Healthcare Essay


Hi .. The question is (Discuss different theoretical approaches to explaining health policy agenda setting. Use a specific health issue ( hiv\aids) to support your discussion.)

1- use simple words and easy to understand for the essay
2-Identification the numbers of pages of the resources because i want to know exactly from where the information. ( i have to give to my teacher my resources and the pages numbers with identification)


Health policy


Introduction. 2

The Multiple Streams Theory. 2

The Punctuated Equilibrium Theory. 7

Multiple Implementation Theories. 10

Conclusion. 12

References. 13


One of the bests of explaining health policy agenda setting is through theoretical analysis. Using various theoretical approaches, policy planners in the health sector can gain insights into the procedures, objective, opportunities, and challenges that can be encountered in the process of setting the agenda in health policy. Different theories address agenda setting from different perspectives. For example, the Multiple Streams Theory highlights the random character of public policy while the Punctuated Equilibrium Theory is based on the view that the process of policymaking exhibits periods of incremental policy change disrupted by frequent bursts of rapid transformation (Walt et al, 2008, p. 311).

            The way policymakers understand various issues relating to agenda setting through a specific theoretical perspective greatly influences the problems that they seek to solve and the approaches they use to solve them. The choice of theory also influences the timelines that public policymakers in the health sector are likely to set based on different theoretical approaches. Theory development efforts can be beneficial to public policy practice because of their power to deepen the policymakers’ understanding of causality. The efforts can also enable policymakers bring coherence to fragmented research findings in the area of health policy agenda setting. This way, policymakers are able to thoughtfully conceptualize the policymaking process. The aim of this paper is to discuss different theoretical approaches to explaining health policy agenda setting. To support this discussion, the issue of HIV/AIDS is used.

The Multiple Streams Theory

            The Multiple Streams Theory focuses primarily on the issue of agenda setting. Proponents of this theory argue that in all situations, the agenda setting process in public policy possesses a random character. The theory identifies three core components that exemplify this random character: problems, politics, and policies. Each of these components tends to flow along in various independent streams. In the problems stream, focus is on broad problems facing societies. Some of these problems are correctly identified and the need for public attention is acknowledged. In the policy stream, focus is on a set of alternative ways of setting up policies aimed at addressing national problems. In this stream, technical proposals and ideas are presented with a view to determine the various ways in which problems can be solved. The politics stream is characterized by social pressure, political transitions, and the prevailing political environment. For the government of the day to decide to take action, these three streams must merge. Moreover, their merger must bring with it a window of opportunity for all the participants.

            Many ideas on how to deal with the HIV/AIDS scourge have been adapted from the Multiple Streams Theory. In this process, ideas on how to open up global policy windows emerged. The problem stream was fulfilled by the emergence of HIV/AIDS as a threat to public health at a global level. The politics stream manifested itself through emphasis on economic, symbolic, organizational, politician, and scientific politics. All of these elements of the politics stream imposed preference of child health over adult health. Emphasis was on the primary importance of child health in efforts to deal decisively with the HIV/AIDS menace. At the policy stream, global policy windows opened and many international health agencies took up the fight against the disease from whether national policymakers had left.

            There are many other situations where the multiple streams can be used to improve public policy outcomes in the fight against AIDS. According to Stillwaggon (2009, p. 1), HIV/AIDS policy at the global level is still being treated like an exceptional case that is abstracted from the context in which people become infected. In this policymaking process, a simplistic theory is used in which there is reliance on outdated health economics tools. (Stillwaggon, 2009, p.1). Instead of focusing on one factor only, policymakers should look at multiple factors such as malnutrition as well as increased risk of vertical and sexual transmission. By restricting their scope to health economics in the formulation of a HIV/AIDS policy, those who set the policy agenda in the fight against the disease fail to pay attention to politics stream. They fail to appreciate the complex global political landscape in which policies aimed at fighting the diseases are to be implemented.

