In the Name of God Original Slides based on Thomas Bossert, Ph.D. Harvard School of Public Health

بـه نام خداوند جـان و خـرد کزین برتر اندیشه بر نگذرد جوهر است انسان و، چرخ او را عرض جملـه فـرع و پـايه اند و او غـرض

Knowledge generation Social movement Political linkage The that moves the mountain

What Starts The Cycle of Reform? Economic crisis Political change External pressure Unhappy interest groups

Health Sector Reform Context

Problem Definition Diagnosis Policy Development Implementation Evaluation Political Decision The Simplified Policy Cycle

Define The Problem Identify Causes Develop Options Implement Evaluate Decide What to Do The Health Systems Reform Cycle POLITICSPOLITICS ETHICSETHICS

Characteristics of Health Systems Complexity: multiple actors with multiple connections Complexity: multiple actors with multiple connections Conflict: different participants have different objectives Conflict: different participants have different objectives Politics matters: decisions inevitably reflect political process Politics matters: decisions inevitably reflect political process Societal context matters: conditions and options reflects culture, history and social norms Societal context matters: conditions and options reflects culture, history and social norms

Politics Affects All Stages in The Policy Cycle Defines problems for debate Defines problems for debate Defines solutions considered Defines solutions considered Shapes adoption of proposals Shapes adoption of proposals Shapes implementation of reforms Shapes implementation of reforms

How Do We Know Which Aspects of Performance Matter? Different groups will have different views Different groups will have different views Political processes often produce an uneasy compromise Political processes often produce an uneasy compromise Reformers can influence those processes Reformers can influence those processes Reformers have to consider ethics and values to know what performance problems to focus on Reformers have to consider ethics and values to know what performance problems to focus on

The Role Of Ethics In Problem Definition Deciding what aspects of performance matter is not just a technical question Deciding what aspects of performance matter is not just a technical question Deciding what matters requires values Deciding what matters requires values Exploring ethical theory allows us to clarify both our assumptions and their implications Exploring ethical theory allows us to clarify both our assumptions and their implications The problem definition influences all that follows The problem definition influences all that follows

How do people think about political processes for policy change and implementation? –When decisions are made: Policy process sequences –How decisions are made: Decision- making models –Who makes decisions: Stakeholder analysis –Boundaries: Governance rules and Broader Contexts Tools for Political Analysis

Developing Options “Process matters” “Process matters” – how you go about this task will influence the political acceptability and the quality of the plan

Reaching A Political Decision Health sector reform is unavoidably political Health sector reform is unavoidably political Doing better requires : political skill, not just Doing better requires : political skill, not just political will political will

Reaching A Political Decision Stakeholder analysis as a starting point Stakeholder analysis as a starting point From “mapping” From “mapping” to strategy

Many Health Sector Reform Efforts Have Failed at The Stage of Implementation Ministers often lack administrative experience Ministers often lack administrative experience Leaders turn over quickly Leaders turn over quickly Implementation is not considered in program design Implementation is not considered in program design Entrenched interests resist Entrenched interests resist Political attention turns elsewhere Political attention turns elsewhere

Policy Reform is a Profoundly Political Process

Health Sector Reform Requires Technical Analysis (TA) Technical Analysis (TA) Ethical Analysis (EA) Ethical Analysis (EA) Political Analysis (PA) Political Analysis (PA)

Political Feasibility is Created, Not Given What Factors Affect the Political Feasibility of Policy Reform?

Perspectives on Politics Politics is how “publics” and organizations make decisions about health resources and policies and how they implement these decisions. Politics is how “publics” and organizations make decisions about health resources and policies and how they implement these decisions. Politics occurs at: Politics occurs at: –National level (Ministries of Health, Legislatures, etc.) –Local governments and communities (civil society) –International donors and conferences –But also internal to bureaucracies, NGOs, consulting firms and academic institutions, etc. MOH is Cons or bypassed

Perspectives on Contexts Economic: are political and policy options different in wealthy vs. poor countries? Economic: are political and policy options different in wealthy vs. poor countries? Social/cultural: Are there different options in Kosovo? Indonesia? Nicaragua? Social/cultural: Are there different options in Kosovo? Indonesia? Nicaragua? Social Capital: Are communities with higher participation and trust able to implement more effective policies? Social Capital: Are communities with higher participation and trust able to implement more effective policies?

Key Problem: Most health experts see their role as technicians and see politics as an obstacle to getting the “right thing” done. Most health experts see their role as technicians and see politics as an obstacle to getting the “right thing” done.

