In the Name of God

Original Slides based on Thomas Bossert, Ph.D. Harvard School of Public Health

بـه نام خداوند جـان و خـردکزین برتر اندیشه بر نگذرد

جوهر است انسان و، چرخ او راعرض

رضـ و او غ ايه اندـرع و پـه فـجمل

Knowledgegeneration

Social movement

Political linkage

The that moves the mountain

What Starts What Starts The Cycle of The Cycle of Reform?Reform?

Economic crisisEconomic crisis Political changePolitical change External pressureExternal pressure Unhappy interest groupsUnhappy interest groups

Economics Management

Politics

Health Sector Reform

Health Sector Reform Context

Problem Definition

Diagnosis

Policy Development

Implementation

Evaluation

Political Decision

The SimplifiedPolicy Cycle

Define The Problem

Identify

Causes

Develop Options

Implement

Evaluate

Decide What to Do

The Health SystemsReform Cycle

POLITICS

ETHICS

Characteristics Characteristics of Health Systemsof Health Systems

Complexity:Complexity: multiple actors with multiple actors with multiple connectionsmultiple connections

Conflict:Conflict: different participants have different participants have different objectivesdifferent objectives

Politics matters:Politics matters: decisions decisions inevitably reflect political process inevitably reflect political process

Societal context matters:Societal context matters: conditions and options reflects conditions and options reflects culture, history and social normsculture, history and social norms

Politics Affects All Politics Affects All Stages inStages inThe Policy CycleThe Policy Cycle

Defines problems for debateDefines problems for debate Defines solutions consideredDefines solutions considered Shapes adoption of proposalsShapes adoption of proposals Shapes implementation of Shapes implementation of

reformsreforms

How Do We Know Which How Do We Know Which Aspects of Performance Aspects of Performance Matter?Matter?

Different groups will have different viewsDifferent groups will have different views Political processes often produce an Political processes often produce an

uneasy compromiseuneasy compromise Reformers can influence those processesReformers can influence those processes Reformers have to consider ethics and Reformers have to consider ethics and

values to know what performance values to know what performance problems to focus onproblems to focus on

The Role Of Ethics The Role Of Ethics In Problem DefinitionIn Problem Definition

Deciding what aspects of performance Deciding what aspects of performance matter is not just a technical questionmatter is not just a technical question

Deciding what matters requires valuesDeciding what matters requires values

Exploring ethical theory allows us to clarify Exploring ethical theory allows us to clarify both our assumptions and their implicationsboth our assumptions and their implications

The problem definition influences all that The problem definition influences all that followsfollows

How do people think about political How do people think about political processes for policy change and processes for policy change and implementation?implementation?– When decisions are made: When decisions are made: Policy Policy

process sequencesprocess sequences– How decisions are made: How decisions are made:

Decision-making modelsDecision-making models – Who makes decisions: Who makes decisions:

Stakeholder analysisStakeholder analysis – BoundariesBoundaries: : Governance rules and Governance rules and

Broader Contexts Broader Contexts

Tools for Political Tools for Political AnalysisAnalysis

Developing Options

““Process matters” Process matters”

– – how you go about this task how you go about this task will influence the political will influence the political acceptability and the quality acceptability and the quality of the planof the plan

Reaching A Political Reaching A Political DecisionDecision

Health sector reform Health sector reform is unavoidably is unavoidably politicalpolitical

Doing better Doing better requires : requires : political political skillskill, , not justnot just

political political willwill

Reaching A Political Reaching A Political DecisionDecision

Stakeholder analysis Stakeholder analysis as a starting point as a starting point

From “mapping” From “mapping”

to strategyto strategy

Many Health Sector Reform Efforts Many Health Sector Reform Efforts Have Failed at The Stage of Have Failed at The Stage of ImplementationImplementation

Ministers often lack Ministers often lack administrative experience administrative experience

Leaders turn over quicklyLeaders turn over quickly Implementation is not considered Implementation is not considered

in program designin program design Entrenched interests resist Entrenched interests resist Political attention turns Political attention turns

elsewhereelsewhere

Policy Reform is Policy Reform is aaProfoundly Profoundly Political ProcessPolitical Process

Political Feasibility Political Feasibility is Created, Not is Created, Not GivenGiven

What Factors Affect the What Factors Affect the Political Feasibility of Political Feasibility of Policy Reform?Policy Reform?