            There is also a tendency for the agenda setting process to generate inefficiencies because of failure to incorporate it into mainstream epidemiology (Baltussen & Niessen, 2006, p. 4). According to StillWaggon (2009, p. 2), this problem is more prevalent in developing world than in the industrialized world. Failure to highlight the multiplicity of problems, politics, and policy streams has created a situation where the HIV/AIDS policy agenda setting process focuses on one issue at any given time. For example, during the 1990s, the policy agenda of the day focused almost exclusively on the role of sexually transmitted infections (STIs) as potential cofactors in the transmission of the disease. Later on, attention shifted to antiretroviral therapy (ART) as the best tool for reducing transmission. Today, attention has once again shifted to male circumcision as one of the measures that can lead to a reduction in HIV/AIDS transmission rates. If the policymaking organs gave equal attention to all the three streams at all time, the world would be a step ahead in the quest to record a decisive victory against the killer disease.

            The concept of multiple streams is also applicable to the process of making policies aimed at bringing about success in the fight against HIV/AIDS in China. The existence of the problems stream is demonstrated increasing scientific information regarding the HIV/AIDS pandemic and its impact on the Chinese society. It is also demonstrated by the growing influence of external stakeholders who continue to persistently advocate for strategic planning in efforts to address the potential consequences of the pandemic. The politics stream has been entrenched in several ways. One of them is the existence of government structures as well as networks of relationships. Another one takes the form of recent improvements in the level of political commitment to the fight against the disease at higher levels of government. In the policy stream, the Chinese government’s political will has paved way for legislation aimed at controlling the spread of HIV/AIDS. For example, the government has already introduced the AIDS Prevention and Control Regulations (Wu, et al, 2007, 679).

            To begin with, the Chinese government is keen on control programs targeting sex workers, gay people, injection drug users, and plasma donors. The next top policy issue is routing HIV testing, which is being implemented in the country’s population especially those who are at a high risk of being infected with the deadly virus. The next step entails treatment for infected citizens. For these programs to emerge, China has had to identify the problem, engage in a process of prolonged political dialogue, and secure collaboration with government officials at various levels. The contributions of researchers, policymakers, and service providers have also been instrumental in the identification of the problem as well as the successful launch of decisive actions.

            Today, efforts are ongoing to extend the Multiple Streams Theory. Ridde (2009, p. 938) argues that although the theory has been in use since the mid-1980s, it has only been applied in public policy agenda-setting only in the context of wealthy countries. Meanwhile, upon reporting the results of a study undertaken in a low-income, African context, Ridde (2009, p. 938) concludes that the Multiple Streams theory can indeed be extended to the explanation of the way agendas are set in public policy-making in the developing world. Nevertheless, the study yields several theoretical propositions aimed at extending the reach and applicability of the Multiple Streams approach. One of the propositions is that the theory should be extended to take care of situations where the exclusion of the indigent is not readily identified as a public problem (Ridde, 2009, p. 946).

Another proposition is that the implementation process may sometimes be unsuited to change (Ridde, 2009, p. 946). This normally happens in situations where the primary objective is to reach political ends rather than solve real problems being encountered by a section of the population (Oliver, 2006, p. 198). The desired outcomes may also fail to be realized if there is a selective understanding of policy issues at the local. In the context of low-income countries, such selective understanding is detrimental to the objective of achieving equity. Furthermore, stakeholders in many low-income countries may develop the perception that they are incapable of taking action (Ridde, 2009, p. 946). This perception may be promoted through lack of political will, absence of technical solutions, and under-funding in a healthcare system that is characterized by centralization. Based on these observations, Ridde (2009, p. 948) argues that the propositions of the Multiple Streams Theory should be amended to makes it applicable not just at the federal level but also at the level of local policy process. The theory should also address the issue of policy entrepreneurs, coupling of streams based on windows of opportunity (Ridde, 2009, p. 949).

According to Ridde (2009, p. 949), policy entrepreneurs can contribute to the realization of favourable outcomes in terms of equity. In the extended framework, one would essentially expect most entrepreneurial opportunities to arise in the policy and political streams in the course of formulating policy (Ridde, 2008, p. 1370). Conversely, one would expect the problem and policy streams to become the main sources of opportunity during the implementation phase (Ridde, 2008, p. 1370). The applicability of this extended version of the Multiple Streams Theory is yet to be tested in the context of HIV/AIDS policy agenda setting.

