Introduction

Emergency contraception is defined by the World Health Organization (WHO) as a contraceptive method used after sexual intercourse that can prevent more than 95% of pregnancies [1]. The most effective and widely used method is the emergency contraceptive pill, which prevents pregnancy by preventing or delaying ovulation without inducing abortion [1,2]. The availability of emergency contraception varies worldwide; it is estimated that of the 195 countries, 147 have at least one brand of emergency contraceptive pill registered, and 47 have none. It is noteworthy that 66 allow access through a pharmacist, 19 allow purchase without a prescription, and some require a legal representative for minors under 18 [2]. Unwanted pregnancy is a significant public health problem. Direct consequences for women include delayed prenatal care, physical and psychological violence, and mental health problems. Children may experience physical and mental health problems, as well as difficulties in school. Thus, it has a financial impact on the affected woman, her family, the community, and the healthcare system. Although rates of unwanted pregnancy have declined overall, inequalities persist based on race, age, income, educational level, and other factors [3]. Unfortunately, due to misconceptions about how it works, emergency contraception legislation has not had an impact at the population level.

In Chile, the Chilean Institute of Reproductive Medicine began studying the issue in 1995. In 2001, the first emergency contraceptive pill was registered. Later, in 2007, a lawsuit was filed challenging the constitutionality of the Fertility Regulation Act, and finally, in 2010, Law No. 20,418 was enacted.

Currently, the role of policy analysis in public health evaluation is increasingly recognized [4]. This is because health system interventions have unpredictable implementation paths, and interpretive and time-dependent decisions by different actors underpin the subsequent process. Public policies refer to specific solutions for managing public affairs or socially problematic situations. On the one hand, a research team can use evaluation to provide information on policy performance to establish the degree of success achieved or make decisions on how to make improvements to achieve results [5]; and, on the other hand, it can use analysis to answer questions related to policy development [4].

When analyzing public policies, it is essential to employ robust conceptual models, such as the health policy analysis triangle, developed in 1994 by Walt and Gilson. This model encompasses the general areas of content, context, actors, and the policy-making process [6].

In Chile, the introduction of the emergency contraceptive pill as public policy has generated considerable public debate and various legal challenges to limit its distribution and use [7]. The milestones that marked the history of this public policy, consolidated with the enactment of Law 20.418, which established the obligation to provide emergency contraceptive pills to all women, can be analyzed using Walt and Gilson’s health policy analysis triangle, since it represents a framework for analyzing health policies that emphasizes the need to consider who (actors) and how (process) decisions are made, what decisions (content) are made, and under what conditions (context) [8].

Viewed in this light, the present study aims to analyze Chilean public policy on access to emergency contraception from the perspective of Walt and Gilson’s health policy analysis triangle. The purpose is to generate evidence on relevant actors, implementation dynamics, activities carried out, and decisions made over time regarding this public policy.

Methods

Study design and search strategy

This work is a retrospective case analysis with a qualitative analytical approach, supported by literature review methods, official online reports, and analysis of relevant documents [9,10], aimed at identifying the public policy governing access to the emergency contraceptive pill through the framework of Walt and Gilson’s health policy analysis triangle [6]. The general areas studied were content, context, actors, and the policy-making process. Content includes policy objectives, operational policies, and related elements. Actors refer to individuals and organizations that act and exert influence. Context alludes to the social, economic, political, cultural, and environmental conditions that may affect public policies. The process denotes how policies are initiated, developed, or formulated, negotiated, communicated, implemented, and evaluated, from agenda-setting through formulation, implementation, and evaluation [4,8]. Walt and Gilson’s health policy analysis triangle links these variables by showing how they influence and interact with one another, placing actors at the center of the triangle [11].

As inclusion criteria, official websites and ministerial reports were incorporated. As the exclusion criterion, only documents that were not available online were excluded.

Recognizing that public policy itself is a determinant of the use of emergency contraception [12], the components of Walt and Gilson’s health policy analysis triangle were organized following a historical structure related to four time periods that characterized the political process of establishing access to the emergency contraceptive pill in Chile.

Data sampling

The information search was conducted from December 2022 to March 2023. A search strategy was developed using the key terms emergency contraceptive pill, public policy, and health policy, combined with the Boolean operator “AND,” in the databases OVID, MEDLINE/PubMed, ClinicalKey, LILACS, and SciELO. Filters were applied for publication years (2000-2022), research area (policy), document type (article, critical analysis, or case study), language (English, Spanish, or Portuguese), and text availability (abstract and full text). Additionally, various documents were reviewed using a manual snowball sampling approach.

Data analysis and processing

Abstracts from each selected study were reviewed, applying eligibility criteria and relevance to the subject matter. The data obtained was used to generate a descriptive qualitative analysis based on historical background, implementation milestones, and relevant actors. The data from the different studies were summarized using a narrative-qualitative synthesis, considering a timeline constructed as the primary analytical structure. No ethics committee was required.

Analysis

An initial search found 30 documents. After a critical analysis in accordance with the study objective, 19 documents were selected: ten scientific articles, seven ministerial documents, and two documents from international organizations. Together, the multidisciplinary texts allowed for the analysis of the access to emergency contraceptive pills policies to be structured according to the components of Walt and Gilson’s Health Policy Analysis Triangle: actors, content, context, and process [8].

