania

Political  African National Congress, ANC (party in  Chama Cha Mapinduzi, CCM (party in
government) government)
 Democratic Alliance (main opposition party)  Chama Cha Democracia na Maendeleo & Civil
 COSATU (Congress of South African Trade Unions, in United Front (main opposition parties)
political alliance with ANC)
 National President, national Minister of Health and other
senior national Cabinet members
 Provincial Ministers of Health and Finance
Government  National Treasury (Ministry of Finance) officials  National Ministry of Finance officials
 National Department of Health officials  National Ministry of Health officials
 Provincial Health Department officials  Prime Minister’s Office—Regional Administration and

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 Local government officials Local government officials (national level, responsible
 Officials in other national government departments with for local government)
insurance reform interests  Officials in parastatals with interests (e.g. National Social
Security Fund)
 National Health Insurance Fund
Health system  Private hospital companies  Large private hospital managers
(outside  Private health insurance organizations  Private health insurance organizations
government)  Health professional organizations  Association of private hospitals
 Health sector trade unions  Other informal community health insurance
Business  Commercial companies  Commercial companies
Social sector –  Treatment Action Campaign  Trade Union Congress of Tanzania
Civil society  Individual academic analysts  Civil society organizations
 Individual academic analysts
International  Not applicable  Bilateral agencies (Swiss, German, Danish, USAID)
 Multilateral agencies (World Bank, WHO)

Note: USAID ¼ United States Agency For International Development.

frame how others think about an issue from behind the scenes influence policy decisions (Table 2). Roberts et al. (2008) note
(e.g. the media), or who may be affected by the issue even that the resources can be tangible (such as money, organiza-
though having no obvious or vested interest in it (e.g. the tions, networks, people, votes, equipment, offices) and intan-
public, civil society organizations). It will also be important to gible (such as information, legitimacy, expertise and access to
repeat the SHA over time, to identify and track new actors that leaders or the media). However, judging the balance of power
emerge as influential players. among actors is always difficult as different combinations of
power are not easily comparable. An SHA requires careful
triangulation of perspectives on these issues across interview-
Gathering perspectives on key issues ees, and testing of initial judgements.
As noted, three key issues are considered within any SHA— Group brainstorming is one approach to gathering perspec-
interests, positions and power—and none are easy to deter- tives in an SHA and can support several repeated and fairly
mine. Table 2 summarizes definitions for these key issues quick analyses. However, working with too small a group
drawn from two sets of broadly similar SHA guidance (Schmeer may exclude or ignore different perspectives, whilst working
1999; Roberts et al. 2008). with a broader group may be difficult to set up and manage.
Power is a central concern within an SHA but it is often Establishing commonly understood definitions of key issues (as
poorly examined in health policy work (Gilson and Raphaely in Table 2) is important, as well as allocating dedicated
2008). The exercise of power can be seen most clearly when discussion time to different sets of issues. Key informant
stakeholders take public leadership within UC debates, whether interviews are more commonly used (e.g. Schmeer 1999), but
of support or opposition. But power is also practised by the less have their own difficulties. Just setting up interviews with policy
obvious act of keeping issues out of consideration in policy elites can take considerable time, as well as the interviews
debates (Ministries of Finance might, for example, prevent themselves. As a result only a few interviews may be conducted
certain taxation options even being considered within UC with some stakeholder groups, and some groups may not be
design), and by influencing others’ views and perspectives on willing to be interviewed at all. The perspectives of some actors
what is or is not appropriate action (Lukes 2005). As noted, for may, therefore, be drawn out primarily through engagement
example, some 2009–10 media reporting in South Africa with other actors, or from documentary or media sources. It
appeared directed at building opposition to new proposals. was particularly difficult in South Africa and Tanzania, for
Power assessments often, therefore, try to take account of all example, to set up interviews with the most senior government
forms of power available to actors by assessing the resources officials because of their time constraints and the researchers’
available to each in judging their potential, relative to others, to limited access to them; in South Africa those involved in
i68 HEALTH POLICY AND PLANNING

