! Three main questions were raised atthe IUHPE conference in June 2002 onnew dimensions in promoting health,with a particular focus on the process ofpolicy change:

How should people with an interest inpromoting health across sectors,approach the policy change process?

What skills are needed to engage in thepolicy change process?

How do we build collaborations acrossthe policy arenas?

In short, the answer to all three of thesequestions is politics. First, the policychange process needs to be approachedthrough politics. Second, engagement inpolicy change requires political skills.And third, collaboration across policyarenas requires management of thepolitical process.

A decade ago, in his election campaignfor President of the United States, BillClinton made famous the slogan, Its theeconomy, stupid! He plastered thosewords on the wall of his campaignheadquarters in Little Rock, Arkansastoremind him and his supporters thatwinning the election required a focus oneconomic promises (Broder, 2000).

But the policy change process is drivenitself by politics. Indeed, more attentionby Bill and Hillary Clinton to the politicsof health care - from its the economy,stupid, to its the politics, stupid! -might have improved their chances ofpassing health reform in the United

Michael R. Reich

The politics of reforminghealth policies

States in 1994 (Skocpol, 1995). The failureof the Clinton reform plan highlights theimportance of the political process forpromoting policy change, and the risks ofunderestimating political challenges. Thisarticle first reviews three political themesabout the policy reform process, andthen presents a systematic approach tothe development of political strategies forreform, using examples of health policy.

1. Political will

The concept of political will persists instatements and commentaries aboutpublic policy. It is most frequentlyinvoked to explain lack of action.Frequently one hears about the lack ofpublic action on some dire problem dueto the lack of political will. Usually thismeans that some politician has notshown sufficient personal courage orgood sense.

One interesting example of resorting topolitical will as an explanation is the 1993World Development Report, publishedby the World Bank, on how to reformhealth systems in developing countries.The report recognised some difficultiesin promoting health reform, but asserted,Broad reforms in the health sector arepossible when there is sufficient politicalwill and when changes to the healthsector are designed and implemented bycapable planners and managers (WorldBank, 1993, p.15).

Unfortunately, the World Bank authorsdid not provide any evidence to supportthe assertion that sufficient politicalwill is a necessary condition for healthreform; nor did the report define theconcept of political will in a succinct orexplicit mannera pattern criticisedelsewhere (Reich, 1994b). It might havebeen helpful if the report had includedthis political concept in the introductorysection on definitions and data notes,along with explanations of sucheconomic concepts as cost-effectiveness,allocative efficiency, and disability-adjusted life year.

Some analysts of policy reform continueto use the concept of political will toexplain inaction. For example, a recentreport on world hunger is titled,Fostering the Political Will to FightHunger (Committee on World FoodSecurity, 2001). This report seeks topromote implementation of nationalpledges agreed to at the World FoodSummit in 1996. The Food andAgriculture Organization decided that theproblem is political determination. TheFAO concluded, To the extent that themeans exist to eradicate hunger itscontinued existence on a vast scale is aconsequence of either deliberate politicalchoice or incompetence in applyingpossible solutions. The FAOs calls formore political will, however, did notsucceed in generating much politicalinterest or determination, as shown bythe poor attendance of national leadersat the conference on hunger, which washeld in Rome in early June 2002(Reuters, 2002).

This focus on political will has a numberof problems for understanding theprocess of policy reform. It personalisespolicy change and emphasises individualleaders. It suggests that all you need ispolitical will by leaders for policy tochange. The leader makes a decision andmakes it happen, implicitly assuming astrong state, good institutional capacity,and adequate political capital. The focuson political will, moreover, tends toignore the political constraints and thepolitical risks to policy reform. In thisviewpoint, policy reform occurs whenpolitical leaders simply exercise theirwill. If reform does not occur, thenthere is a lack of political will.Recognising these problems, policyanalysts typically consider political willto be a flawed concept. Grindle andThomas called the term a catch-allculprit that has little analytic content,adding that its very vaguenessexpresses the lack of knowledge ofspecific detail (Grindle and Thomas,1991, pp. 122-124).