Good ideas are not worth much If They can not be implemented And “Reform” Could not be implemented without Politics

Main Points Politics matters in policy reform efforts Politics matters in policy reform efforts Politics can be systematically analyzed Politics can be systematically analyzed Applied political analysis can improve your effectiveness as a policy reformer Applied political analysis can improve your effectiveness as a policy reformer

Your effectiveness depends on understanding politics Politics has its own rationality You are competing with other interests and other rationalities for: You are competing with other interests and other rationalities for: – access to government, community and international resources, – making changes in policies and “rules of the game” There are many policies you may want to implement that are not feasible in particular governance structures and political contexts There are many policies you may want to implement that are not feasible in particular governance structures and political contexts

Tools for Political Analysis How do people think about political processes for policy change and implementation? –When decisions are made: Policy process sequences –How decisions are made: Decision-making models –Who makes decisions: Stakeholder analysis –Boundaries: Governance rules and Broader Contexts

Policy Process Sequence Signaling Evaluation & Feedback Consultation and Formulation Aggregation Implementation Ratification

Policy Cycle 1 Signaling Signaling –Health technical experts using epidemiological and financial data, international models, etc. –International agencies like World Bank –Protests and political activism Formulation Formulation –Develop a proposed policy change to solve problem that was signaled –Who participates?

Policy Cycle 2 Aggregation Aggregation –Advocacy –media and lobbying –finding out who supports and who opposes –mobilizing the non-mobilized –Bargaining, negotiating and changing the proposal to gain more support –Are implementers involved? Gain “buy-in” and information on what might not work Gain “buy-in” and information on what might not work

Policy Cycle 3 Ratification Ratification –What is the “arena” of decision? President, Congress, Minister of Health, City Council, Mayor, Health Department –Who are the key actors in each arena?

Policy Cycle 4 Implementation Implementation –Stakeholders are different –Inertia of bureaucracies –Active resistance by “losers” –Creating new institutions Start fresh and attract talent Start fresh and attract talent Create political interest in reform Create political interest in reform –Political, Social and Economic Constraints –Unforeseen events – war, economic downturns, disasters

Policy Cycle 5 Feedback Feedback –Did it work? Evaluation planned from beginning (base line) Evaluation planned from beginning (base line) –Why not? Design problem? Design problem? Implementation problem? Implementation problem? –Start cycle again

Decision Making Models (Allison’s Models) Rational Actor Rational Actor Organizational Processes Organizational Processes Bureaucratic Politics – Bargaining Bureaucratic Politics – Bargaining

Rational Actor Model Single actor Single actor Goals and objectives (or problems) Goals and objectives (or problems) Alternative options -- for reaching goals Alternative options -- for reaching goals Value maximizing solutions Value maximizing solutions

Organizational Process Organizations have their own goals Organizations have their own goals “Satisficing” “Satisficing” Incremental decision making Incremental decision making Standard Operating Procedures (SOPs) Standard Operating Procedures (SOPs)

Bureaucratic Politics – Bargaining “Pulling and Hauling” –negotiation among interests “Pulling and Hauling” –negotiation among interests Power and Skills Power and Skills Coalitions Coalitions Compromise solutions Compromise solutions “Where you stand depends on where you sit.” don’t stick with “maximal” rational proposal but don’t go below “minimal” acceptable.

Politics Matrix Signal- ing Consulta- tion Aggrega -tion Ratifica -tion Implementa -tion Evalua- tion RationalActorXX?X OrganizationalProcessX? Bargaining?XX?

Stakeholder Analysis: Bargaining Model Elaborated Politics is a game among major actors – individuals, interest groups, broad social groups Politics is a game among major actors – individuals, interest groups, broad social groups Major actors have different positions over policy goals and means to achieve those goals Major actors have different positions over policy goals and means to achieve those goals

Stakeholder Analysis (2) Major actors have different degrees of power to influence the adoption and implementation of different policies Major actors have different degrees of power to influence the adoption and implementation of different policies We can map the actors’ positions and power in relation to specific policy proposals and their implementation We can map the actors’ positions and power in relation to specific policy proposals and their implementation

Stakeholder Analysis (3) We can develop strategies to increase the amount of support or decrease the amount of opposition to a specific policy in both the “aggregation” and “implementation” stages We can develop strategies to increase the amount of support or decrease the amount of opposition to a specific policy in both the “aggregation” and “implementation” stages

“Think it over...”

Political Feasibility of a Policy Depends on PLAYERS in the Policy Process PLAYERS in the Policy Process POWER of the Players POWER of the Players POSITION of the Players POSITION of the Players PERCEPTIONS of the Policy PERCEPTIONS of the Policy

Positions Actors take positions on “goals” and on “mechanisms” to achieve goals Actors take positions on “goals” and on “mechanisms” to achieve goals Actor positions are not always obvious Actor positions are not always obvious Positions on some parts of reform proposal are relatively fixed Positions on some parts of reform proposal are relatively fixed Other positions may change if you change the mechanisms Other positions may change if you change the mechanisms Positions may change in the process of implementation Positions may change in the process of implementation

What Determines a Political Actor's Political Power? Actor’s own Resources Actor’s own Resources Institutional Structures (opportunities and obstacles) Institutional Structures (opportunities and obstacles) Political situation (changing priorities) Political situation (changing priorities) Implementation of some policies may change power of some stakeholders Implementation of some policies may change power of some stakeholders

