Table 2 Political strategies and associated pressures

Political strategies

 • Favor representatives visits to establish direct relationships with medical specialists and key actors;

 • Emphasize the incremental benefit harbored by the technology;

 • Group together as an association to make unified claims;

 • Lobby for funding, promoting innovation, and proposing new ways to reach the main users of the technology.

In reaction to

 A new set of rules

  • The context of bureaucratization and current budget restriction complicated, codified and institutionalized exchanges between actors;

  • A new set of rules has emerged;

  • There is a large difference concerning the latitude and the freedom of agency between managers and appraisers, as well as medical specialists.

 An increasing number of actors

  • “It can be difficult to explain something very complex in a short message to an increasing number of different actors”;

  • Efforts are increasingly targeted towards medical specialists, while less informative information (and therefore, less technical features) is provided to the other actors involved in the acquisition process.

 A misalignment of goals

  • The need has to be clearly identified by purchasers and it has to coincides perfectly with the technological offer;

  • “The champion is frustrated, because he says we do not understand and yet we have needs; the industry is frustrated because it has a champion, and does not understand why it’s not working; managers are frustrated because they would like to try it but they need more information”;

  • “Administrators do not take the patient’s health into account because they rely only on their annual budget”;

  • Resistance to change may be much greater than the simple fear towards newness found in the target users of the new technology;

  • “Even though we have this study and had the money to do it people must still be prepared to use and pay for it.”

 A complex bureaucratic hierarchy

  • “People have new positions in newly recreated decision-making bodies that were not even there when the initial decisions were taken; the latter cast doubt on decisions that have been taken before.”