tucional) for 72 years, or in postapartheid South Africa under the ANC (African National Congress), what may matter most is a relationship to the leadership structure of the dominant party. In Bangladesh, for example, in 1983, the country’s leader was a new military dictator, who used his substantial political power under martial law to declare a new pharmaceutical policy based on an essential medicines list (Reich 1994). Even that national leader, however, had to contend with intense political opposition from the Bangladesh Medical Association and the multinational pharmaceutical industry. In some cases, political actors seek to shift the venue for decision making to one that they believe will be more favorable to them. Those who lose in the legislature may appeal to the courts. Those who fear that they will lose at the national level may urge decentralization of a policy choice (or the implementation process) to the provinces, where different political parties may be in power. Decentralization can also create incentives for legislative approval in the policy process. Jason Lakin, in his analysis of the recent health reform in Mexico, argues that “prior implementation [of the reform as pilots] in some states and not in others may have actually helped improve the bill’s chances in the legislature by increasing support for the bill among previously excluded states” that wanted similar access to federal resources for health (Lakin 2008, 57). An important part of any electoral political process is the pattern of competition among a country’s political parties. If a group is clearly identified as part of the base of a particular party, its influence will depend on whether that party is in the majority or is part of the governing coalition. Being a swing group can expand one’s influence, especially being part of a party that is courted by multiple potential partners to form a coalition government. All of these contextual factors influence how the political process evolves: whether pharmaceutical policy is considered an important item on the public agenda, whether effective policy proposals are developed and debated, whether top leaders take a positive decision on the proposal, and how an adopted policy is implemented in practice.
Moving to Strategy Development Once reformers have conducted a stakeholder analysis (identifying the key actors and assessing their position and power with regard to the proposed reform), the next step is to design a political strategy to help ensure that the reform will be adopted. The task is to assemble a coalition sufficiently powerful to obtain a favorable political decision. How can reformers turn opponents into supporters, or at least convince them to lessen the intensity of Managing the Politics of Pharmaceutical Policy Reform
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