Table 2 Guidance on assessing power, interests and positions

Roberts et al. (2008) Schmeer (1999)

Interest Degree to which stakeholders likely to be affected by policy The advantages and disadvantages that implementation of the
change. policy may bring to a stakeholder or his/her organization.
(Degree of interest or concern they have in or about a policy will (Also important to consider the level of accurate knowledge
influence how the stakeholder’s resources, and how much of the stakeholder has regarding the policy under analysis, in
those resources, will be used in the policy debate.) order to identify stakeholders who oppose the policy due to
misunderstandings or lack of information.)
Positions View on the policy issue and position in relation to policy change Whether the stakeholder supports, opposes, or is neutral about
being proposed, i.e. support or oppose? the policy.
Also involves assessment of intensity of each group’s position on
an issue.

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Power Potential capacity to influence policy decisions. The ability of the stakeholder to affect the implementation of the
Power judgement based on assessment of stakeholder’s resources health reform policy.
and location in the political system. Judgement of level of force with which the stakeholder might
Interested in power relative to others. support or oppose the policy is based on the quantity of
resources (human, financial, technological, political, and
other) available to the stakeholder and his or her ability to
mobilize them.

relevant, but confidential, policy processes were also difficult to The second challenge is how to ask questions about power
interview. and interests. It may be politically difficult for actors to answer
‘Effective (elite) interviewing [also] requires sound preparation, direct questions about themselves and they may misrepresent
planning and confidence’ (Pierce 2008: 119). Before an interview, their positions. So it is more usual to ask direct questions about
analysts should think about what they already know about the other actors and triangulate responses to get an overall
respondent and their relevant experience, and determine key composite view. It is also important to try and elicit discursive
issues to explore as well as key insights to test with them. responses which can be carefully interpreted by the analyst.
During the interview it is then important to let the conversation Stimulating respondents to think about power might, for
flow, adopting an active listening process that gives confidence example, be achieved by including prompts within questions
to the respondent and allows the interviewer to tease out about the political and economic resources of other actors, as
unexpected insights, test her emerging understandings and well as their alliances with other potentially powerful actors.
identify when the respondent’s positions and views strike a Finally, given that an SHA entails judgements on sometimes
discordant note with her pre-existing understandings. The sensitive issues on the basis of partial information, it is always
texture of the conversation and informal comments may important to think about how to validate the perspectives
themselves give important clues to critical issues. And it gathered. In a brainstorm, the use of visual mapping techniques
remains important to watch the time and keep focused, can assist the process of triangulation. In analysing interview
nudging the conversation along the pre-prepared lines of data, triangulation across different interviews and with other
inquiry as much as possible and being respectful of the evidence (e.g. documentary data, media reports) is important
respondent’s views. and it may also be helpful to present synthesized judgements
There are two other challenges to gathering perspectives in an back to some respondents to allow reflection on their validity.
SHA, whether in a group brainstorm or through interviews. The
first is the need to try and tease out the personal views of
respondents from those that represent the formal position of Analysts: recognizing your positions and resources
the organization/group with which they work. Both perspectives Analysts who conduct SHAs must be self-aware, be they
are likely to be important, but interviewees’ personal views
government officials or independent researchers. The SHIELD
may:
teams comprised both groups of analysts; in addition, some of
 offer valuable, critical insights on other policy actors (and be us were nationals of the country in which we worked, and
based on closer engagement with them than that available some were expatriates working for shorter or longer periods
to the analyst); within the country. And some had been engaged in health
 be a critical driving force of the organization’s positioning financing debates in our country for many years, whilst others
(e.g. in South Africa, the leader of one health professional were new to the field and debates. These differences offered
organization drove a more public-sector-oriented position at both opportunities and challenges for doing an SHA—in terms
one time than the organization’s members themselves held); of who we know and how we are known, or in terms of the
 allow the researcher to think through the multiple perspec- stakeholders to whom we have direct access, the availability to
tives a single actor holds (e.g. in South Africa, government us of third parties who have such access or the value of our
health officials might support health insurance reform as an organization’s reputation in terms of getting such access
ideal but be concerned about the potential loss of their own (Gilson and McIntyre 2008). These factors may influence
health insurance benefits, and the consequences for their which people analysts can gather together for a brainstorm or
families). to which respondents they can gain access; they may also
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i69

