Having supportive family planning/reproductive health (FP/RH) policies is integral to the existence of successful health systems and strong FP programs. Supportive policy has been identified as one of 10 elements of successful FP programming. Policy is also one of the four components of the FP Effort Score used to measure the strength of an FP program. A supportive (or enabling) policy environment is defined as one in which:

• laws and executive orders mandate provision of products and services without imposing undue restrictions on providers or eligibility requirements on clients;
• government and civil society leaders openly speak in favor of RH services and healthy practices;
• public and private resources are adequate to ensure full population coverage; and

• the policy formulation process is characterized by good planning principles and broad participation.

The policy environment is not static, but constantly changes in response to changes in the political and economic arenas, to changes in availability and costs of RH technologies, and to emerging public health issues. Thus, any policy evaluation must address the processes by which policies are formulated and revised as well as the policies themselves.

In order to create a politically supportive environment for FP/RH programs, several policy products/outputs can be developed, such as a law or regulation, a macro-level sectoral policy or financing mechanism, or an operational policy that includes rules, regulations, guidelines, norms, or standards. Several stakeholders can be involved in advocacy and policy dialogue to shape the law or policy. The policy is then officially drafted and voted on by policymakers.

Policy Implementation

Much has been described on how FP/RH policies are developed. However, there is limited evidence on how policies are implemented and what effect they ultimately have. FP/RH policies are implemented within complex political, sociocultural and economic environments. A conceptual framework developed by the Health Policy Project articulates how these complexities relate to one another and how policy development and implementation can lead to better health systems resulting in improved health outcomes. Attention to the policy implementation space implies the following:

• the institutions expected to implement the policy, both at the national and decentralized level,  are clearly defined;
• attention is paid to the institutional relationships and power dynamics among the organizations;
• organizations have the capacity to implement the policy;
• financing is sufficient and resource allocation mechanisms are in place to fund the policy;
• the policy is accompanied by strategic planning and an analysis of policy barriers; and
• strong monitoring and accountability systems are in place.

How FP/RH policies are made, who makes them, and how contentious the issues being addressed are, all have implications for its implementation.

Methodologies for Conducting Research on Policy Implementation

Studies conducted to identify how policies are implemented and measure the effect of their implementation on health systems and health outcomes need to acknowledge how multifaceted the   systems are in which policies are applied and the challenges associated with measuring impact. Several methodologies have been used to conduct policy research. These include descriptive methodologies such as literature reviews and case studies which are commonly used to describe individual examples of how a particular policy was implemented in a specific context. Analytic methodologies used in policy implementation studies include stakeholder mapping and analysis, cross-sectional surveys, and system dynamics. More rigorous methodologies such as quasi-experimental and experimental studies have been used in recent times to show the impact of national and decentralized policies on health systems and even in some cases, improved health outcomes.

Because multiple factors interplay during the implementation of a policy resulting in a specific outcome, policy implementation in one environment at a given time is not replicable in a different environment. Since the study of policy is a complex process involving several stakeholders at various levels of implementation, many studies to date have relied on qualitative research rather than large quantitative surveys to document the details of the policy implementation process. Because of this and the gap in evaluations of policy implementation, more evaluation studies are needed to analyze and document the policy implementation process and highlight the effect that policy implementation has on FP/RH programs and on health outcomes.

Methodological Challenges of Evaluating Policy

• Policy is difficult to quantify.

With few exceptions (such as size of health budgets), policy indicators are inherently qualitative. That is not to say they are not objectively verifiable. Most indicators use a nominal scale (e.g., presence/ absence of a policy), and some indicators may be ordinal (e.g., higher or lower checklist ratings). Even when interval or ratio measures are theoretically possible (e.g., percentage of population in favor of a particular policy), policy and program evaluation budgets are seldom large enough to include them on an on-going basis.

• Policies operate at different levels.

Within the same country, policies can be enacted at different levels of the program and by different
processes. For example, national level FP policies may apply to all government and private health entities in a country. However, decentralized operational policies may only apply to health services in a district. Hence, decentralization adds a further layer of complexity.

• Policy change is usually incremental.

A given policy is complete when it receives official approval at the highest level at which it was intended (e.g., a legislative action signed into law by the president, program protocols published by program director). This is often a multi-year process; adopting an all-or-none criteria (approved vs. not yet approved) may mask significant improvement in the policy environment. Those involved in field applications may find it useful to include benchmarks or progress toward approval (e.g., drafted, discussed in committee, submitted for approval, approved, revised, and updated) as part of the indicator’s definition. In addition to whether a particular policy exists or has been recently adopted, evaluation of the policy environment should consider factors that improve the probability of its implementation, such as political and popular support, and sufficient resource allocations.

• Several factors affect implementation of policy.

Supportive policies improve RH programs only to the extent that the policies are implemented. Most policy assessments include at least the content of the policy or policies. A host of other factors within the policy environment influence policy implementation including the actors involved in the policy reform, the processes used to carry out the reform, and the context within which the policy was developed. Political and popular support, participation, and the planning process itself should be included as policy indicators, because they affect both the likelihood of implementation and the process of policy formulation.

• It can be difficult to establish the link between policy implementation and improved health outcomes.

Conducting rigorous FP/RH policy research has several unique characteristics and challenges. The position/status of the researcher can have an impact on study outcomes. There can be a lack of transparency, collaboration and communication between the government, development partners and agencies, thus preventing the researchers from gaining the necessary information to clearly identify how policies have been implemented. As controlled experiments cannot be conducted in policy studies, we cannot measure attribution and causality. Policy research includes complex variables since several components of policy research interact with each other and this interaction varies by the policy being studied and the specific context. Using facility and administrative statistics in an environment with poor monitoring can lead to inaccurate results. Further, we cannot predict the steps policymakers and other players in the field will make, thus making it challenging for researchers to conduct prospective policy research.

Policy Indicators

Since policy development and implementation is a complex process that can involve a varied number of players within a given context, the policy indicators in this database are only illustrative and should be modified and expanded depending on the local context within which they are applied.