Spotlight: Stakeholder Analysis

October 1, 2016

Stakeholder Analysis is an important tool in the planning of targeted interventions for NCD control and prevention. The multiplicity of NCDs and their associated risk factors necessitate parallel methods that are interdisciplinary (Thomas and Gostin 2013). While coordination between disparate groups can be quite complex, examining linkages between stakeholders is useful in revealing opportunities and challenges. Concannon (2014) defines “stakeholders” as “an individual or group who is responsible for or affected by health-and healthcare-related decisions that can be informed by research evidence.” In this essay, I will also be using Concannon’s “7Ps framework” to map stakeholder connections in relation to NCDs activities:

The first, patients and the public, represents the current and potential consumers of patient-centered health care and population-focused public health. The second is providers, including individuals and organizations that provide care to patients and populations. Purchasers, the individuals and entities responsible for underwriting the costs of health care, such as employers, make up the third group. The fourth group consists of payers who are responsible for reimbursement of medical care, such as insurers. The fifth is composed of public policy makers and policy advocates working in the non-governmental sector. Product makers, representing drug and device manufacturers, comprise the sixth group, and principal investigators, or other researchers, make up the seventh. (Concannon et al. 2012, paper’s emphasis) “A New Taxonomy for Stakeholder Engagement in Patient-Centered Outcomes Research”

Policy Makers and Principal Investigators

How do we effectively utilize these connections between identified stakeholders? Concannon (2014) calls this “stakeholder engagement” – that is, “a bi-directional relationship between stakeholder and researcher that results in informed decision-making about the prioritization, conduct and use of research.” Cottrell (2014) would also agree, but at the same time, advocating for a more proactive union, suggesting that “stakeholder engagement” is the “active engagement of stakeholders in the selection, design, funding, and conduct of research,” allowing stakeholders to “participate in research meetings or comment on research proposals, to more resource intensive, including the use of Delphi techniques to reach consensus about research priorities and involving stakeholders directly making funding decisions or conducting research” Therefore, the ideal situation would be when both sides are able to direct research towards a single focus.

In this particular arrangement of stakeholders, policy makers and principal investigators have important roles to play regarding research production and usage. Stakeholder engagement for NCDs works two ways: making sure that research is aligned with health policy and making sure that research is actually implemented. A disconnect between research and policy is a major barrier. If there is no agreement of health priorities between the parties, valuable NCD research risk being either absent or underutilized.

Insufficient evidence generation of NCDs in low- and middle- income countries currently poses a major challenge. Jones and Geneau (2012) observed lower number of research literature on NCD interventions in LMICs than in higher-income countries. Fan and Song (2015) also found that there is glaring lack of RCTs conducted on NCDs in LMICs when compared to more developed countries and that those RCTs conducted in LMICs “tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias.” How important is country-specific research? Much of the risk factors like unhealthy diets have cultural determinants (e.g. Cameroon, Ghana, and in other parts of Africa where obesity is a symbol of good-living; or smoking habits which have strong social drivers like peer groups), therefore we need context-specific approaches. Policies should be used to create regulatory mechanisms for research quality and for research quantity.

The research gap is exacerbated by the fact that NCDs are often low on priority lists, falling under communicable diseases, even though NCDs comprise more of the burden in some cases (Thomas and Gostin 2013). Many countries still seem to be slow to action in responding to the NCD crisis. In China, for example, where NCDs make up 80% of the total disease burden and an estimated 70% DALYs lost annually, NCDs remain well below health priorities such as infectious diseases, maternal health, and child care (Tang et al. 2013). How decision makers set priorities can greatly influence how the research environment is orientated. Goyet et al. (2015) found that there are a disproportionate number of studies between communicable diseases and noncommunicable diseases in Cambodia, noncommunicable diseases being understudied relative to their disease burden. Surveys also found that researcher interests often lined up with current health priorities (e.g. Kilic et al. 2014). Stakeholder engagement of this type should ensure that decision makers have at their disposal accurate and up-to-date evidence. Moreover, we should also acknowledge the opportunity for a feedback loop: policy makers directing principle investigators to areas that have insufficient research, principle investigators informing policy makers of findings, policy makers refining priorities for continued studies, and so on – each regulating the other side.