Perspectives on Perspectives on PoliticsPolitics

PoliticsPolitics is how “publics” and organizations is how “publics” and organizations make decisions about health resources and make decisions about health resources and policies and how they implement these policies and how they implement these decisions.decisions.

Politics occurs at:Politics occurs at:– NationalNational level (Ministries of Health, Legislatures, etc.) level (Ministries of Health, Legislatures, etc.) – LocalLocal governments and communities (civil society) governments and communities (civil society)– InternationalInternational donors and conferences donors and conferences– But also But also internal to bureaucraciesinternal to bureaucracies, NGOs, , NGOs,

consulting firms and academic institutions, etc.consulting firms and academic institutions, etc.

MOH isCons orbypassed

Perspectives on Perspectives on ContextsContexts Economic: Economic: are political and policy are political and policy

options different in wealthy vs. poor options different in wealthy vs. poor countries?countries?

Social/cultural: Social/cultural: Are there different Are there different options in Kosovo? Indonesia? options in Kosovo? Indonesia? Nicaragua?Nicaragua?

Social Capital: Social Capital: Are communities Are communities with higher participation and trust with higher participation and trust able to implement more effective able to implement more effective policies?policies?

Key Problem:Key Problem:

Most Most health experts health experts see their see their

role as role as technicianstechnicians and see and see

politics as an obstaclepolitics as an obstacle to to

getting the getting the “right thing”“right thing” done. done.

Good ideas are not worth Good ideas are not worth muchmuch If If

They can not be They can not be implementedimplemented

And “Reform” Could not be implemented without Politics

Main PointsMain Points

Politics matters in policy reform effortsPolitics matters in policy reform efforts Politics can be systematically Politics can be systematically

analyzedanalyzed Applied political analysis can improve Applied political analysis can improve

your effectiveness as a policy your effectiveness as a policy reformerreformer

Your effectiveness Your effectiveness depends on depends on understanding politicsunderstanding politics Politics has its own rationalityPolitics has its own rationality You are You are competing with other competing with other

interestsinterests and other rationalities for: and other rationalities for:– access to government, community and access to government, community and

international resources,international resources,– making changes in policies and “rules of making changes in policies and “rules of

the game”the game” There are many policies you may want There are many policies you may want

to implement that are not feasible in to implement that are not feasible in particular particular governance structuresgovernance structures and and political contextspolitical contexts

Tools for Political Tools for Political AnalysisAnalysis

How do people think about political How do people think about political processes for policy change and processes for policy change and implementation?implementation?– When decisions are made: When decisions are made: Policy process Policy process

sequencessequences– How decisions are made: How decisions are made: Decision-making Decision-making

modelsmodels – Who makes decisions: Who makes decisions: Stakeholder Stakeholder

analysisanalysis – BoundariesBoundaries: : Governance rules and Governance rules and

Broader Contexts Broader Contexts

Policy Process Sequence

Signaling

Evaluation & Feedback Consultation and Formulation

AggregationImplementation

Ratification

Policy Cycle 1Policy Cycle 1

SignalingSignaling– Health technical experts using Health technical experts using

epidemiological and financial data, epidemiological and financial data, international models, etc.international models, etc.

– International agencies like World BankInternational agencies like World Bank– Protests and political activismProtests and political activism

FormulationFormulation– Develop a proposed policy change to solve Develop a proposed policy change to solve

problem that was signaledproblem that was signaled– Who participates?Who participates?

Policy Cycle 2Policy Cycle 2

AggregationAggregation– Advocacy –media and lobbyingAdvocacy –media and lobbying– finding out who supports and who opposesfinding out who supports and who opposes– mobilizing the non-mobilizedmobilizing the non-mobilized– Bargaining, negotiating and changing the Bargaining, negotiating and changing the

proposal to gain more supportproposal to gain more support– Are implementers involved?Are implementers involved?