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Michael R. ReichDirector, Harvard Center for Populationand Development Studies9 Bow StreetCambridge, MA 02138, USATel : +1 617-495-2021Fax : +1 617-495-5418Email : michael_reich@harvard.edu

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On other hand, political leaders do needto exercise their will-power to enactpublic policy. Robert Coles wrote aboutthis process in his book on Lives ofMoral Leadership: Men and Women WhoHave Made a Difference. He describedhow Robert Kennedy, as the juniorSenator from New York in 1967, helped agroup of doctors present their findingsabout hunger among Americas poorchildren (Coles, 2000). Coles stressedhow the personal choices of leaders canmake a difference in public policy byselecting problems for publicconsideration. He quoted Kennedy,There are a lot of issues out there, butits our job to decide which ones mattermost (Coles, 2000, p.27).

But Kennedy did more than just speakup; he knew how to transform thedoctors moral outrage and scientificreport into a public issue. He hadpolitical skill as well as political will. Thisexample emphasises the point that dataalone are rarely enough to promotepolicy reform. Often, policy advocatesneed to create incentives for politicalleaders to engage in reform, whichinvolves creating and managing thepolitical benefits of change. To do this,they need political skills in two keyareaspolitical analysis and politicalstrategies. These factors, which will beconsidered next, help create the politicalfeasibility that is needed for policyreform to succeed.

2. Political analysis

The first skill is to assess the politicalintentions and actions of stakeholders.Stakeholders include individuals, groupsand organisations who have an interestin a policy and the potential to influencerelated decisions. Political science has along history of studies concerned withthe role of groups in governmentaldecisions (Truman, 1951). Recently,health policy analysts concerned withdeveloping countries have givenincreasing attention to the importance ofstakeholder analysis (Brugha andVarvasovsky, 2000).

Political analysis of stakeholders needs toconsider all the individuals and groupsthat could be affected by policy reform.The list should include interests who willbe helped and hurt, as well as interestsperceived as being helped and hurt.Political analysis should identify whose

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toes will be stepped on, who expectstheir toes to be stepped on, and howdifferent groups are likely to react whentheir toes are stepped on, or when theythink their toes will be stepped on.

The distribution of political costs andbenefits among stakeholders is a criticalquestion for political analysis. Often,health policy reforms confront aparticular kind of distribution, withconcentrated costs falling on well-organisedgroups and dispersed benefits intendedfor non-organised groups:

Costs: Health policy reform effortscommonly place concentrated newcosts on well-organised, powerfulgroups, for example, on physicians(often well-organised in a nationalmedical association), or on thepharmaceutical industry (oftenwell-organised in an industryassociation). This problem ofconcentrated costs can createsignificant political obstacles to reform,since the high-power groups tend tobecome mobilised to oppose thereform, to protect their interests.

Benefits: Health policy reform oftenseeks to make new benefits available tonon-organised groups, for example, thepoor, marginalised or rural residents.Such groups often are not well-organisedor politically well connected. Inaddition, these changes may onlyresult in modest future benefits foreach individual. Dispersed benefitsamong low-power groups make it moredifficult to mobilise significant politicalsupport for reform.

The combination of concentrated costson well-organised groups and dispersedbenefits on non-organised groupsconstitutes what Mancur Olson called acollective action dilemma (1965). Thisdistribution of costs and benefits createsdisincentives for collective action topromote policy change. Overcoming thepolitics of this collective action dilemmais a major challenge for health reformadvocates.

Even dictators, however, need politicalanalysis to assess the stakeholdersinvolved in policy reform. In 1982, whenBangladeshs new military dictator, H.M.Ershad, decided to introduce a newnational policy for medicines, to givepriority to essential drugs, he needed to

analyse the stakeholders, even undermarshal law (Reich, 1994a). He needed toconsider the position and the power ofthe Bangladesh Medical Association, theTeachers Union, the Bangladeshdomestic pharmaceutical industry, themultinational pharmaceutical companies,the governments of major donorcountries, the World Health Organization,and international consumer groups. Inshort, he needed a political analysis ofthe major stakeholders involved.

