بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. سياست، سياست گذاري و اصلاح نظام هاي سلامت دكتر شهرام توفيقي فلگ شيپ اصلاح نظام سلامت و تامين مالي پايدار پودمان دوم: تحليل كاركرد نظام هاي سلامت خرم آباد 16-14 بهمن 1383

3. What is policy?(1) We shall not attempt to provide a definition of “policy” because it may mean different things according to the context in which the word is used.

4. What is policy?(2) Hogwood and Gunn have listed a number of ways in which the word ‘policy’ is used. There are the most significant and relevent for our purposes:

5. What is policy?(3) 1- Policy as aspiration or general purpose. So-called mission statement comes under this heading. These often state a position or value. ‘ We believe that health of the nation is the first priority in terms of public spending’ is one example of this use of the term ‘policy’.

6. What is policy?(4) 2- Policy as one proposal or as a set of proposals. This is a more specific statement; for example, a government could declare its intention ‘by the year 2010 to reduce the death rate from cancer amongst people aged under 65 years at least a further fifth’.

7. What is policy?(5) 3- Policy as a particular programme. This will involve a ‘package’ or a statement of intended action focusing on a clearly identified group of people or on a type of health care intervention. For example, a government might set out proposals for a systematic health screening programme to detect breast cancer.

8. What is policy?(6) 4- Policy as formally authorised action. This happens when a government, for example, states its intentions in a piece of legislation, a White Paper or Charter, or when a health care organization, such as a hospital, publishes its prospectus.

9. What is policy?(7) 5- Policy as a process. For Hogwood and Gunn,‘process’ refers to to the progress of any policy from its original appearance on the ‘agenda’ to its eventual implementation, review and evaluation.

10. What is policy?(8) 6-Policy as a cultural umbrella covering the activities of health care management. Regarding our policy …

11. Health Policyvs.Health Care Policy

12. Health Care Policy Health care policy is policy relating to the professional intrvention in people’s lives at the: -preventing, -promotion, -maintenance, -cureand -rehabilitation stages.

13. Health Policy Health policy has a much broader remit and at a state or city or national level may involve several different departments, for example, environmental health, water and severage, housing and transport. This wider application is often referred to as ‘public health policy’ as opposed to ‘health care policy’.

14. Health policy reform (1) Policy reform is a profoundly political process. Politics affects the origins, the formulation, and the implementation of public policy, especially when significant changes are involvred. Policy reform requires political skill.

15. Health policy reform (2) The tendency in public health is to portray policy reform as a technocratic or economic process. Both economics and health policy analysts tend to provide detailed prescriptions on what should be done, but without clear instructionson how to do it and without good explanations of why things go wrong.

16. Why is policy reform political? Policy reform is inevitably political because it seeks to changewho gets valued goods in society.

17. Political dimensions of of policy reform: 1- reform represents a selection of values that express a particular view of the good society. 2- reform has distinct distributional consequences in the allocation of both benefits and harms. 3- reform psomotes competition among groups that seek to influence the distributional consequences.

18. Political dimensions of of policy reform: 4- the enactment or non-enactment of reform is often associated with regular political events or with political crisis (timing). 5- reform can have significant conse quences for a regime’s political stability.

19. 1-Values Substance of policy reform represents a value-laden choice of political philosophy, even when the choice is presented as thecnical decision. Three broad value systems, reflecting fundamentally different visions of THE GOOD SOCIETY: 1- utilitarian, 2- communitarian, 3- libertarian.

20. 1-Values: I- Utilitarian The most common value system. This approach employs a consequentialist calculation and comparison of policies to determine which option will achieve the mostresults from the least inputs.

21. 1-Values: I- Utilitarian To carry out this calculation for health sector reform, the WDR adopted the metric of cost-effectiveness, using Disability Adjusted Life Years (DALY). The dominant concern is how to obtain “the most health gain per dollar spent”.

22. 1-Values: II- Communitarian(1) Emphesizes an empirical social conrtact (whether explicit or implicit) that exists whthin some actual community. This philosophical approach can provide a community based notion of the common good, to justify and guide the distribution of resources through health sector.

23. 1-Values: II- Communitarian(2) • Primary health care (PHC) is an example of a communitarian argument to provide health care resources for poor districts. • Community-oriented primary care is based on principles of grounding health policy and health services.

24. 1-Values: II- Communitarian(3) In this approach allocating health resources would not necessarily be concerned about the cost-effectiveness of maximizing health whithin a particular society; it would instead seek to improve health whithin a particular segment of the society, as part of a community-based vision of the common good, regardless of whether those actions were the most cost-effective.

25. 1-Values: III- Libertarian(1) This approach emphesizes the principle of individual liberty, that one is entitled to use one’s natural endowment to make whatever deals and choices one can, as long as the action does not infringe on the life and liberty of others. The state’s role is minimal (minimalist state)

26. 1-Values: III- Libertarian(2) • The libertarian approach enshrines the market as the key to policy reform. • Healt sector reform based on libertarian values would be measured by a process metric, reflecting the degree or state intervention in the economy, with the assumption that if an action reduces state intervention then it generally should be done.