influence how respondents perceive the questions they are contributions by the formally employed.1 The related media
asked and how they frame their answers. debate gave voice to those who preferred earlier policy
The differences amongst the SHIELD researchers also proposals that had focused on mandatorily extending private
influenced our broader understanding of the power plays and health insurance to all formal sector workers and their
nuances in the political context and of UC reform more dependants (Department of Health 1997; Department of
specifically. Some of us knew too little, and had to be cautious Social Development 2002) (see Table 4 and McIntyre and
about making too simplistic a judgment about actors’ positions Ataguba 2012 for more details of scenarios).
and resources. Some of us brought past experience and had to In Tanzania, the scenarios derived from a proposed regulatory
take care to make time-relevant judgements, rather than being framework for health insurance (Lankers et al. 2008) that
biased by earlier insights into the actors of focus (Hyder et al. identified two options for achieving health insurance expansion
2010). (Table 5): a single insurer, and managed competition (in which

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existing schemes would continue to co-exist, but would lie
Knowing your policy context and making within a more structured and regulated system stipulating
interpretive judgements minimum benefit packages etc.) (Borghi et al. 2012).
In making the judgements necessary within an SHA, it is In considering the viability of different policy design options
particularly important to understand the broader policy context it is necessary, first, to consider information about actors’
in which you work (Hyder et al. 2010), and to tease out the general interests in the reform of focus (drawing on a
understandings and insights that inform your judgements combination of interview material and wider contextual under-
in order to allow these assumptions to be tested, and where standing). As Table 6 shows for UC reform in South Africa and
necessary, revised. Tanzania, these interests can be quite wide-ranging, although
A range of frameworks and guidelines are available to support those with specific stakes in the health system appear to
greater understanding of the national contextual features likely have narrower and more focussed interests than those with
to influence policy debates. The fairly widely used framework broader political agendas. Actor concerns are, however, also
of Leichter (1979) identifies four such contextual factors: multi-faceted, often involving some combination of personal,
situational (irregular, impermanent), structural (more perman- organizational and political concerns.
ent), exogenous (external) and cultural. Table 3 highlights Across countries, comparison of stakeholder interests
some of the contextual factors of importance in South African (Table 6) and the reform scenarios outlined in Tables 4 and
and Tanzanian UC debates. It shows that these factors may be 5, as well as, for Tanzania, information gleaned from inter-
important in explaining: views, then allowed some judgements about how and why
stakeholders would react to the policy proposals. The details of
 the particular dynamics of any reform process, such as
the South African and Tanzanian experiences highlight three
moments of movement resulting from windows of policy
sets of lessons about these viability assessments.
opportunity;
First, stakeholder responses to policy proposals are complex
 the power balances among stakeholders;
and quite variable. Some actors may have a dominant concern
 stakeholder interests in particular reforms.
across all dimensions of various reform scenarios. For example,
donors in Tanzania tend to support a single position on a
preferred financing strategy based on the financing model of
Lessons of experience 2: Moving their own country. The UK’s Department for International
beyond the SHA and using it to Development, for example, strongly supported free care through
tax funding, over health insurance, whereas the German (GTZ)
support policy change and Swiss (SDC) aid agencies have strongly promoted health
To prompt thought about the value of conducting an SHA insurance expansion through community and national insur-
prospectively, we outline two possible uses of SHA: first, as an ance schemes.
input into policy proposal design; second, as the basis for However, for other actors, different dimensions of the same
developing a ‘political management’ strategy (Moore 1995) to policy option may have contradictory impacts. Given their
enhance the likelihood of securing policy change. Both are concerns about the role of private sector companies in health
useful to policy drivers, i.e. those pursuing UC reforms. care financing and delivery, the ANC-aligned trade unions in
South Africa, for example, are likely to support a reform
Assessing stakeholder responses to UC policy that collects revenue through a public sector authority and
design scenarios pools this revenue in a central NHI fund administered by a
SHIELD analysts in both countries have developed alternative government-controlled body (scenario 3). However, they might
insurance reform scenarios for consideration in policy formu- also oppose purchasing arrangements that they perceive nega-
lation, starting from the current national health system design. tively affect the benefits and access of their members to health
In South Africa, the scenarios were developed based on the care (could be a problem for scenario 3 depending on the
ruling party’s proposal to introduce a national health insurance benefit package and reimbursement design details).
(ANC 2008; ANC 2010). Although the detailed design was not Department of Health officials (at national or provincial
available at the time of writing, the broad proposal was to level), meanwhile, might support the broad equity goals of
provide universal coverage to a relatively comprehensive benefit scenario 3 and the related intention to strengthen the overall
package funded largely through taxes, with additional health system, but still be fearful of, and even resist, specific
i70 HEALTH POLICY AND PLANNING

