The Health Policy Process

1. The Health Policy Process Gaston Sorgho, Harvard School of Public Health

2. Health sector reform requires • Technical Analysis • Ethical Analysis • Political analysis

3. What you are going to do about an issue How you are going to do it Who will do it Political Policy is mainly deciding • Programmatic • An overarching course of action • A series of objectives and how to reach them • A statement of intent • A long-term plan

4. Health sector reform is a policy reform Policy reform is a profoundly political process

5. 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

6. Why is reform so difficult? • Winners: not well organized, less powerful • Losers : well organized, powerful groups Risky process

7. Participants explain experiences they had/knew about the issue.

8. Reform may be desirable but not necessarily feasible

9. 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 itshould be created.

10. Ask participants to tell how one could build in health reforms’ political feasibility?

11. What matters for reforms’ political feasibility? • Actors • Content • Context • Process

12. Social insurance for financing health services • Decentralising health professional recruitment • Free condoms in family planning clinics Content Process Context • Why do issues reach the agenda? • Who formulates policy? • How is policy implemented? • How policy is evaluated? • Structural factors • Situational factors • Cultural factors • International factors Actors

13. To mention that…We discussed health policy Actors in the previous session andContent of Health sector reform is discussed towards the 2 weeks.

14. POLICY CONTEXT

15. 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 Examples will support each point

16. 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

17. POLICY PROCESS

18. Policy process framework = primary linkage = secondary linkage Issues Agendas Decisions Each box to be discussed, but I do not intend to develop the monitoring

19. Issues Agendas Decisions Policy Formulation And Legitimation Progress/Impact Monitoring Constituency Building Implementation Design and Organizational Structuring Resource Mobilization = primary linkage Policy process framework Politically dominated Technically led

20. Problem Policy (Solutions) Politics (Political will) No Change No Change No Change No Change ACTION How do issues get on to the policy agenda?

21. Policy decisions • Players • 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

22. 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

23. Constituency building 1 2 Proponents Proponents Proponents Neutral Neutral Opponents Political strategy Coalition building

24. 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.

25. What Influences implementation? • Top-down or bottom-up approaches • Types of policy

26. 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

27. Types of policies influence implementation • Simple technical features • Clear goals • Implementation by one actor / structure • Marginal change from status quo • Rapid implementation

28. 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

29. 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.

30. SUMMARY

31. Political feasibility is critical for health sector reform success • Political feasibility is not given itshould be created • Policy process shapes political feasibility • Policy process matters for reform success.

32. 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.

33. 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.

34. The Health Policy Process Gaston Sorgho, Harvard School of Public Health