Based on the analysis of the historical structure, the process was divided into four time periods according to the political milestones that occurred, as presented in Table 1.

Stage 1: Manifestations of the conservative-liberal axis (1995 to 2000)

The emergency contraceptive pill in Chile has been the subject of political and judicial controversy [13], materialized through various legal remedies since March 2001, a similar situation to what occurred worldwide, which hindered legislative progress.

While the global history of emergency contraception dates back to the 1960s [2], in Chile, the political tensions surrounding the introduction of this method into the public health system began in 1995, when the Chilean Institute of Reproductive Medicine initiated its study [14]. The first legal actions consisted of filing constitutional protection actions (recursos de protección) before the Santiago Court of Appeals to obtain authorization for the first product, Postinal. These actions were supported by cross-cutting civil society organizations and reflected the conservative–liberal axis [13]. From 1995 to 2000, there was a series of political, media, and judicial campaigns targeting distributors of emergency contraception and the general public.

Stage 2: Harassment and shortage campaign (2001 to 2006)

Between 2001 and 2006, a campaign of harassment and drug shortages began to develop through a series of legal actions by conservative political actors. It has been demonstrated that people’s perceptions have a significant impact on public policy, particularly in unstable political environments [15].

Stage 3: Legal proceedings surrounding the national fertility regulation standards (2006 to 2009)

After emergency contraception was included on the Ministry of Health’s list of essential medicines, new litigation gave way to intense questioning of emergency contraception. In this context, Walt and Gilson’s health policy analysis triangle could be applied comprehensively to analyze the situation.

Stage 4: Enactment of Law No. 20.418 and subsequent regulatory advances (2010 to 2021)

Following the historical milestones of previous periods, new political processes led by new social actors emerged in this stage, culminating in Law Number 20.418, signed by President Michelle Bachelet in January 2010, along with further regulatory improvements that delineated reproductive rights. The World Health Organization stated that all women and girls have the right to emergency contraception when faced with an unintended pregnancy, and national family planning programs should make it available [1].

In the historical process of developing and implementing the policy for access to the emergency contraceptive pill, resistance to change stood out, originating mainly from conservative groups both inside and outside government, as well as members of civil society. However, there was also strong political support from citizens and aligned groups that can be considered stakeholders, according to the political science literature. While it may be tempting to view actors’ resistance to the process, context, and content of this public policy as motivated by a desire to protect life, the significance of women’s reproductive autonomy as rights holders is often overlooked [16].

Finally, it is striking how policymakers found a window of opportunity to secure approval mechanisms and the promulgation of Law 20.418, advancing respect for women’s reproductive rights as a determinant of their health [17]. Regarding the impact of the implemented public policy, it is worth noting that the rate of unplanned pregnancy in Chile has decreased over the years. Unplanned pregnancy without the use of contraceptive methods fell to 22% in 2018 from 42% in 2006 [18].

Through the documentary and bibliographic review presented in this study, it was possible to analyze the factors proposed by Walt and Gilson and to highlight historical milestones related to the Chilean emergency contraceptive pill. In this framework, the authors place actors—individuals and members of groups or organizations—at the center of the model. Below, characteristics emphasized in the literature are discussed, following a historical structure of four stages that characterized the political process under study. Table 2 presents the elements of Walt and Gilson’s health policy analysis triangle for each stage.

Regarding limitations, although the literature clarifies that case studies do not represent a sample of a specific population or universe, but rather a particular phenomenon analyzed using multiple sources of information, the findings cannot be generalized statistically. Instead, they may be used to explain theoretical propositions related to the decision-making processes involved in formulating and implementing this public policy. This is because the investigators’ objective was essentially an analytical–interpretive generalization of the health policy on access to the emergency contraceptive pill.

Conclusions

The documentary and bibliographic analysis of the health policy for accessing the emergency contraceptive pill incorporated the factors that Walt and Gilson consider to be at play when health policies are developed: political actors, context, content, and process. All of these represent core components of those authors’ health policy analysis triangle as applied to this public policy.

Applying the model to the analysis of access to the emergency contraceptive pill enabled the identification of synergistic processes and the reconstruction of the chronological process of drafting and implementing the policy for the use of the emergency contraceptive pill. Added to this framework are the roles of multidisciplinary scientific evidence, external actors, and the mass media, which undoubtedly influence political debates and the associated decision-making process. These influential actors are neither new nor unique to this particular policy process. Moreover, they constitute ongoing areas of attention arising from interactions that reflect a struggle for power and contending forces.

Consequently, it is essential to foster sustained dialogue among policymakers, health professionals, and the community so that policies involving emergency contraception are effective and sustainable.

Accordingly, evaluating emergency contraception in Chile from the perspective of Walt and Gilson’s health policy analysis triangle reveals that, although policies are in place, their effectiveness is compromised by a lack of knowledge and cultural resistance. It is essential to implement educational and awareness-raising strategies that strengthen access to and acceptance of emergency contraception, thereby ensuring that women have the tools needed to make informed decisions about their reproductive health.