Table 3 Contextual factors influencing stakeholders involved in universal coverage (UC) policy debates in South Africa and Tanzania

Factor Issue Influence over UC debates

South African examples Tanzanian examples
Structural Formal balance of power Particular form of proportional representation Dominance of CCM relative to opposition, rooted
within political system used within national elections, and continued in its history of political leadership, gives it
ANC dominance in popular image and minds of power to push through its desired policy
majority of population, leaves little political changes, and leaves little political influence for
space for a popular/civil society voice in some civil society voices.
policy debates.
Dominance of the ANC in national elections gives
opposition parties little power in national policy
debates [though main opposition party forms
(2010) government in one province so might use

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this power base to seek influence in debates].
Formal/informal balance Strong influence of central Treasury in public The Ministry of Finance is powerful because it has
of power between policy making and has blocked past health control over the budget allocation and can limit
government ministries insurance reform proposals. the amount that goes to the health sector. It
(But new government, elected in 2009, has to also controls the overall basket fund to which
some extent limited power of Treasury by all development partners contribute.
bringing new economic policy agents into policy But has not played very obvious role in health
debates and by specific importance it has insurance debates.
attached to NHI.)
Opportunities for na- Continuing economic power of mainstream busi- n.a.
tional policy actors ness interests (given fairly orthodox economic
outside government to policy frameworks) likely to give them at least
have formal and infor- covert power in UC policy debates.
mal influence over
health policy debates
directly and indirectly
Health system—nature Monopolistic position of private hospital compa- Highly fragmented and poorly regulated insurance
and role of private nies (used primarily by white and wealthy industry limits power of individual, private
health sector population groups) gives companies power in schemes, limiting their capacity to bargain on
the health system and strong interests in prices with private facilities.
purchasing reforms.
Large number of private health insurance compa-
nies (medical schemes), together serving only
16% of the population and each of which must
negotiate prices with providers, undermines
their power in the system and gives them strong
interests in pooling reforms.
Health system—structure As both the NHIF and CHF/TIKA are directly
of public insurance connected to the Ministry of Health and Social
Welfare, it tends implicitly to support the NHIF
position in relation to possible policy reforms,
limiting the potential influence of other actors
in the sector.
Situational Window of opportunity Changing balance of power within the ANC, Low coverage of CHF/TIKA, growing momentum
for policy change culminating in removal of the previous to expanding insurance coverage from Ministry
President in 2008 and election of new ANC of Health and donors, combined with political
government in 2009, provided new impetus to power of NHIF top management, resulted in
move forward with health insurance reform, NHIF taking over CHF management and
despite past years of stagnation, due to new opening up of NHIF to other segments of the
policy agenda agreed among powerful ANC population.
players.
Competing policy Health insurance reform only one of several Health insurance reform only one of several
priorities national priorities competing for resources. national and health policy priorities competing
NHI one of 10 health policy priorities: potential for for resources.
synergies and contradictions between NHI and
other health policy priorities may influence
actors’ positions on it; key actors’ preferences
among policy priorities may influence weight
given to NHI.
For example, as NHI is commonly understood as
essentially a financing issue and not about
improving general public sector performance,
the synergies with priorities such as quality or
management improvement are not seen.