Unfortunately, public healthprofessionals tend not to be well trainedin political analysis. More often, they aretrained to believe that finding the righttechnical answer (in epidemiology oreconomics) is sufficient. Anyone withreal-world policy experience knows thelimits of this approach.

Bill Clinton learned this point the hardway. He confronted an array ofstakeholders when he sought to reformthe health system in the United States in1993. Enormous pressure emerged frominterest groups. At that time, the healthcare industry involved one-seventh of theUS economyand these stakeholdersworked to shape the legislative debate inways that would protect their interests.According to the Center for PublicIntegrity, the debate over health reformwas the most heavily lobbied legislativeinitiative in recent U.S. history, involvinghundreds of lobbying organisations and atotal of more than $100 million (1994).Although a number of key interest groups(including the American MedicalAssociation, and the three main businesslobbies in Washington) initially supportedthe idea of health reform, these groupseventually shifted to a position ofabsolute opposition (Judis, 1995).According to one observer, one of themain reasons the reform plan failed wasthat it did not enlist the cooperation ofthe medical profession (Relman, 1996).

Good politicians know how to analysethe players in a policy arenathroughrepeated practice, experience, andlearning. But sometimes even goodpoliticians need assistance with politicalanalysis. Those of us who are not bornpoliticians need training and help,especially in public health. This trainingcan be obtained through a tool for appliedpolitical analysis: a Windows-basedcomputer software programme thatprovides a step-by-step method for

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analysing stakeholders, developingpolitical strategies, and assessing politicalfeasibility (Reich and Cooper, 1995-2000).

Political analysis, thus, needs to beaccompanied by strategies for policyreform, which will be considered next.

3. Political strategies

Political strategies are causal predictionsabout the future. Strategies areformulated in the structure of, If I do x,then I expect y to happen. Goodpoliticians have an intuitive sense aboutthe strategies that are likely to work in aparticular situation, based on theiraccumulated experience with politicallife. Inexperienced politicians need todevelop these skills, if they are tosurvive and succeed in policy reform.

The literature on agenda-setting forpublic policy shows that the decisionson policy priorities can beunpredictable. But a determined andskilled policy entrepreneur can makethe unthinkable become thinkable. Acrisis can focus attention and alterpolitical calculations about a problem,creating an unanticipated window ofopportunity for policy change. Politicalscientist John Kingdon (1995) has arguedthat the best chances for successfulpolicy change occur when three streamsof events come together: 1) the objectivesituation - the problem stream, 2) theavailability of a possible solution - thepolicy stream, and 3) the flow of politicalevents - the political stream. When thesethree streams converge, according toKingdons theory of agenda-setting, somepolicy response is likely to result,although the response may not resolvethe problem. Within these streams, thepolitical strategies adopted by policyadvocates can make a critical difference.

President Clinton and his advisers, forexample, recognised a window ofopportunity to reform the U.S. healthsystem in 1993, but they incorrectlyassessed how wide the opening was andhow long the window would stay open(Skocpol, 1995). They also adopted somestrategies that created political problems.These decisions included: the decisionto appoint a technocrat with limitedWashington political experience as headof the health reform task force; thedecision to give overall responsibility forhealth reform to Hillary Rodham Clinton;

and the decision to leave politicalbargaining over the plan until after theentire package was presented toCongress. Their strategiesunintentionally mobilised opponentsinto an effective coalition, and failed tomobilise supporters into anythingapproaching an effective coalition. Thiscombination helped kill the chances forreform.

In general, political strategies are neededto address four factors that determine thepolitical feasibility of policy change(Roberts et al., in press).The four factors are:

Players: The set of individuals andgroups who are involved in the reformprocess, and might enter the debateover the policys fate.

