political feasibility and political strategies for health...

Political Feasibility and Political Strategies for Health Policy Reforms

Thomas Bossert, Ph.D.Harvard School of Public HealthAugust 10, 2006

2006/8/15 Bossert - Politics 2

Perspectives on Politics

Politics is how “publics” and organizations make decisions about health resources and policies and how they implement these decisions.Politics occurs at:

National level (Ministries of Health, Legislatures, etc.) Local governments and communities (civil society)International donors and conferencesBut also internal to bureaucracies, NGOs, consulting firms and academic institutions, etc.


Perspectives on Governance

Governance is about rules and processesTypes of Regimes – authoritarian, democraticPolitical Parties, Legislative rules and processesDecentralization – who gets how much power over what?Ministries of Health – what roles and functions, what organizational structure?Also – rules for other organizations – like Board of Directors of Hospitals and donor organizations


Key Problem:

Most health experts see their role as technicians and see politics as an obstacle to getting the “right thing” done.


Your effectiveness depends on understanding politics

Politics has its own rationalityYou are competing with other interests and other rationalities for:

access to government, community and international resources,making changes in policies and “rules of the game”

There are many policies you may want that are not feasible in particular governance structuresand political contexts


Tools for Political Analysis

How do people think about political processes for policy change?

When decisions are made: Policy process sequencesHow decisions are made: Decision-making modelsWho makes decisions: Stakeholder analysisBoundaries: Governance rules and Broader Contexts


Policy Process SequenceSignaling

Evaluation & Feedback Consultation and Formulation

AggregationImplementation

Ratification


Policy Cycle 1

SignalingHealth technical experts using epidemiological and financial data, international models, etc.International donors like World Bank, IDB, USAIDProtests and political activism

FormulationDevelop a proposed policy change to solve problem that was signaledWho participates?


Policy Cycle 2

AggregationAdvocacy –media and lobbyingfinding out who supports and who opposesmobilizing the non-mobilizedBargaining, negotiating and changing the proposal to gain more supportAre implementers involved?

Gain “buy-in” and information on what might not workDonors as potential liability in national context


Policy Cycle 3

RatificationWhat is the “arena” of decision? President, Congress, Cabinet (esp Ministry of Finance), Minister of Health, City Council, Mayor, Health DepartmentWho are the key actors in each arena?

Donors as special external actorsRole of Donor “Conditionality”


Policy Cycle 4Implementation

Inertia of bureaucraciesActive resistance by “losers”Creating new institutions

Start fresh and attract talentCreate political interest in reform

Political, Social and Economic Constraints Unforeseen events – war, economic downturns, disastersDonor “supervision” missions – threats of suspension of funding (but limits to this)


Policy Cycle 5

FeedbackDid it work?

Evaluation planned from beginning (base line)Why not?

Design problem?Implementation problem?

Start cycle again


Decision Making Models (Allison’s Models)

Rational Actor

Organizational Processes

Bureaucratic Politics – Bargaining


Rational Actor Model

Single actorGoals and objectives (or problems)Alternative options -- for reaching goalsValue maximizing solutions


Organizational Process

Organizations have their own goals“Satisficing”Incremental decision makingStandard Operating Procedures (SOPs)


Bureaucratic Politics – Bargaining

“Pulling and Hauling” –negotiation among interestsPower and SkillsCoalitionsCompromise solutions (“vector”)“Where you stand depends on where you sit.”


Politics Matrix

Signal-ing

Consulta-tion

Aggrega-tion

Ratifica-tion

Implementa-tion

Evalua-tion

RationalActor

X X X

OrganizationalProcess

X ?

Bargaining ? X X ?


Stakeholder Analysis:Bargaining Model Elaborated

Politics is a game among major actors –individuals, interest groups, external donors, broad social groupsMajor actors have different positions over policy goals and means to achieve those goals


Stakeholder Analysis (2)

Major actors have different degrees of power to influence the adoption and implementation of different policies

We can map the actors’ positions and powerin relation to specific policy proposals


Stakeholder Analysis (3)

We can develop strategies to increase the amount of support or decrease the amount of opposition to a specific policy


Positions

Actors take positions on “goals” and on “mechanisms” to achieve goalsActor positions are not always obviousPositions on some parts of reform proposal are relatively fixedOther positions may change if you change the mechanisms


What Determines a Political Actor's Political Power?

Actor’s own Resources Institutional Structures (opportunities and obstacles)Political situation (changing priorities)


Estimating Power

Usual Political PowersMoneyVotesSkillsOrganization

“Our” Political PowerCredibilityExpertiseInformationAccessCommitment


Political Strategies for Increasing Support for Reform

Your objective is to: Increase the number of supporters and decrease the number of opponentsIncrease the power of specific supporters and decrease the power of specific opponents


Tools for Strategies

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

Mud slingingQuestion motives or goals of opponents

TradesOffer support for other issues in return for support for yours


Tools for Strategies (2)

Change PerceptionsUse new language: “population control”becomes “family planning” becomes “reproductive health”

Create “information packets”Target information to interests of different actorsDeny opponents negative information


Tools for Strategies (3)

Create a “change team”Team of like-minded technocrats“friends in high places”place friends in other ministries –“colonize” other institutions


Governance and Contexts

Do Political Regimes Make a Difference?Democracy vs Dictatorships? Types of Political Parties?

Does Decentralization make a difference?How should Ministries of Health be organized?Does Social Capital of Communities Make a Difference?

More participation and trust = better policies?


Conclusion

Politics is about decision makingThere are tools for you to use:

Policy processDecision making modelsStakeholder analysis

Governance is about rules for decision makingContexts constrain decision makingUse Politics to achieve your goals!

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