Gain “buy-in” and information on what might Gain “buy-in” and information on what might not worknot work

Policy Cycle 3Policy Cycle 3

RatificationRatification– What is the “arena” of decision? What is the “arena” of decision?

President, Congress, Minister of President, Congress, Minister of Health, City Council, Mayor, Health Health, City Council, Mayor, Health DepartmentDepartment

– Who are the key actors in each Who are the key actors in each arena?arena?

Policy Cycle 4Policy Cycle 4

ImplementationImplementation– Stakeholders are differentStakeholders are different– Inertia of bureaucraciesInertia of bureaucracies– Active resistance by “losers”Active resistance by “losers”– Creating new institutionsCreating new institutions

Start fresh and attract talentStart fresh and attract talent Create political interest in reform Create political interest in reform

– Political, Social and Economic Constraints Political, Social and Economic Constraints – Unforeseen events – war, economic Unforeseen events – war, economic

downturns, disastersdownturns, disasters

Policy Cycle 5Policy Cycle 5

FeedbackFeedback– Did it work? Did it work?

Evaluation planned from beginning Evaluation planned from beginning (base line)(base line)

– Why not?Why not? Design problem?Design problem? Implementation problem? Implementation problem?

– Start cycle againStart cycle again

Decision Making Decision Making Models (Allison’s Models (Allison’s Models)Models)

Rational ActorRational Actor

Organizational ProcessesOrganizational Processes

Bureaucratic Politics – Bureaucratic Politics – BargainingBargaining

Rational Actor ModelRational Actor Model

SingleSingle actor actor GoalsGoals and objectives (or problems) and objectives (or problems) Alternative Alternative optionsoptions -- for reaching -- for reaching

goalsgoals Value Value maximizingmaximizing solutions solutions

Organizational ProcessOrganizational Process

Organizations have their Organizations have their own own

goalsgoals

““Satisficing”Satisficing”

IncrementalIncremental decision making decision making

Standard Operating Procedures Standard Operating Procedures

(SOPs)(SOPs)

Bureaucratic Politics – Bureaucratic Politics – BargainingBargaining

““Pulling and Hauling” –Pulling and Hauling” –negotiationnegotiation

among interestsamong interests PowerPower and Skills and Skills CoalitionsCoalitions Compromise solutions Compromise solutions

““Where you stand depends on where you Where you stand depends on where you

sit.”sit.”don’t stick with “maximal” rational proposal but don’t go below “minimal” acceptable.

Politics MatrixPolitics Matrix

SignalSignal-ing-ing

ConsultaConsulta-tion-tion

AggregAggrega-tiona-tion

RatificaRatifica-tion-tion

ImplementImplementa-tiona-tion

EvaluaEvalua-tion-tion

RationalRational

ActorActorXX XX ?? XX

OrganizationOrganizationalal

ProcessProcess

XX ??

BargainingBargaining ?? XX XX ??

Stakeholder Analysis:Stakeholder Analysis:Bargaining Model Bargaining Model ElaboratedElaborated

Politics is a game among Politics is a game among major major actorsactors – individuals, interest – individuals, interest groups, broad social groupsgroups, broad social groups

Major actors have Major actors have different different positionspositions over policy over policy goalsgoals and and meansmeans to achieve those goals to achieve those goals

Stakeholder Analysis Stakeholder Analysis (2)(2) Major actors have Major actors have different degrees different degrees

of powerof power to influence the adoption to influence the adoption and implementation of different and implementation of different policiespolicies

We can We can mapmap the actors’ positions the actors’ positions and powerand power in relation to specific in relation to specific policy proposals and their policy proposals and their implementationimplementation

Stakeholder Analysis Stakeholder Analysis (3)(3)

We can develop We can develop strategiesstrategies to to increase the amount of support or increase the amount of support or decrease the amount of oppositiondecrease the amount of opposition to to a specific policy in both the a specific policy in both the “aggregation” and “aggregation” and “implementation” stages“implementation” stages

“Think it over...”