The Punctuated Equilibrium Theory

            The Punctuated Equilibrium Theory is based on the view that the process of policymaking is characterized by episodes of minimal change of policy that is followed by incremental policy change before being disrupted by abrupt bursts of rapidity in transformation. This theory is founded on two central concepts: policy image and policy venue. Policy image refers to the conceptualization of a problem as well as a set of solutions. A certain policy image may become predominant as well as gain procedural legitimacy over a very long period before being challenged at specific moments because of the emergence of new understandings of both the problem and the available solutions (Buse, 2008, p. 357). Policy venue refers to the set of institutions or actors that are responsible for making decisions regarding various sets of issues. Some actors tend to hold monopoly over the policy-making process. However, they eventually encounter competition because of the emergence of new actor whose alternative policy images become more prominent. The policy-making process stabilizes and becomes incremental if both the policy image and venue hold sway for a long time. With the emergence of new actors and images, the policy process benefits from both stability and change.

There are many policy-making situations where the Punctuated Equilibrium Theory is applicable in the formulation of policies aimed at fighting against HIV/AIDS. In this fight, a critical juncture may be said to have been reached when new medical technologies emerged. Another critical juncture was characterized by changes in the demographics of HIV, which include increased attention to children and women. The applicability of the theory may also be tested in the context of various HIV/AIDS programs. In the US, Ryan White HIV/AIDS Program (RW) was established to cater for the HIV-infected individuals encountering the challenge of limited access to medical coverage. For such individuals, the program acts as a “payer of last resort”. Such people tend to be sidelined by mainstream medical insurance programs: Medicaid and Medicare. These programs impose strict eligibility criteria especially among the elderly. The main target group for RW encompasses individuals whose condition has not yet progressed to become AIDS and have not reached the threshold of poverty required for them to get into Medicaid (Mugavero, Norton & Saag, 2011, p. 244). RW is the largest program being implemented at the federal with a specific mandate to address HIV care.

In 2008, the program’s budget amounted to $2.1 billion (Martin & Keenan, 2011, p. 4). Between 1991 and 2001, federal funding for RW increased steadily from $4.1 million to $2.2 billion (Martin & Keenan, 2011, p. 4). It remained steady for a few years but started declining slightly in 2006 (Martin & Keenan, 2011, p. 4). Most of the decisions of the programs are devolved to states. The federal administration provides grants to different jurisdictions through different titles.

According to Martin & Keenan (2011, p. 12), the Punctuated Equilibrium Theory can be used to explain the process of allocating funds to the RW program. When the program was launched, it constituted a major change in policy venue. At that time, the dominant policy image in the US was one where there was widespread recognition that individuals infected with the HIV virus needed to be provided with a safety-net program. Changes in the policy venue undeniably led to a burst of rapid transformation in regards to the policy process. For example, it led to the emergence of a detailed methodological discourse regarding the appropriateness of different allocation formulas. In the current phase of transformation, the debate is characterized by highly technical approaches to resource allocation (Martin & Keenan, 2011, p. 12). This highly technical nature of the debate has started acting as a hindrance to the reformulation of the policy image to make it more appealing to the public (Martin & Keenan, 2011, p. 12). For the policy image to change once again, a significant triggering event should unfold, thereby creating a platform for a new issue to emerge. The new issue should bring about a dramatic change in the way the problem is defined or lead to the establishment of a new policy venue. However, according to Martin & Keenan (2011, p. 12), it is rare for issues to be reframed at the macro-level.

According to (Martin & Keenan (2011, p. 12), another aspect of policy venue in the fight against HIV/AIDS in the US is the fragmentation of interest groups. for example, the AIDS Coalition to Unleash Power (ACTUP), one of the most vocal activist groups that thrived during the early stages of the HIV/AIDS pandemic, has been fracturing in recent times primarily because of racial and gender divisions. Other causes of this fragmentation include conflict of interest between insider and outsider strategies, politics of expertise, and debates over the effectiveness of internal participatory mechanisms (Martin & Keenan, 2011, p. 12). At the same time, the policy image has changed mainly through the emergence of new at-risk population, leading to considerable loss of cohesive group identity.