Furthermore, policy makers need to consider partner stakeholder concerns. In a recent study on obstacles to NCD research in Turkey, researchers responded that major challenges to working on NCDs included “inadequate opportunities for specialization due to heavy teaching workloads, the lack of incentives to pursue research, a lack of financial resources even when interest existed, and insufficient institutional mechanisms for dialogue between policy makers and researchers over national research priorities” (Kilic et al. 2014). Stakeholder engagement hinges on a proactive political will in attracting, incentivizing, and supporting principle investigators to NCDs. Policies targeted to this end, swinging popularity to neglected areas, is an important step for improving the dissemination of knowledge.

Lastly, when quality research is generated, clear communication channels is vital for transitioning research into practical application or as Concannon (2012) states “to move research evidence off of bookshelves and into practice.” Policy Makers must act as research distributors, but principle investigators must also advocate for their own findings, making sure that research is not completely alienated from those that have or might have an interest in the research.

The search for efficient and effective solutions depends on enthusiastic stakeholder engagement. If policy is able to ensure the quality and sufficiency of evidence produced, the benefit will be enormous as evidence flows through the stakeholder map, enlisting other stakeholders to the same goals.

Patients/Public and Providers

Much of the literature on NCDs have advocated integrated primary health care (PHC) as a crucial measure in the fight against NCDs (e.g. Checkley et al. 2014 and Abegunde et al. 2007). There are obvious advantages to having a strong PHC system for both the prevention and control of NCDs.

In the area of prevention, primary providers divert catastrophic costs simply by providing early intervention so that disease does not get a chance to develop to a stage requiring continuous treatment. Early detection and patient counseling has shown to be cost-effective and successful in reducing risk factors as well as improving outcomes in high-income countries (Beaglehole et al. 2008). Ideally, a primary health care focus would provide individualized care – a provider that will offer regular check-ups and who is familiar with individual family histories, able to inform individuals of a predisposition to disease, and able to advise on lifestyle changes (e.g. to stop smoking or reduce alcohol consumption). If the connection is strong between stakeholders, meaning that there is mutual respect and trust, the role of providers could be very useful in addressing the tricky challenge that is behavior change for healthier lifestyles.

A major challenge of NCDs is ensuring access to primary health care for all people. Lacking this valuable source of information means that many will not have the chance to address their health problems before it becomes irreversible. Poor and rural areas of LMICs are most at risk for this unfortunate situation. Xiao (2014), for instance, discovered that in rural areas of southern China “only one quarter of DM[Diabetes Mellitus] patients in rural areas were aware of their illness, compared to 40% among urban patients; one fifth of rural patients and two fifths of urban patients received treatment for diabetes.“ Similarly, Silva-Matos and Beran (2012) found low levels of awareness among NCD patients in Mozambique – “just over 10% of people identified as having diabetes knew they had this condition.” Reaching all potential patients is the most pressing challenge. At the same time, decision makers will lack a major source for information to properly set priorities. The obvious barriers to guaranteeing health care access is the lack of human resources as well as the policy changes needed to solve the challenge (I will address these problems further in the following section).

Where treatment is concerned, providers play an important role in the management of illness that will often last a patient’s whole life: “to identify patients’ needs, plan care over time, monitor responses to treatment, and access health outcomes” (Beaglehole et al. 2008). Resource-scarce settings highlight the value of this stakeholder connection. In areas estranged from the main health system, patients will need the help of a provider who is able to navigate a sometimes faraway resource. In this way, providers can act as a hub for patients to reach other stakeholder groups such as Payers and Product Makers.

Inconsistent stakeholder relationships can negatively affect evidence generation. So policy-wise, the first steps should be aimed at identifying regions where these two stakeholders, provider and public/patient, are disconnected from each other and then connecting public/patient to PHC pathways. There is an enormous opportunity here for health systems to develop PHC alongside the progress towards reducing NCDs.