Political Feasibility of a Political Feasibility of a Policy Depends onPolicy Depends on

PLAYERS in the Policy PLAYERS in the Policy ProcessProcess

POWER of the PlayersPOWER of the Players POSITION of the PlayersPOSITION of the Players PERCEPTIONS of the PolicyPERCEPTIONS of the Policy

Positions

Actors take positions on “goals” and Actors take positions on “goals” and on “mechanisms” to achieve goalson “mechanisms” to achieve goals

Actor positions are not always obviousActor positions are not always obvious Positions on some parts of reform Positions on some parts of reform

proposal are relatively fixedproposal are relatively fixed Other positions may change if you Other positions may change if you

change the mechanismschange the mechanisms Positions may change in the process Positions may change in the process

of implementationof implementation

What Determines a What Determines a Political Actor's Political Political Actor's Political Power?Power?

Actor’s own Resources Actor’s own Resources Institutional Structures (opportunities Institutional Structures (opportunities

and obstacles)and obstacles) Political situation (changing Political situation (changing

priorities)priorities) Implementation of some policies may Implementation of some policies may

change power of some stakeholderschange power of some stakeholders

Estimating PowerEstimating Power

Usual Political Usual Political PowersPowers

MoneyMoney VotesVotes SkillsSkills OrganizationOrganization

““Our” Political Our” Political PowerPower

CredibilityCredibility ExpertiseExpertise InformationInformation AccessAccess CommitmentCommitment

Political Strategies for Political Strategies for Increasing Support for Increasing Support for ReformReformYour objective is to: Your objective is to:

– Increase the Increase the numbernumber of supporters of supporters

and decrease the and decrease the numbernumber of of

opponentsopponents

– Increase the Increase the powerpower of specific of specific

supporters and decrease the supporters and decrease the powerpower

of specific opponentsof specific opponents

Tools for StrategiesTools for Strategies

Compromise Compromise – Move from “maximizing” policy to “best Move from “maximizing” policy to “best

compromise”compromise” Mud slingingMud slinging

– Question motives or goals of opponentsQuestion motives or goals of opponents TradesTrades

– Offer support for other issues in return Offer support for other issues in return for support for yoursfor support for yours

Tools for Strategies (2)Tools for Strategies (2)

Change PerceptionsChange Perceptions– Use new language: “population Use new language: “population

control” becomes “family control” becomes “family planning” becomes “reproductive planning” becomes “reproductive health”health”

Create “information packets” Create “information packets” – Target information to interests of Target information to interests of

different actorsdifferent actors– Deny opponents negative Deny opponents negative

informationinformation

Tools for Strategies (3)Tools for Strategies (3)

Create a “change team”Create a “change team”– Core of like-minded technocratsCore of like-minded technocrats – ““friends in high places” friends in high places” – place friends in other ministries place friends in other ministries

– “colonize” other institutions– “colonize” other institutions– Problem of keeping the team Problem of keeping the team

together during implementationtogether during implementation

Tools for Strategies (4)Tools for Strategies (4)

Additional Additional “implementation “implementation specific”specific” strategies strategies– ParticipationParticipation of implementing of implementing

stakeholders in formulation and stakeholders in formulation and aggregation stageaggregation stage

– Convince resistant stakeholders that Convince resistant stakeholders that change is inevitablechange is inevitable – Dylan’s “get – Dylan’s “get out of the way if you can’t lend a hand, out of the way if you can’t lend a hand, ‘cause the times they are a changin.”‘cause the times they are a changin.”

– Use the Use the enforcementenforcement power of the power of the state to sanction those who do not state to sanction those who do not implementimplement

Governance and Governance and ContextsContexts Do Do Political RegimesPolitical Regimes Make a Difference? Make a Difference?

– Democracy vs Dictatorships? Democracy vs Dictatorships? – Types of Political Parties?Types of Political Parties?

Does Does DecentralizationDecentralization make a difference? make a difference? How should How should Ministries of Health Ministries of Health be be

organized?organized? DoesDoes Social Capital Social Capital of Communities Make of Communities Make

a Difference?a Difference?– More participation and trust = better policies?More participation and trust = better policies?

Who Initiates Who Initiates Decentralization Decentralization Reform?Reform?