Today, the HIV/AIDS pandemic is growing most rapidly among the poor who are heavily dependent on public HIV-care programs. In most cases, these poor people lack political power. According to Martin & Keenan (2011, p. 11), infighting as well as the diminishing political power of once-influential HIV/AIDS interest groups may have greatly contributed to a reduction in their ability to confront congressional leaders in regards to the issue of redistributing funds. For the policy-making process to stabilize and become incremental, the dynamism of the new policy venue in the form of activist groups and HIV-care programs such as RW should be maintained. At the same time, the new policy image in the form of a new at-risk population should continue to exist. With the emergence of new actors and images, the policy process in the US will benefit in terms of both stability and change.

Multiple Implementation Theories

            In multiple implementation theories, researchers seek to determine whether decision-making is a bottom-up or top-down process or it is a matter of striking a balance between the two. Even in a stable democracy such as the US, public policy portrays numerous characteristics of the top-down approach. From this perspective, public policy is said to be a reflection of the interests of the governing elite. In this theory, the process of policy development is conceptualized differently from that of implementation. However, it may be possible for bureaucrats to affect the way policy is implemented. Such influence notwithstanding, this theory proposes that all decisions tend to be monitored to ensure that no significant alterations are made. Another dimension within this theoretical framework is the notion that policy tends to be significantly influenced by the so-called “street-level bureaucrats” (Walt et al, 2008, p. 312). These bureaucrats are essentially the front-line staff members who are capable of altering policies significantly.

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            For the most part, multiple implementation theories set out to investigate and explain the gap between policy objectives and the actual process of implementation (Schofield, 2001, p. 255). Most of the issues highlighted in this regard relate to health and education. Unfortunately, most emphasis has been on Western countries, most of which are high-income areas. Like in the case of Multiple Streams Theory, Multiple Implementation theories need to focus more on the public policy needs of low-income countries. Since the circumstances of these two categories exhibit remarkable differences, one would expect to find corresponding variations in the applicability of various provisions of these theories.

            There is also a tendency among researchers to apply social science theory to health policy analysis (Gilson & Raphaely 2007, p. 301). Instead of relying primarily on literature on policy studies, these researchers draw insights from various disciplines including anthropology, organizational management, and sociology (Gilson & Raphaely 2008, p. 301). The most commonly used frameworks include social capital theory (Szreter & Woolcock, 2004, p. 651), social construction theories, state-society theory, actor network theory, innovation theory, and the rational approach rational approach (Hoeijmakers, et al, 2007, p. 113). For instance, in social construction theory, focus may be on how policy-makers promote positive or negative construction of target populations, leading to the perpetuation of health inequalities through unfair distribution of resources.

            Multiple implementation theories are applicable to public policy agenda setting in regards to the fight against HIV/AIDS. For example, Castro & Farmer, (2005) use anthropological theory to make policy suggestions regarding the reduction of stigma subjected to HIV/AIDS patients. Castro & Farmer, (2005) suggest that by introducing high quality HIV care in rural Haiti, the Haitian government can greatly contribute to a reduction in stigma, thereby leading to an increase in the uptake of testing. Regarding the same matter of stigma, Parker & Aggleton (2003, p. 18) emphasize the usefulness of notions of symbolic violence, hegemony, and social processes in efforts to open u new possibilities not just for research but also for intervention.


            All the three theories discussed in this paper provide valuable insights into the different approaches that policymakers use in health policy agenda setting. The Multiple Streams Theory is the most widely discussed approach in public policy literature. It is based on three streams: problems, politics, and policy. Since it was first developed during the mid-1980s, the theory has become dominant not just among policymakers in the health sector but also policy entrepreneurs. The main problem with this theory is that its application has been tested widely in the high-income, Western world but it remains largely untested in low-income countries. In future, researchers should focus more on the applicability of the theory in dealing with various health problems being encountered in low-income countries such as the HIV/AIDS pandemic.

            The Punctuated Equilibrium theory is also gaining prominence in public policy discourse. The arguments it presents in regards to sudden bursts of transformation in the health sector through a confluence of policy images and policy venues are relevant in the context of the fight against HIV AIDS. Similarly, Multiple Implementation Theories provide crucial insights on how to deal with HIV/AIDS stigma while at the same time creating a platform for a multi-disciplinary approach to health policy agenda setting.


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