What is policy?(1)

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What is policy?(1)

• We shall not attempt to provide a definition of
  policy because it may mean different things
  according to the context in which the word is
  used.

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What is policy?(2)

• Hogwood and Gunn have listed a number of ways in
  which the word policy is used.
• There are the most significant and relevent for
  our purposes

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What is policy?(3)

• 1- Policy as aspiration or general purpose.
• So-called mission statement comes under this
  heading. These often state a position or value.
  We believe that health of the nation is the first
  priority in terms of public spending is one
  example of this use of the term policy.

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What is policy?(4)

• 2- Policy as one proposal or as a set of
  proposals.
• This is a more specific statement for example, a
  government could declare its intention by the
  year 2010 to reduce the death rate from cancer
  amongst people aged under 65 years at least a
  further fifth.

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What is policy?(5)

• 3- Policy as a particular programme.
• This will involve a package or a statement of
  intended action focusing on a clearly identified
  group of people or on a type of health care
  intervention. For example, a government might set
  out proposals for a systematic health screening
  programme to detect breast cancer.

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What is policy?(6)

• 4- Policy as formally authorised action.
• This happens when a government, for example,
  states its intentions in a piece of legislation,
  a White Paper or Charter, or when a health care
  organization, such as a hospital, publishes its
  prospectus.

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What is policy?(7)

• 5- Policy as a process.
• For Hogwood and Gunn,process refers to to the
  progress of any policy from its original
  appearance on the agenda to its eventual
  implementation, review and evaluation.

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What is policy?(8)

• 6- Policy as a cultural umbrella covering the
  activities of health care management.
• Regarding our policy

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Health Policy vs.Health Care Policy
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Health Care Policy

• Health care policy is policy relating to the
  professional intrvention in peoples lives at
  the
• -preventing,
• -promotion,
• -maintenance,
• -cure and
• -rehabilitation stages.

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Health Policy

• Health policy has a much broader remit and at a
  state or city or national level may involve
  several different departments, for example,
  environmental health, water and severage, housing
  and transport.
• This wider application is often referred to as
  public health policy as opposed to health care
  policy.

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Health policy reform (1)

• Policy reform is a profoundly political process.
• Politics affects the origins, the formulation,
  and the implementation of public policy,
  especially when significant changes are
  involvred.
• Policy reform requires political skill.

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Health policy reform (2)

• The tendency in public health is to portray
  policy reform as a technocratic or economic
  process.
• Both economics and health policy analysts tend to
  provide detailed prescriptions on what should be
  done, but without clear instructions on how to do
  it and without good explanations of why things go
  wrong.

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Why is policy reform political?

• Policy reform is inevitably political because it
  seeks to change who gets valued goods in society.

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Political dimensions of of policy reform

• 1- reform represents a selection of values that
  express a particular view of the good society.
• 2- reform has distinct distributional
  consequences in the allocation of both benefits
  and harms.
• 3- reform psomotes competition among groups that
  seek to influence the distributional consequences.

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Political dimensions of of policy reform

• 4- the enactment or non-enactment of reform is
  often associated with regular political events or
  with political crisis (timing).
• 5- reform can have significant conse quences for
  a regimes political stability.

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1-Values

• Substance of policy reform represents a
  value-laden choice of political philosophy, even
  when the choice is presented as thecnical
  decision.
• Three broad value systems, reflecting
  fundamentally different visions of
• THE GOOD SOCIETY
• 1- utilitarian, 2- communitarian, 3- libertarian.

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1-Values I- Utilitarian

• The most common value system.
• This approach employs a consequentialist
  calculation and comparison of policies to
  determine which option will achieve the most
  results from the least inputs.

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1-Values I- Utilitarian

• To carry out this calculation for health sector
  reform, the WDR adopted the metric of
  cost-effectiveness, using Disability Adjusted
  Life Years (DALY).
• The dominant concern is how to obtain the most
  health gain per dollar spent.

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1-Values II- Communitarian(1)

• Emphesizes an empirical social conrtact (whether
  explicit or implicit) that exists whthin some
  actual community.
• This philosophical approach can provide a
  community based notion of the common good, to
  justify and guide the distribution of resources
  through health sector.

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1-Values II- Communitarian(2)

• Primary health care (PHC) is an example of a
  communitarian argument to provide health care
  resources for poor districts.
• Community-oriented primary care is based on
  principles of grounding health policy and health
  services.

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1-Values II- Communitarian(3)

• In this approach allocating health resources
  would not necessarily be concerned about the
  cost-effectiveness of maximizing health whithin a
  particular society it would instead seek to
  improve health whithin a particular segment of
  the society, as part of a community-based vision
  of the common good, regardless of whether those
  actions were the most cost-effective.

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1-Values III- Libertarian(1)

• This approach emphesizes the principle of
  individual liberty, that one is entitled to use
  ones natural endowment to make whatever deals
  and choices one can, as long as the action does
  not infringe on the life and liberty of others.
• The states role is minimal (minimalist state)

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1-Values III- Libertarian(2)

• The libertarian approach enshrines the market as
  the key to policy reform.
• Healt sector reform based on libertarian values
  would be measured by a process metric, reflecting
  the degree or state intervention in the economy,
  with the assumption that if an action reduces
  state intervention then it generally should be
  done.

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1-Values III- Libertarian(3)

• Libertarian values, and the role of the market,
  provided the foundation for many policy reform
  efforts in poor countries in the 1980s.
• These reform sought to reduce the degree of state
  intervention in the economy, through, for
  example, privitization, competition, reducing
  regulation, decentraliation and limiting public
  expenditure.

