Stakeholder analysis for the development of a community pharmacy service aimed at preventing cardiovascular disease

Abstract

Background

Participatory approaches involving stakeholders across the health care system can help enhance the development, implementation and evaluation of health services. These approaches may be particularly useful in planning community pharmacy services and so overcome challenges in their implementation into practice. Conducting a stakeholder analysis is a key first step since it allows relevant stakeholders to be identified, as well as providing planners a better understanding of the complexity of the health care system.

Objectives

The main aim of this study was to conduct a stakeholder analysis to identify those individuals and organizations that could be part of a leading planning group for the development of a community pharmacy service (CPS) to prevent cardiovascular disease (CVD) in Australia.

Methods

An experienced facilitator conducted a workshop with 8 key informants of the Australian health care system. Two structured activities were undertaken. The first explored current needs and gaps in cardiovascular care and the role of community pharmacists. The second was a stakeholder analysis, using both ex-ante and ad-hoc approaches. Identified stakeholders were then classified into three groups according to their relative influence on the development of the pharmacy service. The information gathered was analyzed using qualitative content analysis.

Results

The key informants identified 46 stakeholders, including (1) patient/consumers and their representative organizations, (2) health care providers and their professional organizations and (3) institutions and organizations that do not directly interact with patients but organize and manage the health care system, develop and implement health policies, pay for health care, influence funding for health service research or promote new health initiatives. From the 46 stakeholders, a core group of 12 stakeholders was defined. These were considered crucial to the service's development because they held positions that could drive or inhibit progress. Secondary results of the workshop included: a list of needs and gaps in cardiovascular care (n = 6), a list of roles for community pharmacists in cardiovascular prevention (n = 12) and a list of potential factors (n = 7) that can hinder the integration of community pharmacy services into practice.

Conclusions

This stakeholder analysis provided a detailed picture of the wide range of stakeholders across the entire health care system that have a stake in the development of a community pharmacy service aimed at preventing CVD. Of these, a core group of key stakeholders, with complementary roles, can then be approached for further planning of the service. The results of this analysis highlight the relevance of establishing multilevel stakeholder groups for CPS planning.

Introduction

Current approaches to health planning underline the importance of involving stakeholders across the health care system early in the planning process, in order to overcome challenges in the implementation of health services into practice.1, 2, 3 According to Varvasovskzky and Brugha,⁴ stakeholders are “actors who have an interest in the issue under consideration, who are affected by the issue, or who – because of their position – have or could have an active or passive influence on the decision-making and implementation processes.” Theory⁵ and experience6, 7 suggest that multilevel stakeholder groups bring different benefits to health service planning processes, such as in-depth knowledge of the context in which the service will be implemented, innovative ideas, and logistic and financial support. Moreover, the collaboration between stakeholders makes health service planning more transparent, nurtures networking, increases the translation of research findings into practice, fosters co-learning, and develops stakeholders' feelings of ownership on the planned health services.8, 9, 10, 11, 12, 13 As a result of participatory planning approaches, health services and associated reforms of the health care system are not only more likely to address the existing or emerging population and system needs, but also to be suitably and efficiently developed, implemented and evaluated.2, 5, 10, 14

According to the guidelines for the design of participatory processes,¹⁵ these processes must be informed by a stakeholder analysis (also called stakeholder mapping). A stakeholder analysis encompasses identifying and assessing the individuals and organizations that have a vested interest or can influence a particular initiative. Thus, stakeholder mapping can be used to generate knowledge about the relevant actors related to a particular issue allowing for a deeper understanding of their relative influence and interest on a problem. Importantly it can also provide useful information on the likely role that they may or can play in solving the problem. As a result, the stakeholders that are critical and crucial for the success of a particular initiative can be clearly determined, and solutions that are feasible and acceptable from multiple perspectives can be found.10, 16 Due to their usefulness, stakeholder analysis are applied in a variety of sectors (e.g., business management,¹⁷ public and non-for-profit management,¹² health management,¹⁶ health policy,¹⁶ biosecurity risk,14, 18 natural resource management research¹⁹). Reed and Curzon¹⁰ described three different theoretical approaches to stakeholder mapping (i.e., normative, instrumental and descriptive) along with the methods that can be used for identifying and categorizing stakeholders, and analyzing their relationships. Bryson¹² described a range of stakeholder identification and analysis techniques classified into 4 broad categories according to their purpose: (1) organizing participation; (2) creating ideas for strategic interventions; (3) building a winning coalition around proposal development, review and adoption; and (4) implementing, monitoring and evaluating strategic interventions. Despite their wide use, stakeholder analyses are often undertaken without following a systematic process.¹⁹ Different methods for data gathering have been described in the literature, including interviews with individuals; structured questionnaires; workshops and focus groups with multiple participants; expert opinions; snowballing sampling; etc.16, 19 It should be noted that the theoretical approaches, methods and techniques to be used in a particular stakeholder analysis should be selected and adjusted according to the particular purpose of the analysis, the timing in which it is conducted (i.e., stage of the project) as well as the availability of resources.¹⁶ In order to facilitate the understanding of the complexity of the results of stakeholder analyses, various graphical techniques can be used, including stakeholder maps and matrices. For example, Hernández-Jover et al¹⁸ used a stakeholder identification map for the representation of stakeholders and several matrices in which stakeholders were located according to their influence and interest on 3 core issues.

In the context of health service planning, conducting a stakeholder analysis at the onset of the planning process not only clarifies the complexity of the context in which services will be implemented but also avoids the involvement of stakeholders who are not representative.9, 10 In this regard, a recent analysis on current service development practices highlights the role of stakeholder maps in explicitly conducting an early exploration of the ‘ill-defined problem space’ before generating a particular solution.²⁰ Despite its importance, stakeholder mapping is poorly described in the health service literature, where, interestingly, a number of articles reporting the development of health programs that used participatory planning approaches lack this type of analysis.6, 21, 22, 23 Without such information, it is difficult to understand the reasons behind the involvement of each stakeholder or to be certain that the key stakeholders have been engaged. An appropriate description of stakeholder analysis24, 25 meets the recommendations for comprehensively reporting participatory processes⁶ and increases the transparency of such processes, allowing for their evaluation and improvement.

Participatory planning approaches are useful in pharmacy practice, where the development, evaluation and implementation of services, and the integration of community pharmacists into the health care team still remains a challenge.26, 27 The planning process and development of CPSs is further discussed elsewhere along with some general information about how research can inform such a process.²⁷ A stakeholder analysis is a type of study that should be conducted at the outset of the CPS planning process to inform the group of stakeholders that may be involved in such a process. A multilevel stakeholder group may help understand and address the complexities of the health care system in which community pharmacy services (CPSs) need to be embedded, and so improve the implementation of those services.27, 28 A specific area in which CPSs are seen to be particularly relevant is in the prevention of cardiovascular disease (CVD),²⁹ which is a major public health problem.30, 31 According to the World Health Organization, interventions at the primary-care level are considered to be the optimal approach to reverse the progression of CVD, prevent long-term complications, and reduce the use of associated health care resources.³¹ Community pharmacists are highly accessible health care professionals at the primary-care level and their positive impact on the control of cardiovascular risk factors has already been shown.²⁹ In order to promote the development and further implementation of a CPS aimed at preventing CVD in Australia, this study conducted a stakeholder analysis to identify those key stakeholders that could be part of a leading planning group. As a secondary objective, current gaps and needs in cardiovascular care and the role of community pharmacists were explored.