The Health Policy Process

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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

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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 regimes 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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Actors
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To mention thatWe discussed health policy
Actors in the previous session andContent of
Health sector reform is discussed towards the 2
weeks.
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POLICY CONTEXT
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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
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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
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Policy process framework
Politically dominated
Technically led
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How do issues get on to the policy agenda?
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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

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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
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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

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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