27. 1-Values: III- Libertarian(3) • Libertarian values, and the role of the market, provided the foundation for many policy reform efforts in poor countries in the 1980s. • These reform sought to reduce the degree of state intervention in the economy, through, for example, privitization, competition, reducing regulation, decentraliation and limiting public expenditure.

28. 1-Values: III- Libertarian(4) • In the 1980s a major international debate arose over the health and nutrition consequences of structural adjustment policies, with UNICEF in particular calling for efforts to protect the poor and vulnerable groups in poor countries and to place “the human dimension” at the core of economic policy reform. • This bebate led to some backing off from strong libertarian positions and promoted efforts to strengthen the state’s capacity to protect social welfare, which is a more utilitarian view.

29. 2-Distributional consequences(1) • Policy reform is often intended to produce a particular redistribution. • Reform can redirectbenefits from urban to rural, or from rich to poor, or from organized to non-organized, or from one ethnic group to another, depending in part on the philosophical assumption of the reform.

30. 2-Distributional consequences(2) • Policy reform is political because it seeks to affect who ges what, and it affects group competition in society over who gets what. • This can have a significant impact on the ease of implementation. • Experience with economic reform suggests that targeting the poor encounters significant political obstacles.

31. 3-Group Competition • Policy reform affects the interests of groups in society, including interest groups, bureaucartical agencies, and political parties. • Political leaders are particularly concerned about the differential impacts on groups in the government coallition. Every regime has its allies and partners, arranged in various types of coallitions, to provide support for government and its poilcies.The crucial challenge for political leadership is to avoid injuring the interests of all coallition members simultaneousely.

32. 4-Timing • Reform is usually more feasible at the beginning of a regime than at the end of a egime. Although some politicalleaders at the end of their time in power may introduce reforms to prolong their power or reap some last-minute benefits. • Major concurrent events (either real or symbolic) can open up political windows for reform. Disasters, both natural or human-created, provide policy entrepreneurs with an occasion to push for long-desired ideas.

33. 5-Regime Stability • Policy reform is political because it can pose significant political risks and can provide significant political benefits for regimes in power and for opposition groups out of power.

34. Political models of policy reform 1- The Political Will Model 2- The Political Faction Model 3- The Political Survival Model

35. Introduction to Political Analysis

36. Objectives for Session Political Analysis • Introduce basic principles of applied political analysis • Explore ideas of political feasibility for policy reform • Introduce a method of applied political analysis

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

38. Politics Affects All Stages inThe Policy Cycle • Defines problems for debate • Defines solutions considered • Shapes adoption of proposals • Shapes implementation of reforms

39. Policy Reform is aProfoundly Political Process

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

41. Political Feasibility is Created Not Given • What Factors Affect the Political Feasibility of Policy Reform?

42. Political Feasibility of a Policy Depends on: • PLAYERS in the Policy Process • POWER of the Players • POSITION of the Players • PERCEPTIONS of the Policy

43. Why is Health Sector Reform so Difficult? • COSTS tend to be concentrated on organized groups, possessing political resources. • BENEFITS tend to be dispersed among non-organized groups, lacking political resources.

44. POWERDepends onPolitical Resources • Money • Organization • People • Votes • Skills • Information • Access to Leaders • Access to Media • Symbols • Legitimacy

45. POSITIONDepends On: The Policy’s Consequences: • Monetary • Symbolic • Organizational • Political • The Player’s Interests: • Values • Political Goals • Economic • Organizational

46. Political Feasibility Is Shaped By Political Strategies • To changePOWERof supporters and opponents • To change the POSITIONof supporters and opponents • To change the PERCEPTIONSof the problem and the policy

47. Reform Strategies:1- POWER STRATEGIES(1)Help Supporters Increase supporters’ political resources: • Increaselegitimacy of supporters • Increaseaccess to decision-makers • Increase public visibility • Giveinformation to supporters • Help them raise money

48. Reform Strategies:1- POWER STRATEGIES(2)Undermine Opponents Decrease opponents’ political resources: • Decreaselegitimacy of your opponents • Decreaseaccess to decision-makers • Decrease public visibility in media • Split offkey sub-groups • Question their motives

49. Reform Strategies:2- POSITION STRATEGIES(1)Increase Commitment of Allies or Non-mobilized Players • Compromise: Change the proposed policy • Exchange: Offer them something else they want (in another policy or field) • Persuade: Explain how the proposed policy advances the player’s interests

50. Reform Strategies:2- POSITION STRATEGIES(2)Decrease the Commitment of Opponents • Compromise: Change proposed policy • Compensate: Offer them something to compensate for perceived losses • Persuade: Explain how the proposed policy would advance common goals • Threaten: Threaten legal or political action