As we have been conducting diagnosis at the other levels of our ecological model, our individual educational diagnosis, our community diagnosis, our organizational diagnosis, we also need to conduct a policy diagnosis to learn how the process happens, what are the priorities, how it can be influenced. Policy diagnosis includes efforts to understand the actions and motivations of people at these three policy levels: those who establish the policies, those who interpret the policies, and those who are expected to carry them out. These diagnoses must find out what their knowledge sources are, how do they make their decisions, where do they get input, do they by chance have access to research, do they get information from lobbyists, do they get information from the community. It's important to realize that policy research does not often have immediate impact on government decisions because of the many pressures on politicians to make their decisions. New technical knowledge, things like iodized salt, creep into the policy making process and gradually alter the assumptions and concepts of the people who make policy. One of our former heads of department, the Department of Preventive Medicine at the University of Iowa, who is retired now came back to give a lecture and he addressed this issue. The researchers in Nigeria were in the forefront of looking at the importance of iodized salt in Nigeria, and had conclusive results of its benefits. And yet, it wasn't until 11 years later that government, through the Ministry of Health, acknowledged this and developed policies that would help encourage those companies that produced or imported salt to take this up. Oftentimes, they say the prophet in his own land is not recognized. It was back in the 1950s that the issue of growth monitoring of children, the importance of salt sugar solution during diarrhea was recognized and pioneered in a hospital in the western part of Nigeria. Because at that time, there were staff from places such as London who moved to different parts of the developing world, they shared these ideas, they published these ideas, and eventually, organizations like UNICEF and other ministries of health picked up on the ideas and brought them back to Nigeria, and it wasn't until 1984 that a policy of oral rehydration and salt sugar solution made at home became part of the normal healthcare policy. Policy knowledge reflects subtle shifts, diffusion of ideas, or issue of diffusion of innovation and ideas and communities can also be applied in the policy arena. With the particular exception or particular characteristic that much is at stake in terms of policymaker decisions because of resource allocation. And so, it's not simply a matter of ideas eventually spreading from one member of a legislature to another but also an idea gaining salience and political worth. Researchers in Mexico documented that policy making depends on the political context not necessarily on the need or health relevance of the particular problem. They found not only did researchers have a small input, but under certain political conditions, the public itself had very little input into policy making. Interestingly enough, the government of Mexico is just in the process of changing, for the first time in over 70 years, a different party is in power and this may make it possible for the researchers' hopes that democratic changes in the country would make it possible for more public input included and that more input by researchers and research findings into policy making. They also noted that policy making, in developing countries in particular, depends in large degree on the influence of donor agencies. One can possibly even see this in the US in terms of the influence of money that's made available by federal government programs and whether county health departments or state health departments accept the strings attached in order to get the money. Prior to the late 1980s, there was no clearly stated policy in Nigeria on malaria but because a number of donor agencies were concerned about malaria control, experts were assembled and a malaria policy was developed and later adopted by the National Council of Health which includes health ministers from all the different states. Programming such as family planning, guinea worm control is often instigated because foreign money is made available, foreign expertise is offered, and ministries go along with these programs. Not that there isn't need, not that guinea worm does not need to be eradicated, not that high parity and maternal mortality are not serious problems, but focus on these to the exclusion of other problems has been a common observation. Policy formation goes through different stages according to one model. Stage model sees sequential steps of gathering information, making decisions, designing strategies, determining funding, involving different institutions and actors along the way. The stage model is useful for identifying the times and places and different tactics for influencing policy but it can also be misleading in the sense that the policy making process is not linear. The multi-stream model looks at the different flow and timing of policy action and variety of inputs, various interpretations of the problem that needs priority policy attention, alternative solutions, political pressure occur throughout the policy making system just like force field. And over time, one force or another may be stronger. At some point, a priority or compelling problem is linked to a strategy or solution that meets the test of political feasibility and is accepted. This merger in time and place of resources and needs results through sustained effort by policy entrepreneurs or advocates for policy change. In fact, in addition to using a stream metaphor, one can use a web metaphor, policy making and learning occur within a web of interacting forces involving multiple sources of information. Again, information that may be persuasive, information that comes from people with an agenda that policy making takes place in the context of complex power relationships and changing institutional arrangements. Different agencies come and go. Agencies provide much of the technical component. Legislatures change every so many years, different issues arise in the environment, lobbying groups change over time.