(continued)
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i71

Table 3 Continued
Factor Issue Influence over UC debates
South African examples Tanzanian examples
Health policy history and Given small policy field, and long history of Although history of engagement is more limited
experience engagement amongst limited numbers of actors, (since early 2000s), the situation is similar to
individuals have strong influence in policy South Africa.
debates. Relatively limited technical knowledge within
government regarding insurance design, com-
bined with weak engagement with research
community, means that policy goals may not get
implemented as intended.
Cultural Feelings of solidarity Limited Existing community networks (informal groups
helping each other) improves solidarity and

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could facilitate insurance expansion.
Exogenous Donor influence Less relevant Health sector dependence on donors gives them
influence in national health policy debates, e.g.
certain donors supported development of CHF in
its early years, and continue to support pilot
initiatives to improve performance. DFID advo-
cated for removal of user fees in mid 2000s.

Notes:
ANC ¼ African National Congress, political party in government.
CCM ¼ Chama cha Mapunduzi, political party in government.
NHIF ¼ National Health Insurance Fund.
CHF/TIKA ¼ Community Health Fund.
DFID ¼ Department for International Development.

Table 4 Examples of differences in health care financing reform scenarios: South Africa

Revenue collection Pooling Purchasing

Scenario 1: Status quo Medical schemes (i.e. private 16% population covered by medical Medical schemes purchase mainly
insurance) exist, collecting funds schemes (increase to 21% in next from private for-profit providers
from members. 15 years as formal employment on a fee-for-service basis, speci-
General tax allocations to health increases). fied package of services (mainly
sector, for public health services Rest of population covered by hospital and chronic care).
(<12% of government budget tax-funded services. Tax funds used to allocate budgets
in 2010). to public hospitals and clinics, to
provide relatively comprehensive
services, with some rationing.
Scenario 2: Mandatory ex- All formal sector workers and their Nearly 40% of the population Same as for status quo. Major
tension of medical scheme dependants would have to join covered by medical schemes difference is that given the
cover to all formal sector private medical schemes. within 15 years. smaller size of the population
workers & their depend- General tax allocations to health Rest of population covered by dependent on tax-funded services
ants (SHI) sector (would require a smaller tax-funded services. compared with status quo option,
share of government budget than a wider range of services could
at present). be provided from public funds,
with e.g. less rationing.
Scenario 3: Universal Increased allocations to health Everyone in country entitled to Relatively comprehensive package
coverage sector from general tax revenue, benefit from services paid for of services (from community level
plus additional dedicated health from the single pool of public prevention activities to specialist
taxes/mandatory contributions. funds. inpatient care, with PHC
Medical schemes only provide Medical scheme membership gatekeeping), and some rationing,
additional cover for those who likely to decline to about 10% purchased from accredited public
choose this (generally higher of population. and private providers; paid
income groups). using range of mechanisms but
avoiding fee-for-service.

Notes:
SHI ¼ Social Health Insurance.
PHC ¼ primary health care.

proposals that may threaten their positional power in the relation to scenario 2, lower income employed groups might
health system (around NHI governance, for example) or want to be insured through private insurance, believing the
proposals that they perceive might threaten their families’ private sector to be more efficient than government, and yet be
health care benefits (the benefit package, for example). And, in unhappy with a tiered system in which they get fewer benefits
i72 HEALTH POLICY AND PLANNING

Table 5 Examples of differences in insurance reform scenarios: Tanzania

Revenue collection Pooling Purchasing

Scenario 1: Single Contributions from NHIF and Two scenarios: The NHIF purchases from govern-
insurer CHF/TIKA members managed Entire formal sector covered by the ment, faith-based and private
by NHIF. Moves towards NHIF, and 52% of informal sector for-profit providers of all levels
cross-subsidization between NHIF covered by the CHF/TIKA. Other of care. CHF/TIKA members have
and CHF/TIKA. schemes cease to exist. Total access to all public providers.
Tax funding to subsidize both population coverage between
schemes, and services provided 62–76% depending on assump-
by public providers. tions about rate of growth of
Out-of-pocket payments from the formal sector over time;
uninsured or for services not Universal coverage.
covered by insurance.

