Background: Global health policy is created largely through a collaborative process between development
agencies and aid-recipient governments, yet it remains unclear whether governments retain ownership over
the creation of policy in their own countries. An assessment of the power structure in this relationship and its
influence over agenda-setting is thus the first step towards understanding where progress is still needed in policymaking for development.
Methods: This study employed qualitative policy analysis methodology to examine how health-related policy
agendas are adopted in low-income countries, using Tanzania as a case study. Semi-structured, in-depth, key
informant interviews with 11 policy-makers were conducted on perspectives of the agenda-setting process and
its actors. Kingdon’s stream theory was chosen as the lens through which to interpret the data analysis.
Results: This study demonstrates that while stakeholders each have ways of influencing the process, the power
to do so can be assessed based on three major factors: financial incentives, technical expertise, and influential
position. Since donors often have two or all of these elements simultaneously a natural power imbalance ensues,
whereby donor interests tend to prevail over recipient government limitations in prioritization of agendas. One
way to mediate these imbalances seems to be the initiation of meaningful policy dialogue.
Conclusion: In Tanzania, the agenda-setting process operates within a complex network of factors that interact
until a “policy window” opens and a decision is made. Power in this process often lies not with the Tanzanian
government but with the donors, and the contrast between latent presence and deliberate use of this power seems
to be based on the donor ideology behind giving aid (defined here by funding modality). Donors who used
pooled funding (PF) modalities were less likely to exploit their inherent power, whereas those who preferred
to maintain maximum control over the aid they provided (ie, non-pooled funders) more readily wielded their
intrinsic power to push their own priorities