Power: The relative power of eachplayer in the political game (based onthe political resources available toeach player).

Position: The position taken by eachplayer, including whether the playersupports or opposes the policy, andthe intensity of commitment towardthe policy for each player (i.e., theproportion of resources that the playeris willing to expend on the policy).

Perception: The public perception ofthe policy, including the definition ofthe problem and the solution, and thematerial and symbolic consequencesfor particular players.

Next we consider political strategies forthese four factors.

Strategy #1: Players

Reform advocates can consider politicalstrategies that try to change the set ofplayers, by creating new friends anddiscouraging foes. These strategies seekto mobilise players who are not yetorganised and demobilise players whoare already organised. It means changingthe number of mobilised players, assupporters and opponents, by recruitingpolitical leaders to the health policycause, and away from the side of theopponents. New players can bepersuaded to enter the game and takecontrolling positions, and current playerscan be influenced to leave, becomeinactive, or wait on the sidelines. Policy

advocates who want the political systemto decide in favour of reform need toconsider all such optionsin order toinfluence the political feasibility ofreforming health policy.

Mobilising groups requires convincingpeople that they should pay the costs ofgetting involved in an issue they have sofar ignored, or the substantial costs oforganising a new group. Sometimes,mobilising an existing group may requiresimply bringing the issue to the groupsattention. Once the group knows what isgoing on, it may decide to take a position.

The case of national policy for safemotherhood in Indonesia shows how askilled policy entrepreneur can mobilisekey players and shape the policy agenda(Shiffman, in press). In this instance, abureaucrat moved from the nationalfamily planning agency to the Ministry ofWomens Roles and developed aneffective campaign to raise attention tothe persistent high rate of maternalmortality (390 deaths per 100,000 birthsin the Indonesian Demographic andHealth Survey published in 1994). Thisindividual succeeded in mobilising thepresident, the Ministry for Home Affairs,provincial bureaucracies, and donoragencies, by defining the problem as abroad issue involving the well-being ofpregnant women and the low status ofwomen in society.

Another example of creating a neworganisation and mobilising a broadcoalition of groups for policy reform isthe successful campaign to introduce a25-cent tax on each pack of cigarettes inCalifornia, in November 1988, through astate-wide initiative (Meyers, 1992). Thisinitiative succeeded after many failedefforts to introduce legislation, reflectingthe tobacco industrys enormouslobbying power (Field, 1996). Supportersfor this policy called themselves theCoalition for a Healthy California, andthey involved the American CancerSociety, the state hospital association andmedical association, as well as a majorenvironmental group and the firefightersunion. By defining the issue as a healthissue and an environmental issue(because of forest fires from cigarettes),the policy advocates formed a broadcoalition that helped create theconditions for successful reform.

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Strategy #2: Power

A second set of political strategies isdesigned to change the distribution ofpower among key players, strengtheningpower among friends and weakeningpower among enemies. Since a groupsimpact on the policy process dependspartly on its resources, reform advocatescan adopt strategies to enhance thepolitical resources of supporters anddecrease those resources of opponents.Here are some examples: 1. Give or lend money, staff, or facilities

to groups that support the reform;

2. Provide information and education tosupporters to increase their expertise;

3. Give allies expanded access to lobbykey decision makers;

4. Provide allies with media time andattention to enhance their legitimacy.Focus attention on their expertise,impartiality, national loyalty, and otherpositive social values.

A tough political strategist can do the samein reverse to opponents, seeking to reducetheir access to political resources.

One example where power-basedstrategies contributed to policy reform isthe introduction of health insurance forschool children in Egypt in 1992(Nandakumar et al., 2000). In thisinstance, the ministers personalcommitment to reform made a significantdifference in passing a new law throughEgypts parliament. The minister usedvarious political strategies to confrontopposition from within the governmentbureaucracy and from oppositionpoliticians: he removed a high-rankingbureaucrat from office; he negotiatedwith politicians to agree on a financingsource for the programme; and heappealed to the highest levels of politicalsupport when progress slowed. Once thelaw was passed, the minister acceleratedimplementation of the programme, tocover all school children with the newhealth insurance programme within oneyear. The case shows that how policyreform can become politically feasiblewhen driven by a high-ranking politician.