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1-Values III- Libertarian(4)

• In the 1980s a major international debate arose
  over the health and nutrition consequences of
  structural adjustment policies, with UNICEF in
  particular calling for efforts to protect the
  poor and vulnerable groups in poor countries and
  to place the human dimension at the core of
  economic policy reform.
• This bebate led to some backing off from strong
  libertarian positions and promoted efforts to
  strengthen the states capacity to protect social
  welfare, which is a more utilitarian view.

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2-Distributional consequences(1)

• Policy reform is often intended to produce a
  particular redistribution.
• Reform can redirect benefits from urban to rural,
  or from rich to poor, or from organized to
  non-organized, or from one ethnic group to
  another, depending in part on the philosophical
  assumption of the reform.

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2-Distributional consequences(2)

• Policy reform is political because it seeks to
  affect who ges what, and it affects group
  competition in society over who gets what.
• This can have a significant impact on the ease of
  implementation.
• Experience with economic reform suggests that
  targeting the poor encounters significant
  political obstacles.

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3-Group Competition

• Policy reform affects the interests of groups in
  society, including interest groups,
  bureaucartical agencies, and political parties.
• Political leaders are particularly concerned
  about the differential impacts on groups in the
  government coallition. Every regime has its
  allies and partners, arranged in various types of
  coallitions, to provide support for government
  and its poilcies.The crucial challenge for
  political leadership is to avoid injuring the
  interests of all coallition members
  simultaneousely.

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4-Timing

• Reform is usually more feasible at the beginning
  of a regime than at the end of a egime. Although
  some politicalleaders at the end of their time in
  power may introduce reforms to prolong their
  power or reap some last-minute benefits.
• Major concurrent events (either real or symbolic)
  can open up political windows for reform.
  Disasters, both natural or human-created, provide
  policy entrepreneurs with an occasion to push for
  long-desired ideas.

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5-Regime Stability

• Policy reform is political because it can pose
  significant political risks and can provide
  significant political benefits for regimes in
  power and for opposition groups out of power.

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Political models of policy reform

• 1- The Political Will Model
• 2- The Political Faction Model
• 3- The Political Survival Model

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• Introduction to Political Analysis

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Objectives for Session

• Political Analysis
• Introduce basic principles of applied political
  analysis
• Explore ideas of political feasibility for policy
  reform
• Introduce a method of applied political analysis

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Problem Definition
Evaluation
Diagnosis
The Simplified Policy Cycle
Implementation
Policy Development
Political Decision
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Politics Affects All Stages inThe Policy Cycle

• Defines problems for debate
• Defines solutions considered
• Shapes adoption of proposals
• Shapes implementation of reforms

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• Policy Reform is aProfoundly Political Process

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Health Sector Reform Requires

• Technical Analysis (TA)
• Ethical Analysis (EA)
• Political Analysis (PA)

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Political Feasibility is Created Not Given

• What Factors Affect the Political Feasibility of
  Policy Reform?

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Political Feasibility of a Policy Depends on

• PLAYERS in the Policy Process
• POWER of the Players
• POSITION of the Players
• PERCEPTIONS of the Policy

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Why is Health Sector Reform so Difficult?

• COSTS tend to be concentrated on organized
  groups, possessing political resources.
• BENEFITS tend to be dispersed among non-organized
  groups, lacking political resources.

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POWER Depends onPolitical Resources

• Information
• Access to Leaders
• Access to Media
• Symbols
• Legitimacy

• Money
• Organization
• People
• Votes
• Skills

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POSITION Depends On

• The Policys Consequences
• Monetary
• Symbolic
• Organizational
• Political

• The Players Interests
• Values
• Political Goals
• Economic
• Organizational

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Political Feasibility Is Shaped By Political
Strategies

• To change POWER of supporters and opponents
• To change the POSITION of supporters and
  opponents
• To change the PERCEPTIONS of the problem and the
  policy

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Reform Strategies1- POWER STRATEGIES(1)Help
Supporters

• Increase supporters political resources
• Increase legitimacy of supporters
• Increase access to decision-makers
• Increase public visibility
• Give information to supporters
• Help them raise money

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Reform Strategies 1- POWER STRATEGIES(2)Undermi
ne Opponents

• Decrease opponents political resources
• Decrease legitimacy of your opponents
• Decrease access to decision-makers
• Decrease public visibility in media
• Split off key sub-groups
• Question their motives

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Reform Strategies 2- POSITION
STRATEGIES(1)Increase Commitment of Allies or
Non-mobilized Players

• Compromise Change the proposed policy
• Exchange Offer them something else they want (in
  another policy or field)
• Persuade Explain how the proposed policy
  advances the players interests

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Reform Strategies 2- POSITION
STRATEGIES(2)Decrease the Commitment of
Opponents

• Compromise Change proposed policy
• Compensate Offer them something to compensate
  for perceived losses
• Persuade Explain how the proposed policy would
  advance common goals
• Threaten Threaten legal or political action

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Reform Strategies 3- PERCEPTION
STRATEGIESChange Nature of the Issue

• Reframe the problem definition by introducing new
  language
• Associate your cause with positive symbols
• Get endorsement from credible public figures
• Use conflict and victims

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NEGOTIATION TIPS

• Avoid value-dividing negotiations (I win, you
  lose)
• Seek value-creating negotiations (win-win
  outcomes)
• In conflicts, try principle-based negotiations
  first, and seek to build trust

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• Health reform is a profoundly political process
  throughout the policy cycle

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• Yet reform teams tend to focus on the technical
  rather than the political

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• Explicit political strategies can enhance a
  reforms political feasibility

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• Thank you!
• Any question?