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Scenario 2: Managed NHIF covers public formal sector; Status quo Formal sector schemes purchase
competition a mix of schemes cover the from government, faith-based
private formal sector; the CHF/ and private for profit providers
TIKA covers the informal sector. of all levels of care. CHF/TIKA
No cross-subsidization between as above.
schemes.
Tax funding to subsidize NHIF and
CHF/TIKA.
Out-of-pocket payments from the
uninsured or for services not
covered by insurance.

Notes:
NHIF ¼ National Health Insurance Fund.
CHF/TIKA ¼ Community Health Fund.

and less access than more wealthy groups. In Tanzania, re-distribution implied within them, but there was also a
meanwhile, despite the NHIF management’s strong support possibility that scenario 3, involving a decreased role for private
for a single insurance model (scenario 1), there are simultan- insurance, would be opposed by an alliance of commercial and
eous concerns about the financial sustainability of cross- political actors. In Tanzania, meanwhile, many stakeholders
subsidization across formal and informal sector members, as were concerned in 2010 about the cross-subsidization between
well as the acceptability of such an approach to NHIF members. schemes implied by scenario 1, fearing that the existing
In addition, whilst this stakeholder does not support compe- insurance schemes were not sufficiently well established to
tition within the health insurance sector (scenario 2), it broadly ensure that cross-subsidization was financially sustainable. In
supports the principle of greater price regulation that is implicit contrast, as noted, the NHIF management had voiced some
within this scenario. opposition to scenario 2, and this had held back the overall
For other actors, meanwhile, the potential impact of reforms discussions about insurance regulation. In either country, to
might be concentrated around one particular dimension of any move the policy process forward these design barriers needed to
scenario. Providers are a good example of this in both countries. be considered within an overall political management strategy
Purchasing reforms will affect them most directly by determin- (see below). One strategy option might be to alter design
ing how much they will earn and how long they will wait to be elements in ways that sufficiently reduce the balance of
reimbursed for services rendered. In addition, in both countries, opposition to a particular set of proposals to allow movement
the national Treasury/Ministry of Finance seems to be generally in the policy process. However, policy re-design can be risky. An
concerned about the potential impact of revenue collection earlier South African analysis showed that insurance re-design
reforms on overall taxation levels and so, on the economy more to seek the support of a particularly powerful stakeholder
generally. In Tanzania, moreover, the managers of smaller (the National Treasury) resulted in proposals that could not
insurance schemes are especially concerned about the mechan- achieve the original objectives of the reform drivers, and
ism for revenue collection and are keen that UC be achieved were strongly opposed by an alliance of powerful actors
through managed competition to ensure that their place within (Gilson et al. 2003).
the insurance market is secured. Third, all viability judgements are just that: judgements. Even
Second, such assessments highlight specific design barriers to when due care has been paid to validation, they may be
the further development or implementation of policy proposals. inaccurate or, in a rapidly changing policy context, already out
The most critical design barriers are those likely to generate of date. Reform drivers must, therefore, always find ways of
sufficient opposition to block further policy development, testing viability judgements as they move forward, and
including those that are seen as problematic by a number of adapting them as necessary. They must also balance the risks
stakeholders and those that perhaps only one relatively power- of using viability judgements in their decision-making against
ful actor sees as problematic. For example, in the 2010 South those of not using them. Experience suggests that recognizing
African political climate neither scenarios 1 nor 2 were likely to and seeking to take account of stakeholder positions and power
have enough support to be taken forward, given the lack of is, on balance, the better strategy.
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i73