Strategy #3: Position

The third set of political strategiesinvolves bargaining within the existing

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distribution of power, to change theposition of players. This can involvethreats, promises, trades, and deals.Interest groups sometimes use publicthreats to protect their policy positions.For example, strikes by physicians inKorea forced government to make majorchanges in health policy reforms, inorder to protect physician incomes andinterests. Physicians in Korea forced thegovernment to delay its implementationof the Diagnosis-Related-Group-basedpayment system, and compelled thegovernment to raise the reimbursementfees to physicians substantially in oneyear (Kwon, in press).

Consumers can also use boycotts topromote their policies and compel othersto change their positions. A famousinternational example is the consumerboycott of Nestle products to protestcorporate policies on infant formulamarketing in developing countries. Thisboycott helped force Nestle to change itsmarketing policies for infant formula andhelped create an environment for theWorld Health Organization to pass theInternational Code of Marketing Breast-Milk Substitutes in 1981 (Sethi, 1994).

Strategy #4: Perception

A public appeal to change perception ofan issue can be an effective politicalstrategy, especially in political systemsthat are open and competitive. Thisapproach can be effective in influencingbureaucratic and political leaders as wellas the public. Political strategies forperceptions seek to change how peoplethink and talk about policy reform, howthe issue is characterised, and whichvalues are at stake. The perception of anissue also affects how it is connected (ornot) to important national symbols orvalues. Is this reform going to advancethe nations identity in some fundamentalway?

Perception strategies relate to how thehuman mind works. Human beings oftenhave trouble grasping complex factpatterns and seek ways to make sense ofa confusing reality. This is especially truein situations where reality is complex,outcomes are uncertain, and conflictinggoals are involvedall of which occur forhealth policy reform. In such cases,policy advocates need to manage publicperceptions, because these change howproblems are defined and which answers

are acceptable. At the center of thepolitical debate is a contest over imageand language, over the symbols forhealth reform (Edelman, 1977). How isthe problem characterised, how are thechoices described, and how is the issueframed?

In the Dominican Republic, efforts toreform the health system in 1996 weredesigned to transform the states rolefrom direct service provider to financerand regulator. Similar approaches wereadopted at the time in many LatinAmerican countries, with financialsupport from the multilateraldevelopment banks. In the DominicanRepublic, however, the press interpretedthese efforts as privatisation of healthservices, and the supporters of healthreform were unable to create analternative public perception of the plan(Glassman et al., 1999). This perceptionof the proposed policy created a strongreluctance among both politicians andbureaucrats to support the reformespecially when opposition arose fromthe powerful medical association andfrom non-governmental organisationsactive in the health field.

In the failed Clinton health reform, theopposition won the public perceptionbattle, hands down. Certain healthindustry interest groups engineered apublic relations campaign and organiseda grassroots opposition movement thattransformed the political environment ofhealth reform. A classic example was thetelevision commercials of Harry andLouise, a middle-class married couple,who presented the Clinton plan asundermining their lives. Sponsored bythe health insurance industry, these adsraised deep fears that the Clinton planwould limit the freedom of choice forexisting health insurance and wouldproduce a government-run healthsystem (Johnson and Broder, 1996). Thecampaign connected to deeply felt socialvalues in the American middle-classtoday: the growing sentiments againstgovernment bureaucracy, and the fearsof an eroding standard of living. Incontrast, the proponents of the Clintonhealth reform failed in the arena ofpublic perceptions. They created acomplicated package that defied simpleexplanation. The reform proponentsfailed to find effective symbols to explainhow the Clinton plan would work, whatthe plan would do, or how it would

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connect to core social values. As one keytechnocrat later reflected, Many peoplecouldnt understand what we wereproposing. There were too many parts, toomany new ideas, even for many policyexperts to keep straight (Starr, 1995).

