1. THE INFLUENCE OF STAKEHOLDERS IN HEALTH SYSTEMS AND POLICY In Whose Interest?

2. Who is a stakeholder? An individual or group with a stake in an issue or problem May be part of a formal group  Ex. Professional or trade association May be part of an informal group  Ex. Coalition or community network Interested in influencing the shape, pace or direction of a policy AKA: Interest groups

3. Interests Not Always Apparent People may not be able to identify their true interests  Objective interests: policies or actions that actually affect people  Subjective interests: policies or actions that people think affect them People may have multiple and competing interests See: Stone, Deborah. Policy Paradox, Ch. 9. Interests

4. Groups can influence public perception of “interests” People are more likely to organize around a threatened or actual loss than around a potential gain People are more likely to respond to concentrated benefits or costs than to diffused benefits or costs  Ex. National health insurance movement- diffused benefit to general public; concentrated costs to medical profession, insurance companies, small employers, etc. See: Stone, D. Policy Paradox, Ch. 9. Interests

5. Examples of Stakeholders Consumers: Patients Providers: Health professionals, hospitals Payers: Insurers, MCOs, government Government: Administration, legislators Accreditation organizations Employers: Large, small Suppliers: Drug and device companies Labor: Unions, professionals organizations Political parties Researchers and consultants Media

6. Kingdon’s Categories Business and Industry Professional Labor Public Interest Government Officials (acting as lobbyists) Academic Researchers

7. Mapping Stakeholders Peripheral Related Primary

8. How Are Stakeholders Involved? Agenda setting  Identify issues, ideas or problems  Propose solutions (legislation or regulation) Advocate directly and indirectly  May be proactive (propose new solutions)  May be reactive (block proposals from passing)

9. Forums for Stakeholder Advocacy In the U.S. Legislative branch  Congress, state legislature, county commissioners, etc. Executive branch  Agencies, commissions Courts In Ukraine: ________? Other countries _____?

10. How Do Stakeholders Influence Public Policy? Personal relationships Knowledge  Inform policymakers about issues and policy options  Lobby policymakers, testify in public forums  Conduct research to inform policy debate Financial resources  Contribute to campaigns and political parties  Pay for mass media campaigns  Sponsor research or fact findings  Exercise economic power

11. How Do Stakeholders Influence Public Policy? Electoral resources  Working on campaigns  Contributing to campaigns Mobilizing grassroots  Especially effective if possible to mobilize policymakers’ constituents Access to media and opinion shapers  Affect public opinion  Bring issues to attention of policymakers Lawsuits

12. Stakeholder Analysis Identify the stakeholders  Who is affected by what we do or by the issue under consideration?  Who are allies and opponents of this issue?  Think broadly Identify stakeholder’s interest  Do they support or oppose proposal?  Why?

13. Stakeholder Analysis What is the stakeholder’s influence?  What is the source of their power or influence?  Who do they know? Rank order stakeholders by their importance Are their ways to influence stakeholder’s position?  Redefine their interests  Compromise  Fragment their constituency  Neutralize their influence  Other stakeholders  PR/mass media campaigns

14. Case Study: Hog Waste Spills North Carolina is the 2 nd largest pork producing state in the U.S. Small rural communities (mostly African American) for years complained about the smell of the hog farms 1994-1995: Large hog waste spills-brought media attention to the problem of lagoons Issue: How to address the problem of hog waste

15. Case Study: Hog Waste Spills Primary Stakeholders:  Hog farmers  Didn’t want new restrictions on farming, waste disposal  Concerned about economic impact  Hog producers (Murphy farms, etc.)  Didn’t want any restrictions on farming, waste disposal  Concerned about potential economic impact  Large contributors to Democratic and Republican parties  Wendell Murphy previous powerful Democratic Senator  Low-Income Rural Communities  Wanted to eliminate hog waste- smells, impact on environment  No unified voice (Some rural residents are hog farmers)

16. Case Study: Hog Waste Spills Secondary Stakeholders?

17. Case Study: Hog Waste Spills Issue debated for years with little action Major spills brought headline news- creating a “crisis” Hog industry wanted to relocate to Moore County  Economic base of Moore County is golf and tourism  Country club members concerned about potential impact of hog processing plants on tourism  Close friends with Richard Morgan, one of the most powerful House leaders (Republican)

18. Case Study: Hog Waste Spills Alliance between environmentalists, community activists and Moore County country club officials Led to moratorium on hog operations proposed/pushed by Republican House

19. Conclusion There are many different types of stakeholders with differing interests in health policy The motivation (interests) of stakeholders may vary for any given issue Stakeholders use multiple strategies to influence the healthcare system

20. Conclusion Stakeholders have a significant impact on policies and programs affecting healthcare Evaluating the role of stakeholders requires careful analysis