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Introduction to Health Policy & PolicyAnalysis

Siriwan Pitayarangsarit, DDS.MPH, PhD.Director, International Health Policy Program, Thailand

Email: siriwan@ihpp.thaigov.net

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Acknowledgement

• The summary slides of the review session “Health Policy, Process and Power: Review Session” by Health Policy Unit, LSHTM

• The Book “An Introduction to Health Planning in Developing Countries. Second edition. 1999 Oxford University Press” by Andrew Green

• Professor Gill Walt, Department of Public Health and Policy, LSHTM (My PhD supervisor)

• Slides on Stakeholder analysis from Rachata Tungsiripat

Health Policy and health care system in Thailand

Health care system:Organization and financing of health care:– State plays both purchaser and provider role.– MoPH health care providers are majority in the health care

system.– Health insurance for all (Universal Coverage)

Health system in a wider aspect :-Health include physical, mental, and spiritual well being-Health assembly: a participatory process in Agenda setting

Philosophy of the Health Care System• Market VS State Welfare• Characteristic of health care market:

– Uncertainty of incidence– Externality – Public good– Unbalance information

• Health system objectives– Equity– Efficiency - Sustainability– Quality of health care– Accountability -Responsiveness

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The Policy Process• Problem identification

– How do issues get onto the policy agenda?• Policy formulation

– What were the considerations in the process?– How the involved actors influenced the policy and

decision?• Policy implementation

– How the policy was executed and implemented? • Policy evaluation

– Did the policy accomplish its goals?

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Policy Analysis• Analysis FOR policy

– information for policy – policy advocacy– often prospective

• Analysis OF policy: – policy determination (how policy is made, why, when)– policy content– policy performance– typically retrospective

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Defining PolicyAn overarching course of action

• A strategy• A series of objectives and how to reach them• A statement of intent• A long-term plan

or• Deciding what you are going to do about an issue• Deciding how you are going to do it• Deciding who will do it

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วเิคราะห์สาระนโยบาย: การจาํแนกนโยบาย

(Differentiating Policy)•By importance

High politics issuesLow politics issues

•By levelInternational levelRegional levelNational levelLocal level

By typeDistributiveRegulatorySelf-regulatoryRe-distributive

By instrumentStatements (official circulars)RegulationsLaws

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Analysis FOR policy• Situation Analysis• Priority-setting• Option appraisal

– Cost-Effectiveness analysis– Efficiency analysis– Equity analysis– Survey on Acceptability – Feasibility analysis– Resource availability estimation

• Program evaluation

Analysis FOR policy

(See Andrew Green, An Introduction to Health Planning in Developing Countries)

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Situation Analysis• General country characteristics

– Demographic information– Political system, governance structure of related organizations– economic system– Educational and cultural characteristics

• Problem status: prevalence & incidence– Country level: in general and country specific– Global level or regional level

• Health infrastructure, capacity and resources; present and projected

• Governance structure• Surveillance system, • informed process for policy-making

Analysis FOR policy

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Priority-setting• A demand-based market mechanism versus a needs-

based planning approach• Perspectives of prioritization

– Outcomes: human health or economic growth– Need: Perceived by community or by professionals– Target groups: age, geographic location, diseases (by using

burden of disease approach)– Interventions: by using cost effectiveness or implementation

feasibility as criteria• Actors participated in the decision-making

– For national policy: national level representatives from authorities to implementers

Analysis FOR policy

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Priority-setting instruments• Resource allocation process- centralized /

decentralized• Economic appraisal – BOD, Cost effectiveness

analysis, cost benefit analysis, etc.• Multivariable decision matrices got giving

priority to a health problem: Size of the problem + Consequences + demand from the public + technical feasibility of a solution

• Value judgement of the decision-makers and society

Analysis FOR policy

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Option appraisal• Identify alternative options: review of the international

experience, past experience• Economic appraisal: cost effectiveness, cost-benefit

analysis, cost-utility analysis, • Feasibility analysis: technical, administrative, and legal• Financing analysis: costing analysis, resource

availability estimation, additional cost, whose cost?, distributional and equity effects

• Survey on Political acceptability of the activities: community, health workers, politicians or authorities

• Trial: pilot activities to provide more information

Analysis FOR policy

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Program evaluation

• Formative evaluation: conducted while an activity is still being carried out

• Summative evaluation: conducted after the completion of a project or activity

• Evaluation : – Inputs– Implementation process– Outputs/ outcomes, require baseline information

Analysis FOR policy

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A framework for analysis of a policy

• Context• Actors• Process• Content

Source: Walt & Gilson (1994)

Context

Actors

Content Process

Analysis OF policy: To explain a phenomenon of a policy regarding the policy determination, policy content, and policy performance by answering the questions on how and why

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The Policy ProcessA Rationalist Model -

Policy formation in distinct stages:• Problem identification

– How do issues get onto the policy agenda?• Policy formulation

– What were the considerations in the process?– How the involved actors influenced the policy and

decision?• Policy implementation

– How the policy was executed and implemented? • Policy evaluation

– Did the policy accomplish its goals?

