Political Processes/Actors Initiating or Sustaining Health Systems Reform

1. Political Processes/Actors Initiating or Sustaining Health Systems Reform Presented on 1 June 2006 at the Health Systems Strengthening Seminar Belize City, Belize By Marilyn Entwistle Advisor, Health Services Administration PAHO/WHO Trinidad and Tobago

2. By the mid-1990s, virtually every Latin American & Caribbean country had either embarked upon health sector reform or was considering to do so

3. PATHWAY TO HEALTH REFORM

4. REFORM IS LIKE A PUZZLE

5. FROM WHICH PERSPECTIVE

6. HEALTH REFORM CONTENTS ARE: • the result of the political process surrounding reform process • the epidemiological, economic & organizational considerations embedded in its content

7. Health reforms have varied in content & scope but they share certain common features

8. Most involve changes in the: • institutional configuration of the health care system • role of the public & the private sector

9. Health reforms involving institutional change have included: • decentralization of decision making & resource management • institutional changes involved in the modernization of the State

10. Health reform is a highly political process mobilizing many groups within the State & in society, whose interests may be affected by the envisioned reform

11. Reformers have based re-configuration of their health care systems on two major changes

12. Creation of new actors or organizations that are to assume roles & responsibilities, such as the provision & articulation of health care services under a new scheme of collaboration

13. Transformation of the old actors, or existing public institutions, so they may operate under the new rules of the game

14. The political process has to deal with: • the interplay of the different actors involved • their potential to influence the process • the strategies used by reformers to pursue their reform agenda

15. When a health reform initiative reaches the public agenda, the country’s political process is unleashed presenting a series of opportunities and obstacles for its successful implementation

16. Those interested in promoting reform may follow a series of political strategies in order to enhance the State’s capacity to bring about reform

17. But What To DO?

18. INTEREST GROUPS

19. DOES THE POWER OF THE INTEREST GROUP MAKE A DIFFERENCE?

20. Interest groups who perceive that their interests may be affected by reform may try to influence the process

21. Health reform outcomes can be expected to reflect the interests of the most powerful interest groups and/or the weightiest political coalition

22. STAKEHOLDER FATIGUE

23. What about reforms that will benefit some groups while negatively affecting others? Decision-makers will take into consideration the interests and power of stakeholders who might step up in favour of or against the reform

24. Powerful interest groups can “capture” the State, leading reformers to redesign the reform initiative & even to stop reform in spite of its technical soundness & potential for enhancing the common good

25. However what about when policy makers decide to continue to support a reform in spite of visible resistance from powerful social groups?

26. LOOKING BEYOND THE OBVIOUS

27. INSTITUTIONAL CONTEXT

28. A country’s institutional setting sets the group rules for political competition, thereby determining the degree of access that interest groups have to influence the reform agenda

29. By the same token, institutions determine the room for maneuver available to reformers & thus the degree of autonomy the State counts on to promote reform

30. For example, in a democratic regime there is a higher possibility of powerful interest groups capturing the State & perpetuating an inequitable status quo

31. However, the same democratic institutions might give greater access to politically weak groups able to influence reform in their favour to confront more powerful interest groups resisting reform

32. It has been argued that political systems with a strong executive power are better able to isolate reform formulation from interest group politics. This would seem to enhance the political feasibility of the reform initiative & speedier implementation

33. Circumventing the channels for interest representation & limiting the access of actors may not necessarily enhance the chances of the reform's survival

34. Politics that are suppressed by these means at one stage of reform may simply resurface at another stage requiring consensus-building & the pursuit of coalition strategies to ensure the political feasibility of the reform

35. Important to take into consideration at what stage of the reform process any opposition to reform may peak & how “reformers” will deal with it

36. Interest groups opposing reform may choose the most opportune moments in which to voice opposition

37. Political & economic consequences of health reform are of such magnitude that the determining factors – and determinant actors – are beyond the Ministry of Health. They may lie in the core ministries in control of the economy

38. CHANGE TEAMS

39. The act of creating a change team, empowering it & placing it in a position to lead a reform process can be considered as a strategy in & of itself

40. A government may use this strategy as a means of augmenting its autonomy from interest group pressure with the intent of enhancing its changes of bringing about reform

41. Change teams can be • locatedin different points of the policy context & • activeat several stages of reform process For example: • an advisory committee/group • congressional commission • planning commission • ad hoc inter-agency task force • health reform unit/secretariat

42. The change team needs to: • win the or, at the very least, • neutralize the resistance of other factions within the government and/or interest groups

43. Their capacity for strategic political maneuvering during reform process will prove as much a determinant to its accomplishment as the team’s technical capacity

44. POINTS TO THINK ABOUT

45. As the reform process develops, reform will pass through a number of points in which its content may be altered & even the very chance of it begin implemented at all may be put at risk

46. Reform will be affected by those actors who have access to these points & can influence the policy process during that particular stage

47. Actors that participate in decision-making at each point, as well as those who manage to influence them, are not the same at each stage

48. The same actors may have different roles at the different stages of the reform process

49. Their agenda & power will be different at each point & their potential to influence the content of reform will vary

50. So as the final note … Political Processes and Actors may end up changing your vision … or health reform puzzle