the health policy process gaston sorgho, harvard school of public health

The Health Policy Process

Gaston Sorgho,

Harvard School of Public Health

Health sector reform requires

• Technical Analysis

• Ethical Analysis

• Political analysis

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

Health sector reform is a policy reform

Policy reform is a profoundly political

process

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

Why is reform so difficult?

• Winners: not well organized, less powerful

• Losers :well organized, powerful groups

Risky process

Participants explain experiences they had/knew

about the issue.

Reform may be desirable

but not necessarily feasible

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.

Ask participants to tell how one could build in health

reforms’ political feasibility?

What matters for reforms’ political feasibility?

• Actors

• Content

• Context

• Process

Actors

•Structural factors •Situational factors• Cultural factors• International factors

Context

Content

• Social insurance for financing health services

• Decentralising health professional recruitment • Free condoms in family

planning clinics

• Why do issues reach the agenda?

• Who formulates policy?• How is policy implemented?• How policy is evaluated?

Process

To mention that…

We discussed health policy Actors in the previous session and

Content of Health sector reform is discussed towards the 2 weeks.

POLICY CONTEXT

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

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

POLICY PROCESS

Policy process framework

Policy Formulation

and Legitimation

Implementation Design and

Organizational Structuring

Resource

Mobilization

Progress/Impact Monitoring

Constituency Building

AgendasDecisions

Issues

Each box to be discussed, but I do not intend to develop the monitoring = primary linkage

= secondary linkage

Policy Formulation

And Legitimation

Implementation Design and

Organizational Structuring

Resource

Mobilization

Progress/Impact Monitoring

Constituency Building

= primary linkage

Technically led

AgendasDecisions

IssuesPolitically dominated

Policy process framework

How do issues get on to the policy agenda?

Problem Policy (Solutions)

No Change

No Change

No Change

Politics (Political will)

ACTION

No Change

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

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

Constituency building

Proponents

Neutral

Opponents

Neutral

Proponents

Political strategyCoalition building

Proponents1 2

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.

What Influences implementation?

• Top-down or bottom-up approaches

• Types of policy

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

Types of policies influence implementation

• Simple technical features

• Clear goals

• Implementation by one actor / structure

Marginal change from status quo

Rapid implementation

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

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.

SUMMARY

• 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.

• 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.

Commitment to the reform1. An agency must be designated or

created2. Endowed with authority to

implement the course of action,3. 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.

The Health Policy Process

Gaston Sorgho,

Harvard School of Public Health