Political Impetus: Towards a Successful Agenda-Setting for Inclusive Health Policies in Low- and Middle-Income Countries; Comment on 'Shaping the Health Policy Agenda: The Case of Safe Motherhood Policy in Vietnam'

Agenda-setting is a crucial step for inclusive health policies in the low- and middle-income countries (LMICs). Enlightened by Ha et al manuscript, this commentary paper argues that ‘political impetus’ is the key to the successful agenda-setting of health policies in LMICs, though other determinants may also play the role during the process. This Vietnamese case study presents a good example for policy-makers of other LMICs; it offers insights for contexts where there are limited health resources and poor health performance. Further research which compares various stages of the health policy process across countries, is much needed.

T here is growing consensus internationally that health policy-making should be more inclusive. Such a policy approach can ensure better and equitable access to care for target populations. Further, the interventions within such inclusive policies must be evidence-based; for instance in the maternal and child health (MCH) arena, the focus on skilled birth attendance as a strategy for ensuring safe motherhood. However, providing the "public good" in inclusive policies requires a rather large resource input, usually a challenge for governments in low-and middle-income countries (LMICs). This paper draws upon Ha et al case, 1 and reflects upon the key factors for inclusive health policy-making in LMICs, based on Vietnam's experience with maternal health policymaking.

Agenda-Setting of Inclusive Health Policy is a Political Process
Agenda-setting is the initial and crucial step of a policy cycle. 2 For LMICs where resources are limited and the health situation is poor, agenda-setting gains particular importance and urgency. But the attention of the decision-makers in the government to address public health issues is always limited, given that there are many more public policy issues besides health to be taken care. The key question then is: What can persuade the decision-maker to select the public health priorities from numerous competing public policy priorities? This is an important question for researchers in LMICs -as a better understanding the conditions and mechanism for a successful agenda-setting, can help set the stage for more effectively influencing the policy process to achieve the public health goals. From Vietnam's case, what we found is that agenda-setting is not only the technical verification for certain policy options, but it is also a political process. During this process, in Vietnam, the government is usually the most influential actor because of its strongest implementation capacity, its ability of controlling resources such as funds, personnel, materials, and its consideration of accountability.

Multiple Political Mechanisms Led to the Agenda-Setting
Ha et al rightly chose the theoretical model of "policy window" proposed by Kingdon, 3 as an effective analytic tool to explore the black box of policy process particularly the initial stages. The statement of "policy window" model argues the confluence of problematic events, policy options' availability, and political wills would lead to the agendasetting on a certain issue. However, a simple concurrence of all the three policy streams cannot naturally lead to a particular agenda being set; and the so called "confluence" expectedly contains complex internal interactions between the key determinants, such as people, events, evidence, etc. Ha el al 1 paper provides a good empirical example with a sophisticated application of the theoretical lens to the case of maternal health policy process in the Vietnamese context. Moreover, this paper introduced the determinants of actors and evidence into the analysis, which are more closed to the reality and has further enriched the theoretical framework. From this paper, we figure out several insightful viewpoints.
"Political Stream" as the Fundamental Determinants Through the lens of the "policy window, " there are three major types of key determinant in the case of safe motherhood policy in Vietnam. They are, the political awareness, the policy option and the maternal health problems. "Political stream" is the underlining impetus playing not so visible, but surely a fundamental role. 4 The adoption of Millennium Development Goal (MDG) goals (especially the MDG 5) indicated the top level commitment of Vietnamese government on enhancing human development issues, which greatly raised the political priority of MCH-related affairs, and provided a favorable environment for the development of the National Plan of Action for Safe Motherhood (NPSM). With the political background of MDGs, decision-makers in Vietnam were pushed to take the relevant actions -this was perhaps due to tacit international pressure or perhaps the result of policy actors leveraging the opportunity offered by the international environment to put maternal health on the national policy agenda forefront. In parallel, the "policy stream, " known as the national strategy of reproductive health in the case, provided a clear and feasible operational option for the decisionmakers to turn to. Finally, the "problem stream, " the evidence from the maternal mortality survey, became the crucial and final piece to catch the decision-makers' attention, and to precipitate decisive policy action. In general, the "confluence" process of the case indicates that only under favorable political background, the evidence and policy options could be put on the policy agenda. The case illustrates how the political will is the internal impetus, while the policy problem and policy options are perhaps more the external triggers, shaping the health policy agenda-setting.
The Policy Champion's Leverage Role Another highlight of Ha et al paper is the discussion on the policy champion. Although, and as discussed earlier, given the competing policy priorities for decision-makers, it is very hard to get the maternal health policies high on the priority list of the decision-makers. Ha et al 1 demonstrate how, therefore, it is necessary or even critical to have some key persons who could successfully persuade the authority to bring certain issue onto the policy agenda. Ha et al highlight the critical roles such persons, aptly called "policy champion, " 5 can play in the policy process. From the Vietnamese case one can see that how important it is for the policy champion to be in the right position (Ministry of Health) in order for him/her to find the potential opportunity to leverage the policy window. The case also indicates that a policy champion must also had a good command over and ability to use evidence, to draw the political attention to leverage the policy window. The case highlights how the role of a strong policy champion, particularly in a resource constrained setting of LMICs, needs to go further, to also include the mobilization of evidence to take the agenda forward -in Vietnam, the policy champion mobilized the World Health Organization (WHO) to provide funds for maternal mortality survey which was eventually seen as much more reliable and authoritative during advocating with the Ministry of Health to develop the safe motherhood policy. The case also highlights the importance of personal credibility of the policy champion; that the policy champion was an obstetrician with 40 years working experience, served as a persuasive argument towards policy-makers in itself. All of these made him as a strong advocator and effective in shaping the policy agenda-setting process.

The Supportive Contextual Environment
The contextual factors at that point of time in Vietnam's polity also facilitated the policy agenda-setting. In this case, the institutional arrangement, and influence from the donors was also a political consideration, which in turn facilitated the agenda-setting. The existing policy framework or macro governance pattern, as set by the Vietnamese National Strategy of Reproductive Health and the guideline for monitoring, supervision and evaluation Ha et al case exemplifies how the presence of a high level policy framework increases the political legitimacy of the specific policy option, so that the local governor feels responsible and willing to take action. This paper also leads us to reflect on the effective way in which the engagement of and assistance by international donor, can shape the policy process. This case emphatically shows how the international conventions have been effective in being translated and internalized into the domestic policy in LMICs. The findings also suggest that the international donor community should take better cognizance of those factors shaping successful agenda-setting locally in LMICs, eg, the political focus and the policy champion, support to whom from the donors would greatly facilitate the policy process and in turn create the desired effects of development assistance.

The Needs for the Further Research
In general, Ha et al paper gave us valuable insight into the successful agenda-setting of health policy in LMICs. However, one paper cannot cover all the key points, and there would be some additional points to be stressed in the research in the future. Firstly, it is important expand the focus on later stages of the policy process. We assume that the political impetus, policy champion would still play a key role in the following policy stages, and it would be very interesting to understand how the process further plays out. Obviously there are many other analytical models on policy-making and implementation, and we really look forward more in-depth analysis based on the practical experience from Vietnam. Secondly, we think it is valuable to make international comparisons with other LMICs. As Chinese researchers, we find quite a lot of similarity between these two countries in the MCH policies, but also some difference like the role of civil society organizations or donors. Therefore, it would be interesting and worthwhile to compare the domestic experience to outside of Vietnam, to get more valuable findings on maternal health policy.