Provider and Policy Makers

As stated previously, a PHC focus would be essential to providing consistent and reliable health data on NCDs. The preferred source of surveillance data would be at the primary level due to its cost-effectiveness and convenience (if PHC are utilized enough). As NCDs are an umbrella term for a host of diseases, there is a strong risk for surveillance data fragmentation if NCD patients are diffused through secondary or tertiary levels of health care. We see this particular situation in Tunisia where many patients often skip over primary care to private providers due to inadequacies in PHC: “Patients face a lack of specialist staff, a shortage of essentials drugs, long waits for appointments, and lagging quality of service” (Ben Romdhane et al. 2015). In non-integrated systems, NCD data can be quite dissimilar among providers. And field data collection done by independent bodies can be logistically challenging being prone to informal methods and dependent upon unreliable situations (Deepa et al. 2011). The gap between these provider groups prevents quality information from reaching the policy makers. Integration is needed among facilities offering specialized care for NCDs as well as perhaps standardized protocols for health surveillance.

More often than not LMICs do not even have the formally trained human resources to tackle such an undertaking due to “brain drain” movement and urban/rural differences in distribution. This is a major problem with no easy remedy. However in regions where the lack of trained health workers is glaring, task-shifted community health workers have proven to be quite effective in surveying and screening for NCDs (e.g. Menon et al. 2014 and Joshi et al. 2014). More importantly, task-shifting will allow for the scaling up of prevention and treatment programs for NCDs thereby increasing access of health care in underserved areas. If task-shifting policies are implemented adequately, this will provide a solution to the awareness gaps seen in the previous section. Decision makers will then also recover a source of NCD data.

In addition to being information brokers, community workers are often asked to meet other roles required of them by the community such as organizing community groups for health promotion activities, educating patients on self-treatment (task-shifting to the patient), and managing interventions (Ogedegbe et al. 2014). Much of the literature agree that task-shifting can effectively reduce NCDs, but the challenge here for policy makers is ensuring up-to-date evidence flows to this stakeholder allowing them to provide more quality of care – which we can see as implementing research on the field, an extension of the Policy Makers and Principle Investigators group.

The onus is policy makers to maximize this particular resource. A supportive work environment is key for improving health care and retaining scarce human resources. Policy support should foster a continuous information exchange: community providers being a source of surveillance data and policy makers being a source of practical research. In order for this loop to work, stakeholder engagement on the side of the community provider requires empowerment – being able to demand meaningful reforms from policy makers.

Policy Makers and Patient/Public

Much of our previous groups have stressed for a more collaborative union, but in this case, we should emphasize the need for the Patient/Public stakeholder to disturb the balance of power as there is often a gross skewing of power between the public and the governing bodies in LMICs. The patient/public stakeholder needs to demand prioritization for NCDs in order to mobilize lethargic governments. Moreover, this stakeholder has opportunity to make best use of stakeholder analysis as they are able to involve themselves in every other stakeholder group via stakeholder engagement. At the same time, the civil/social will has to also be directed internally towards condemning harmful substances and promoting healthy lifestyles. The position of Patient/Public in the middle of evidence flows, poised to evaluate the commitment of their government to these health goals, is essential to demanding transparency in evidence generation, holding the government accountable for lapses in evidence, and calling for PHC reforms in neglected regions where there is an absence of adequate health care.

Conclusion

The “7Ps Framework,” being a patient-centered definition, does have limitations as it fails to account for a range of additional stakeholders farther away from this core nucleus. If we were to consider changing unhealthy diets, for example, we would need to map another level of stakeholders such as food producers, food suppliers, and other commercial enterprises along the supply chain. A modified stakeholder framework for LMICs would also require categories to include global organizations and partnerships since these global forces are very influential in LMICs’ priority setting for health. Nevertheless, the “7Ps framework” is a good starting point for identifying immediate stakeholders, and it is capable of generating sufficient evidence through stakeholder collaboration. How do we design policy that is far-reaching, able to elicit cooperation from diverse but connected sectors? Careful examination of every possible linkage has the potential to contribute meaningful recommendations and foster significant policy improvements toward the control and prevention of NCDs.