Estimating Power Usual Political Powers Money Money Votes Votes Skills Skills Organization Organization “Our” Political Power Credibility Credibility Expertise Expertise Information Information Access Access Commitment Commitment

Political Strategies for Increasing Support for Reform Your objective is to: –Increase the number of supporters and decrease the number of opponents –Increase the power of specific supporters and decrease the power of specific opponents

Tools for Strategies Compromise Compromise –Move from “maximizing” policy to “best compromise” Mud slinging Mud slinging –Question motives or goals of opponents Trades Trades –Offer support for other issues in return for support for yours

Tools for Strategies (2) Change Perceptions Change Perceptions –Use new language: “population control” becomes “family planning” becomes “reproductive health” Create “information packets” Create “information packets” –Target information to interests of different actors –Deny opponents negative information

Tools for Strategies (3) Create a “change team” Create a “change team” –Core of like-minded technocrats –“friends in high places” – place friends in other ministries – “colonize” other institutions –Problem of keeping the team together during implementation

Tools for Strategies (4) Additional “implementation specific” strategies Additional “implementation specific” strategies –Participation of implementing stakeholders in formulation and aggregation stage –Convince resistant stakeholders that change is inevitable – Dylan’s “get out of the way if you can’t lend a hand, ‘cause the times they are a changin.” –Use the enforcement power of the state to sanction those who do not implement

Governance and Contexts Do Political Regimes Make a Difference? Do Political Regimes Make a Difference? –Democracy vs Dictatorships? –Types of Political Parties? Does Decentralization make a difference? Does Decentralization make a difference? How should Ministries of Health be organized? How should Ministries of Health be organized? Does Social Capital of Communities Make a Difference? Does Social Capital of Communities Make a Difference? –More participation and trust = better policies?

Who Initiates Decentralization Reform? Broad Process of Reforms to Increase Power of Local Governments Broad Process of Reforms to Increase Power of Local Governments Ministry of Health Leading Decentralization Reform Ministry of Health Leading Decentralization Reform Imposed by External Initiatives? Imposed by External Initiatives?

Who is in favor of decentralization? New Democratic Leaders New Democratic Leaders –Cory Aquino in Philippines Dynamic Ministers of Health Dynamic Ministers of Health –Ketele Kalumba in Zambia Donor Agencies Donor Agencies –World Bank, WHO, USAID Local Governments Local Governments –Associations of Local Governments

How do we estimate their power? When is presidential support enough? When is presidential support enough? Are political parties reliable supporters? Are political parties reliable supporters? Can donor initiatives be a political liability? Can donor initiatives be a political liability? Are associations of municipalities organized enough to lobby? Are associations of municipalities organized enough to lobby?

Who is Opposed to Decentralization? Central Ministry Officials Central Ministry Officials Regional and District Ministry of Health Officials oppose devolution Regional and District Ministry of Health Officials oppose devolution Unions of Health Providers Unions of Health Providers Political Parties in Opposition if Governing Parties propose Reform Political Parties in Opposition if Governing Parties propose Reform

Potential pros & cons proscons MOH Now / Future position Loss of Power MOH Officials Now / Future position Loss of Power /Job Security MOH Province Gain Power Future position Local GOV Gain Power Future problems

Powers of Opponents Media attacks Media attacks Unions strike Unions strike Political Parties block legislation Political Parties block legislation

Political Feasibility of a Policy Depends on PLAYERS in the Policy Process PLAYERS in the Policy Process POWER of the Players POWER of the Players POSITION of the Players POSITION of the Players PERCEPTIONS of the Policy PERCEPTIONS of the Policy

PERCEPTION STRATEGIES Change Nature of the Issue Reframe the problem definition by introducing new language Reframe the problem definition by introducing new language Associate your cause with positive symbols Associate your cause with positive symbols Get endorsement from credible public figures Get endorsement from credible public figures Use conflict and victims Use conflict and victims

NEGOTIATION TIPS Avoid value-dividing negotiations (I win, you lose) Avoid value-dividing negotiations (I win, you lose) Seek value-creating negotiations (win- win outcomes) Seek value-creating negotiations (win- win outcomes) In conflicts, try principle-based negotiations first, and seek to build trust In conflicts, try principle-based negotiations first, and seek to build trust

Hazards of Formulation and Adoption Assuming that adoption is end of process Assuming that adoption is end of process Isolation of reformers within Ministry Isolation of reformers within Ministry Ministry refusing to participate in broad reform Ministry refusing to participate in broad reform Local governments do not participate in reform formulation Local governments do not participate in reform formulation

Hazards of Implementation Central Ministry can undermine decentralization by control of certification, norms, funds Central Ministry can undermine decentralization by control of certification, norms, funds Unions of civil servants can protest and can ally with opposition political parties Unions of civil servants can protest and can ally with opposition political parties

Conclusion Every Top Middle manager in Health have to: Have a political Map Do stakeholder analysis periodically Learn political skills Have a change team

Thanks for your kindly attention