Table 6 Stakeholder interests

Stakeholder group Interests

South Africa Tanzania
Party of government Contribution to broader political agenda of redistribution Government focus on MDG achievement along with
and improved ‘service delivery’ for the majority poor as national strategy for growth and reduction of poverty
espoused in 2007. (NSGRP) targets.
Minister of Health and Social Welfare committed to
expanding insurance coverage to 45% by 2015.
Opposition parties Fit of type of financing reform with economic ideology Commitment to increasing resources to health and
and policy preferences. enforcing exemptions from user fees (CUF, Chadema);
free primary health care for all (CUF); development
of a community health insurance scheme (Chadema).

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Trade Unions ANC-aligned Unions: The broader political agenda of (Not interviewed, but likely to be concerned about the
redistribution secured through change in ANC balance interests of their members in terms of affordable,
of power in 2007. good quality care.)
But also the ‘bread and butter’ interests of their members
(affordable, good quality care).
Ministry of Finance Fit of health care financing reform with wider economic Fit of insurance reform with wider economic policy.
officials policy (e.g. concern for employment and growth Concerns about accountability of public funding
impacts) and specific policy instruments (e.g. tax (resistance to health facility accounts).
instruments).
Ministry of Health National and provincial departments: contribution to Concerned with increasing the number of primary
officials strengthening health system, but also concerns about facilities and increasing access to health care through
future roles in health system after NHI implementation greater enforcement of exemptions within the user
and personal impacts on health cover for families. fee system and expansion of insurance cover.
Lobby for additional funding for health from the Ministry
of Finance.
Public sector managed n.a. NHIF: desire to control the health insurance sector, and
insurance schemes consolidate power by absorbing other schemes.
Private health sector Providers: purchasing arrangements and opportunities, Providers: resistance to capitation funding; desire for
actors threats to market growth. increase to reimbursement rates; greater collaboration
Insurers: pooling and governance arrangements, and with government through public–private partnership.
opportunities, threats to market growth. Insurers: concerns with moral hazard, desire for greater
regulation, interest in expanding into informal sector.
Health professionals Public: direct impact on work environment and payment Public: chronic health worker shortage, affects motivation
mechanisms. and quality of care. Salary concerns.
General: impact on professional and salary opportunities.
Business sector Employment costs. Same as South Africa.
Worker health and productivity.
Social sector – Civil Improved health care for poorer and vulnerable groups. Increase civil society participation in health policy
society decisions.
Specific concerns about equity in the allocation of and
funding for human resources for health.
International actors n.a. Desire to promote equity in access to care, distribution
of funding and human resources in the health sector
through the development of a health financing strategy.

Notes:
MDG ¼ Millennium Development Goal.
ANC ¼ African National Congress.
Chadema ¼ Chama Cha Democracia na Maendeleo.
CUF ¼ Civil United Front.

Developing a political management strategy Trade Unions), or because different groups within the overall
As noted, a range of visual maps can be used to summarize a actor grouping had different perceptions of gains and losses
stakeholder analysis. Forcefield analysis maps (Varvasovszky (Department of Health officials).
and Brugha 2000), for example, provide a comprehensive Such maps can help identify the broad viability of a particular
picture of the balance of support and power around a policy policy direction (or proposal), as well as highlight potential
issue at a particular time. Figure 1 presents a forcefield analysis supporters and opponents. Figure 1 suggests, for example, that
map focused on the broad idea of universal coverage reform in the balance of power in South Africa in 2010 was probably
South Africa in 2010. Stakeholders identified in italics had the broadly in favour of UC reforms, but that this could not be taken
potential both to support and oppose reform—perhaps reacting for granted. In part this was because it appeared that a range of
differently to different reform dimensions (e.g. ANC-aligned stakeholders had not yet taken a clear position and so, in effect,
i74 HEALTH POLICY AND PLANNING

