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The Health Policy Process
Gaston Sorgho, Harvard School of Public Health
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Health sector reform requires
Technical Analysis Ethical Analysis Political analysis Health Reform is often discussed and developed with a great emphase on the technical analysis. This is useful and necessary in the context that one has to elaborate arguments in favor of the reform, to build knowledge on the refom, and finally to convince on the opportunity of a given reform. We have discussed technical analysis in previous sessions. While critical, technical analysis is not enough to insure the reform will move as to a consensuel objective and more important, that the reform will be implemented and sustained long enough to produce the expected results. The technical analysis was discussed largely in the workshop. The ethical analysisaimed to defining / clarifying the basis that justify the type of reform to undertake in that sense it makes explicite the set of values choises underlying the reform. We will not develop the ethical analysis but we need to mention it for purpose of clarity and to completing the picture for the health sector analysis. The policy analysis is strongly correlated to the political analysis and the sens of looking at the HSReform process.Therefore they constitue one single issue with respect to Health Sector Analysis requirement. We are focussing our attention on this step.
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Policy is mainly deciding
What you are going to do about an issue How you are going to do it Who will do it Political Programmatic An overarching course of action A series of objectives and how to reach them A statement of intent A long-term plan
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Health sector reform is a policy reform
Policy reform is a profoundly political process
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Why is policy reform political?
Reform represents a selection of values Distinct distributional consequences ( benefits / looses) Reform promotes competition among groups The enactment or non-enactment related with political events / crisis Significant consequences for a regime’s political stability or longevity
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Why is reform so difficult?
Winners: not well organized, less powerful Losers : well organized, powerful groups Risky process
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Participants explain experiences they had/knew about the issue.
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Reform may be desirable but not necessarily feasible
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Political feasibility of reform
Policy needs to be adopted and implemented in order to produce the expected results Political feasibility is critical for Policy success Political feasibility is not given it should be created.
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Ask participants to tell how one could build in health reforms’ political feasibility?
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What matters for reforms’ political feasibility?
Actors Content Context Process
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Content Actors Process Context
Social insurance for financing health services Decentralising health professional recruitment Free condoms in family planning clinics Actors Structural factors Situational factors Cultural factors International factors Context Why do issues reach the agenda? Who formulates policy? How is policy implemented? How policy is evaluated? Process
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To mention that… We discussed health policy Actors in the previous session and Content of Health sector reform is discussed towards the 2 weeks.
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POLICY CONTEXT
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Examples will support each point
Contextual factors Structural factors: political system, economic or demographic structure Situational factors: violent events, change in government or political leadership Civil Servants: Size, quality and organization International factors: conditionality, globalisation These factors produce different effects on the content and the process of the reform. They will influence the reaction of each individual or group of actors with respect to the reform. The situational factors are often associated with Big reforms, while the structural factors are involved in reforms which are taking place in a stable/normal political setting . Let us build a little bit more on the political factor, given its important effect on the overall Policy of HS Reform. Examples will support each point
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Contextual factors For both retrospective and prospective policy analysis it is essential to contextualise the background Political, economic and social factors will influence the way policies are developed and implemented
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POLICY PROCESS
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Policy process framework
Issues Agendas Decisions Policy Formulation and Legitimation Progress/Impact Monitoring Constituency Building Implementation Design and Organizational Structuring Resource Mobilization Each box to be discussed, but I do not intend to develop the monitoring = primary linkage = secondary linkage
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Policy process framework
Agendas Decisions Issues Politically dominated Policy Formulation And Legitimation Implementation Design and Organizational Structuring Resource Mobilization Progress/Impact Monitoring Constituency Building = primary linkage Technically led
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How do issues get on to the policy agenda?
Problem Policy (Solutions) No Change No Change Politics (Political will) ACTION
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Policy decisions Players Power Position Perception
Individuals, groups , institutions entering the debate Power Political model Political resources Position Position taken Willing to spend resources on the policy Perception Definition & solution of the problem Measures & symbolic consequences
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Policy formulation New Ideas vs Dominant paradigms
International learning Policy innovation outside the health sector Theory Should be looking forward Ahead to political decision: acceptability Ahead to implementation: administrative capacity, civil servant attitude toward government, etc.. Design process As much political as analytical
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Constituency building
1 2 Proponents Proponents Proponents Neutral Neutral Opponents Political strategy Coalition building
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Resource mobilization
Substantial financial, human and technical resources needed Support from constituencies and networks Continue advocacy to maintain resources required: sustainability of sources of funds.
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What Influences implementation?
Top-down or bottom-up approaches Types of policy
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Implementation in practice
Top-down approaches Rational, prescriptive Implementation is part of managing a sequential process Bottom-up approaches Incremental, iterative Implementers are active participants Top down policy making is assumed that policy formulation occurs largely within national government, or between national policymakers and donors. Once devised it is largely a technical process to be implemented by administrative agencies at national or sub-national levels Eg MoH – Health planners operationalise policies by designing appropriate programmes, with guidelines, rules and monitoring systems. Then transferred to local health authorities to be put into practice Ie very linear view of policy process, rational – and prescriptive - how things ought to be Bottom up suggests implementers play an important role – ie can change policies because they are closer to local situation. More descriptive – how things actually happen Eg De Roo and Marse – Dutch policymakers – new technology regulated – heart transplants not licensed, so no insurance cover, no funds for investment. Heart surgeons thought govt being too slow, so 2 hospitals organised heart transplant, with strong support from interest group.
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Types of policies influence implementation
Simple technical features Clear goals Implementation by one actor / structure Marginal change from status quo Rapid implementation
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Types of policies influence implementation
Marginal change from status quo Incremental change is easier to get agreed Risks of error are less Amount of information needed is smaller Capital and other costs are lower
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Types of policies influence implementation
Rapid implementation Short duration of the execution of policy is less likely to encounter organized resistance, leadership changes, distortions in policy.
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SUMMARY
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Political feasibility is critical for health sector reform success
Political feasibility is not given it should be created Policy process shapes political feasibility Policy process matters for reform success.
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Policy process involves both
Technical expertise to produce analytical recommendations Political acumen to create the right environment that allows for Policy discussion Policy change Less a sequential move than a simultaneous one.
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Commitment to the reform
An agency must be designated or created Endowed with authority to implement the course of action, An adequate budget must be appropriated to enable the agency to carry out its mandate. The absence of any one of these elements, especially the budget, suggests there is not yet full commitment to the policy.
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The Health Policy Process
Gaston Sorgho, Harvard School of Public Health
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