Agenda Setting in Public Health Policy

Introduction. Definitions. The public policy process, in simplified form, can be understood as a sequence of four phases: agenda setting, formulation, implementation, and evaluation. Agenda setting is the first phase, the issue-sorting stage, during which some concerns rise to the attention of policy makers while others receive minimal attention or are neglected completely. The importance of this phase lies in the fact that there are thousands of issues that might occupy the attention of policy makers, but in practice only a handful actually do gain their consideration.

Research in this field investigates how issues emerge on the policy agenda, defined (Kingdon, 1984, p. 3)as ‘the list of subjects or problems to which governmental officials, and people outside of government closely associated with those officials, are paying some serious attention at any given time.’ Kingdon (p. 4) distinguishes between the governmen­tal agenda, the list of subjects that are getting attention, and the decision agenda, the subset of issues on the governmen­tal agenda that are ‘up for an active decision.’

Agenda Setting and Priority Setting. The subject of public policy agenda setting has inspired considerable research, but little of that is in the field of public health. There has been much greater attention in public health scholarship to a concept that is related to but distinct from agenda setting: priority setting. While those investigating priority setting in health have studied how scarce resources are allocated among health causes, their predominant concern has been how scarce resources should be allocated, a normative issue.

Often they are moti­vated by uneasiness that resources and attention are not fairly distributed. For instance, the Global Forum for Health Research monitors resource commitments for health research. It is committed to redressing what it calls ‘the 10/90’ gap - a concern that only 10% of the world’s re­search funds are being applied to conditions of the develop­ing world that account for 90% of the world’s health problems (Global Forum for Health Research, 2004).

An assumption in much, if not all, of this research tradi­tion is that there are objective facts about the world - such as the burden caused by a particular disease and the cost- effectiveness of an intervention - that can be used to make rational decisions on health resource allocation. As Reichenbach notes (2002), one example of priority-setting research is cost-effectiveness analysis, which seeks to evaluate alternative interventions based on how much health improvement can be purchased per monetary unit.

A second example is the disability-adjusted life year (DALY), a measure of the number of years of healthy life lost due to individual conditions, enabling comparisons across diseases. Its developers have used DALYs to identify the ten diseases posing the greatest burden globally: peri­natal conditions, lower respiratory infections, ischemic heart disease, cerebrovascular disease, HIV/AIDS, diar­rheal diseases, unipolar major depression, malaria, chronic obstructive pulmonary disease, and tuberculosis (Lopez et al, 2006).

Researchers have also combined studies of DALYs with cost-effectiveness analysis to inform a disease control priority project that offers recommendations concerning which interventions should be prioritized globally (Jamison et al., 2006).

In contrast to priority-setting research, inquiry on agenda setting is concerned primarily with explaining how attention and resources actually are allocated (although agenda-setting researchers often are motivated by norma­tive concerns). Central to their inquiry is an interest in power.

They investigate matters such as which actors are able to put issues on the agenda, how they come to hold this capacity, and how this influence alters agendas away from what might be considered a ‘rational’ allocation ofresources. Reichenbach (2002), for instance, demonstrates that despite epidemiological evidence that cervical cancer presents a higher burden than breast cancer in Ghana, the latter received greater political priority.

This outcome was due in part due to local politics as well as to the influence of international women’s groups from North America, along with the higher incidence of breast than cervical cancer among wealthier Ghanaian women.

Another difference from priority-setting research is that many individuals investigating agenda setting are influenced by a tradition called social constructionism, which views issues not as problems objectively ‘out there’ waiting to be discovered, but rather as created in the process of social interactions.

This idea is similar to the observation that drives agenda-setting research: There are thousands of conditions in society causing harm that may become social priorities, including drug addiction, HIV/AIDS, road traffic injuries, and homelessness. In practice, however, only a handful of these conditions become widely embraced social priorities (Hilgartner and Bosk, 1988).

Thus, we cannot explain how some problems become prominent and others are neglected by appeal to material facts alone: We must also consider social pro­cesses, such as how problems are defined and framed, who holds the power to define them, and how interest groups mobilize to advance their agendas.