The Six Dimensions of Advocacy for Health Equity

Overview

Through DRIVERS' work on advocacy for health equity, a  framework was developed to break down advocacy into its main constituent parts. This framework is intended to be 'heuristic', in that it helps you to explore all aspects of an advocacy effort. It was developed as a result of discussions between partners involved in DRIVERS, and is documented in Advocacy for health equity: A synthesis review (Milbank Quarterly, in press).

The framework is termed the 'Six dimensions of advocacy for health equity', and its six dimensions are listed below:

  • Dimension 1: The types of scientific evidence useful for advocacy for health equity efforts and methods of transferring and translating this knowledge to policy-making processes.
  • Dimension 2: Who advocates for health equity and to whom? There are many potential targets, many potential advocates, and also potential intermediaries such as the media or politicians. Who advocates and to whom is often a dynamic and changing situation.
  • Dimension 3: The different categories of advocacy messages (e.g. health as a value & social justice, human rights, environmental sustainability, economic), and how well they fit with your particular issue, goals, context and who you are advocating to.
  • Dimension 4: The importance of tailoring your advocacy effort according to context, political constituency, etc.
  • Dimension 5: The barriers and enablers of effective advocacy.
  • Dimension 6: The practices and activities that could increase the effectiveness of your advocacy efforts (e.g. media outreach, stakeholder analysis, working in alliances, taking advantage of ‘windows of opportunity’).

In the sections below we provide additional information about some of the dimensions, based on our work over the course of the DRIVERS project.

Taking a closer look

The sequence of activities as part of advocacy for health equity

Advocacy is a dynamic and fluent process that does not necessarily follow ordered steps. A cyclical model is provided in many existing toolkits; these appear to be based on the well-established project cycle. However, work in DRIVERS suggests that advocacy involves going 'back and forth' between different stages and rarely follows a linear or cyclical model.

For this reason, and as a result of exercises conducted during a workshop with experts, we propose considering the following two-stage checklist when advocating for health equity.

Who advocates and to whom? (Dimension 2)

Who advocates and to whom is similarly dynamic: the targets of advocacy can become advocates in their own fields. Media has a special position as an effective potential intermediary between these two categories. The following table presents an overview of some of the major advocacy actors.

Enablers and barriers of advocacy for health equity (Dimension 5)

Enablers

  • Making use of evidence in developing messages;
  • Return on investment evidence (both social and economic);
  • Tailor-made messages that attract the attention of target audience(s); these should be communicated in a variety of ways, using different media (including social media);
  • Knowing your audience and aligning agendas with the targeted group of stakeholders in order to maximise interest and impact;
  • Repeating the message and linking it to something the target audience(s) value;
  • Choosing opportune times, particularly "windows of opportunity", to increase the effectiveness of efforts.

Barriers

  • Some stakeholders involved in developing messages may simultaneously be the targets of advocacy; this can create confusion about purpose of advocacy.
  • Advocacy is often an ad hoc responsibility, covered by different persons at different times depending on resources - there is not usually a specific advocacy role in organisations.
  • The nature of advocacy has changed over time (e.g. over the last ten years) and advocates increasingly need to look outside political structures to have an impact on policy.

Practices that can improve the effectiveness of efforts (Dimension 6)

Advocacy for health equity is a highly dynamic process, and there are many things to bear in mind. Below is a list of the main points noted by experts from across Europe:

  • Consider the issue at stake, the political and economic context, possible cultural issues and timing;
  • Define the issue and the concrete goals of the advocacy action;
  • Tailor messages by country or context;
  • Try to develop advocacy messages that change ‘hearts and minds’;
  • Prepare a priority list or ranking of advocacy targets;
  • Identify the right individual rather than the “right type of person” and engage him/her directly through lobbying;
  • Try to find "champions", who can work within their own organisations or based on their own influence to help the effort - and make efforts to keep them on board!
  • Aim to act as an interface between sources of information and the target audience while aligning the agendas and interests of the various parties involved. This requires flexibility and creativity;
  • Build alliances when appropriate, but remember that alliances are unwieldy and require skill and effort to maintain;
  • Try to time the release of different messages so that different messages are not sent out at the same time.

The following more general points may also be worth bearing in mind:

Working in alliances: Health is determined by social determinants of health, which requires broad alliances from different sectors and with different interests. This requires particular skills and capacity building as part of an explicit advocacy strategy.

Different levels of governance (e.g. national, European): It's important to consider the regulatory framework and the level of governance itself. What level of governance is responsible (or "competent" in EU jargon) to take action? Regions increasingly have responsibility for health, but not in all member states. Advocating at the local level may involve targeting or working with strong personalities who yield considerable power. The right arguments need to be chosen according to level.

Lobbying: Lobbying within administration can be extremely limiting to a career, unless the ‘right’ idea is advanced at the right time. Political cycles are important – most are short term. Try to adapt advocacy to these ideas; even mentioning them as part of your efforts can draw attention!

Negative repercussions of being an advocate: Being an advocate within the civil service or academia can have negative repercussions. Outsiders may therefore have much more potential power to challenge the current agenda and change issues. Advocacy can therefore seem more or less overt depending on where the advocate is placed.

Translating “advocacy” into other languages: Advocacy translates differently in different languages. Being an advocate is usually not a profession in Europe, unlike in the USA, though certain sectors specialise in it.

Effectiveness? Some indicators of success

How do you know if your advocacy effort is effective? This is important, not only so you can improve your efforts but also because your funder may want to know. Following are some possible indicators that could be used to help you evaluate the success (or otherwise) of your efforts - these are ordered roughly in order of importance, most important first:

  • Resources are allocated to addressing the issue;
  • An interest group/all-party group is set up to champion the issue;
  • The private sector is interested in the issue and in funding actions on it;
  • You see your issue mentioned in other sectors’ policies and initiatives;
  • The right people take up your cause and agree to sit around a table to discuss things and take action;
  • The problem is discussed publicly;
  • The media reports your message;
  • Stakeholders adopt ‘the vision’ and use the same language;
  • You/your organisation are/is seen as an ‘expert’: you are asked to give input and people know your organisation';
  • Your issue is addressed in official documents, reports, policy recommendations;
  • Politicians publicly acknowledge the issue (interviews, press, speeches);
  • People contact you to discuss get more information about the issue;
  • Everyone involved in the coalition plays to their strengths and performs, and there’s shared trust within the coalition;
  • You identify the key person who can make the change or changes the balance.