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Figure 1 Forcefield analysis map, South African UC reform debates 2010

were not mobilized as supporters or opponents. The map suggests (b) Continuing to group together supportive actors with
that the policy drivers pursuing UC needed to adopt active varying levels of power through the policy committees
stakeholder management strategies with the aim of getting responsible for developing proposals, to build their
enough sufficiently powerful supporters behind the preferred overall power;
policy direction to secure the next steps towards policy change. (c) Maintaining the shared vision of the ANC’s 2007 ‘service
Schmeer (1999) suggests that stakeholder management delivery’ agenda (which included NHI), to allow co-
strategies should target those stakeholders who are willing to ordination among the different interested and powerful
initiate or lead an action for or against a new health policy, or actors within the ANC and government, ultimately
convince others to do so. Roberts et al. (2008) suggest that perhaps even drawing the Cabinet into support.
stakeholder management can focus on changing:
(2) Offsetting opposition through:
 the positioning of policy actors (through deals, promises,
trades and threats around the policy issue of focus); (d) Maintaining the fairly long-standing division within
 the distribution of power among key players (e.g. by the health insurance industry that results from com-
dividing the opposition or providing resources to supporters petition for members between schemes, undermining
to empower them); its overall power;
 the number of actors actively engaged in the policy process (e) Convincing the National Treasury, a powerful opponent
(e.g. by creating friends and discouraging foes); of reform in 2010, that its objections about the total
 actors’ perceptions of policy problems, issues and solutions costs of employment, and impact on employment
(e.g. by changing how people think and talk about them, levels, of the UC scenario did not hold, as the total
and which values are perceived to be at stake). costs of employment would be less than under the
Given the 2010 South African actor map (Figure 1), it might status quo scenario.
have been possible to sustain moves towards comprehensive In addition, in developing such strategies it is essential to
health financing reform by: start by being clear about the power (e.g. formal positions,
(1) Building support through: knowledge, rhetorical and interpersonal skills, charisma,
connections and networks) of the policy drivers who will
(a) Encouraging large employers to become active sup- implement them (or advocates pressing for change) relative to
porters, by persuading them that the UC proposals others, and to think about how they can strengthen that power.
would reduce their workforce costs; It is also important to think about when and how to implement
 STAKEHOLDER ANALYSIS TO SUPPORT UNIVERSAL COVERAGE i75

the actor management strategies within a broader political does not entail generalization about which UC reform package
management strategy. The limited published experience around offers most gain in any setting, but rather about how to
political management and health financing (Glassman et al. manage the reform process within a particular context.
1999; Thomas and Gilson 2004), as well as relevant theory
derived from experience (Moore 1995; Brinkerhoff and Crosby
2002; Roberts et al. 2008), suggest that such strategies must
Funding
consider:
This research was funded by the International Development
 which stakeholders to prioritize for engagement: perhaps Research Centre (IDRC) (Grant number 103457) and the
those who have complementary resources to you or who European Commission (Sixth Framework Programme; Specific
have enough power to block/resist policy momentum, or Targeted Research Project no: 32289). Preparatory work by Judy
who make key decisions relevant to UC reforms, or whom Daire was funded through a post-doctoral fellowship under the

Downloaded from http://heapol.oxfordjournals.org/ at National Institute of Education Library, Serials Unit on April 27, 2015
you cannot do without when implementing reform; South African Research Chairs Initiative of the Department of
 an overarching communication strategy to create support Science and Technology and National Research Foundation.
and offset opposition through the symbols, words and
messages used around UC proposals, and especially by
senior political leaders and policy champions (such as the
Minister of Health or President);
Conflict of interest
 where and when key decisions of relevance to UC will be None to declare.
made—and how to influence those decisions;
 the broader decision-making moments likely to influence
the overall movement towards UC, which may either act Endnote
as catalysts for opposition to UC (parliamentary debates, 1
In August 2011 the South African government released a Green Paper
legislation hearings, provider salary negotiations) or offer on NHI for public comment, with proposals that broadly resemble
opportunities to push ahead with policy (political elections scenario 3.
or routine budget cycles);
 the unexpected—as every process of policy change, especial-
ly around high politics issues such as UC, is dynamic and
contested;
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