4. Reflections on the politics ofhealth policy reform

This review of political strategies formanaging health policy reform hasimportant implications for the theme ofnew dimensions in promoting health.The bottom line is, Its the politics,stupid! But politics here is not just bigP politics of major politicians, but alsolittle p politics of what goes on withinand between all sorts of organisationsand people. Health promotionthroughenvironmental policy, employmentpolicy, education policy, and other policydomainsrequires an engagement inpractical politics and the application ofpolitical skills.

To be effective, public health advocatesneed to become better at politics,learning how to create politicalincentives for leaders and how to dealwith political risk. At the IUHPEconference in London, Richard Parish,the Chief Executive of the HealthDevelopment Agency in England, said,We need to persuade politicians that therisks of not doing something are greaterthan the risks of doing somethingdifferent. This political persuasionrequires courage, creativity, and acapacity to recognise opportunities forchange. One of the under-appreciatedbenefits of globalisation is that it cansometimes make leaders aware of theadvantages of change and reform, thatthe old ways of doing things are notalways the best. Advocates for reforminghealth policies need to manage thepolitics of change, through hard-nosedpolitical analysis and innovative politicalstrategies.

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This article is based on a Keynote Address to the5th International Union for Health Promotion andEducation European Conference on the Effectivenessand Quality of Health Promotion, held in London,11-13 June 2002. The articles ideas are developedand applied to health sector reform in a forthcomingbook (Roberts et al., in press, Chapter 4).

Acknowledgments

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Kingdon, J.W. Agendas, Alternatives, and PublicPolicies. 2nd edition. New York: HarperCollins, 1995.

Kwon, S. Pharmaceutical Reform and PhysicianStrikes: Separation of Drug Prescribing and Dispensingin Korea, Social Science and Medicine, in press.

Meyers, R. The California Tobacco EducationCampgain: The Media Component, A Special Report,Boston: Center for Health Communication, HarvardSchool of Public Health, May 1992.

Nandakumar, A.K., Reich, M. R., Chawla, M., Berman, P.and Yip, W. Health Reform for Children: The EgyptianExperience with School Health Insurance, HealthPolicy, 50:155-170, 2000.

Olson, M. The Logic of Collective Action: Public Goodsand the Theory of Groups, Cambridge, MA: HarvardUniversity Press, 1965.

Reich, M. R. Bangladesh Pharmaceutical Policy andPolitics, Health Policy and Planning 9(2):130-143,1994a.

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Reich, M. R. and Cooper, D. M. PolicyMaker:Computer-Assisted Political Analysis, Software andManual, Brookline, MA: PoliMap, 1995-2000. (A freedownloadable version of the software is available athttp://www.polimap.com/.)

Relman, A. S. Book Review of Boomerang: ClintonsHealth Security Effort and the Turn Against Governmentin U.S. Politics, by Theda Skocpol, New England Journalof Medicine 335:601-602, 1996.

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Roberts, M. J., Hsiao, W., Berman, P., and Reich, M. R.Getting Health Reform Right, New York: OxfordUniversity Press, 2003, Chapter 4.

Sethi, S. P. Multinational Corporations and the Impactof Public Advocacy on Corporate Strategy: Nestle andthe Infant Formula Controversy, Boston: KluwerAcademic Publishers, 1994.

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Skocpol, T. The Rise and Resounding Demise of theClinton Plan, Health Affairs, Spring, 1995, pp. 66-85.

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Promotion & Educations editorial team isvery pleased to announce that following thepublication of each issue of the journal, theeditorial and abstracts will be available in

the publications section of the IUHPE website (www.iuhpe.org) in English, Frenchand Spanish. This service was effective as of the previous issue (Volume IX/3.2002).The IUHPE is delighted to offer this service within the framework of a continuedimprovement of the journals quality and service.

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