Broad Process of Reforms to Broad Process of Reforms to Increase Power of Local Increase Power of Local GovernmentsGovernments

Ministry of Health Leading Ministry of Health Leading Decentralization ReformDecentralization Reform

Imposed by External Initiatives?Imposed by External Initiatives?

Who is in favor of Who is in favor of decentralization?decentralization?

New Democratic LeadersNew Democratic Leaders– Cory Aquino in PhilippinesCory Aquino in Philippines

Dynamic Ministers of HealthDynamic Ministers of Health– Ketele Kalumba in ZambiaKetele Kalumba in Zambia

Donor AgenciesDonor Agencies– World Bank, WHO, USAIDWorld Bank, WHO, USAID

Local GovernmentsLocal Governments– Associations of Local GovernmentsAssociations of Local Governments

How do we estimate How do we estimate their power?their power? When is presidential support When is presidential support

enough?enough? Are political parties reliable Are political parties reliable

supporters?supporters? Can donor initiatives be a Can donor initiatives be a

political liability?political liability? Are associations of Are associations of

municipalities organized municipalities organized enough to lobby?enough to lobby?

Who is Opposed to Who is Opposed to Decentralization?Decentralization?

Central Ministry OfficialsCentral Ministry Officials Regional and District Ministry of Regional and District Ministry of

Health Officials oppose Health Officials oppose devolutiondevolution

Unions of Health ProvidersUnions of Health Providers Political Parties in Opposition if Political Parties in Opposition if

Governing Parties propose Governing Parties propose ReformReform

Potential pros & consPotential pros & cons

prospros consconsMOHMOH Now / Future Now / Future

positionpositionLoss of Loss of PowerPower

MOH MOH OfficialsOfficials

Now / Future Now / Future positionposition

Loss of Loss of Power /Job Power /Job SecuritySecurity

MOH MOH ProvinceProvince

Gain PowerGain Power Future Future positionposition

Local GOVLocal GOV Gain PowerGain Power Future Future problemsproblems

Powers of OpponentsPowers of Opponents

Media attacksMedia attacks

Unions strikeUnions strike

Political Parties block Political Parties block

legislationlegislation

Political Feasibility of a Political Feasibility of a Policy Depends onPolicy Depends on

PLAYERS in the Policy PLAYERS in the Policy ProcessProcess

POWER of the PlayersPOWER of the Players POSITION of the PlayersPOSITION of the Players PERCEPTIONS of the PolicyPERCEPTIONS of the Policy

PERCEPTION STRATEGIESPERCEPTION STRATEGIESChange Nature of the Change Nature of the IssueIssue Reframe the problem definition by Reframe the problem definition by

introducing new languageintroducing new language Associate your cause with positive Associate your cause with positive

symbolssymbols Get endorsement from credible Get endorsement from credible

public figures public figures Use conflict and victims Use conflict and victims

NEGOTIATION TIPSNEGOTIATION TIPS

Avoid value-dividing negotiations Avoid value-dividing negotiations (I win, you lose)(I win, you lose)

Seek value-creating negotiations Seek value-creating negotiations (win-win outcomes)(win-win outcomes)

In conflicts, try principle-based In conflicts, try principle-based negotiations first, and seek to negotiations first, and seek to build trustbuild trust

Hazards of Formulation Hazards of Formulation and Adoptionand Adoption

Assuming that adoption is end of Assuming that adoption is end of processprocess

Isolation of reformers within Isolation of reformers within MinistryMinistry

Ministry refusing to participate Ministry refusing to participate in broad reformin broad reform

Local governments do not Local governments do not participate in reform formulationparticipate in reform formulation

Hazards of Hazards of ImplementationImplementation Central Ministry can Central Ministry can

undermine decentralization undermine decentralization by control of certification, by control of certification, norms, fundsnorms, funds

Unions of civil servants can Unions of civil servants can protest and can ally with protest and can ally with opposition political partiesopposition political parties

ConclusionConclusion

Every Top Middle manager in Health have to:

1. Have a political Map2. Do stakeholder analysis

periodically3. Learn political skills4. Have a change team

Thanks for y

our

kindly

atte

ntion