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Context

• Situational factors• Structural factors• Cultural factors• International factorsOr grouped as Historical background,

Endogenous context, and Exogenous context

Actors

• national politicians and bureaucrats• national interest groups• international organizations• Civil society and the media

Content• level of the policy-national / regional • Type of the policy – high politics• knowledge of best practice• epidemiological knowledge – tipping point

to pandemic

• Why do issues reach the agenda?• Who formulates policy?• How is policy implemented?• What makes policies change?• Who evaluates?

Process

Analysis OF policy

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What is theContext?

• Historical Background

• ‘Endogenous’ Context– Local Political Systems– Local Socio-economic factors

• ‘Exogenous’ Context– Role of international actors– Relations with international community

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• Situational factors

eg violent events, change in government or political leadership

• Structural factors

eg pluralist or elitist political systems, economic or demographic structure

• Cultural factors

eg ethnicity, language, the status of women

• International factors

eg conditionality, globalisation

Leichter’s Contextual Factors

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Political systems:a key contextual element

• Policy environments– Public accountability– Public transparency– Predictable rule of law– Freedom of speech & association

• People’s ability to participate– Pluralist political systems– Elitist political systems

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Political systems: The distribution of Power

• Power is a highly contested concept

– Pluralist democracies are open and competitive

– Elitist societies are governed by a small governing elite

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• Authority

• Influence

• Manipulation

• Coercion

What do we mean by power?

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Summary on 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

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Who are the Actors?• The state (or statesmen)

– politicians, civil servants or bureaucrats, public sector employees– Representing state or government power

• The market– Business, industry, companies, corporations (multinational and

transnational) – Symbolising economic power and the production of goods and

services

• Civil society – The public space between the state and the individual citizen– activities take an organized and collective form

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What is an Interest Group?

‘Interest groups are generally defined as organizations, although often in close partnership with government.

(Wilson, GK 1990 ‘Interest Groups’ Blackwell Publishers)

As such, interest groups provide the institutional linkages between government or the state and major sectors of society’

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Summary on Actors• ‘Actor’ is a shorthand term, which may refer to

individuals, groups, organizations• Division into state, market and civil society is

conceptually useful, but complex: actors cross boundaries, have multiple roles

• Actors have very different levels of power and influence

• Stakeholder analysis - one tool to identification of actors and possible roles

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What is the Policy Agenda?

• … the list of subjects or problem to which government officials and people outside of government (closely associated with those officials) are paying some serious attention at any one time …

Kingdon, 1984

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How do issues get onto the policy agenda?

• Hall et al. model– Legitimacy– Feasibility– Support

• Kingdon 3-stream model– Problems– Policies (solutions)– Politics (political will)

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A Theory on agenda setting

• The Hall et al. model•Legitimacy -those issues with which governments feel they should be concerned

•Feasibility–technical knowledge, skills, infrastructure

•Support–public support for the issue

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Agenda Setting Through Three Streams

The Kingdon model• Problem Stream

indicatorsfocusing eventsfeedback

• Politics Stream (political will)visible participantshidden participants

• Policy Stream (solutions)window of opportunity

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No Change

Problem Policy (Solutions)

No Change

No Change

Politics (Politicalwill)

Kingdon’s - 3 Stream model

ACTION

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How rational is policy formation?

• Rationalist models criticised for being too idealistic, not descriptive of reality.

• Incrementalist models - policy said to evolve in series of small changes - ‘muddling through’ with what exists

• Mixed scanning models - see some policy making as rational, but other aspects as incremental

See Walt, 1994, Chapter 3

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What Influences Implementation?• Top-down or bottom-up approaches

• Top-down approaches• Rational, prescriptive - linear models or stages of implementation. • Implementation is part of managing a sequential process

• Bottom up approaches• Incremental, iterative• Implementers are active participants

• Inter-organizational relations • Types of policy: policy characteristics

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Implementation in practice: Inter-organizational relations

– International-national perspectives • ‘power without responsibility?’

– Central-local perspectives• budgetary & legislative control

– Clinic (or unit) perspectives• Professional autonomy?• Local knowledge

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Easy Implementation difficult

marginal change big

simple technical features complex

support interest groups resist

perfect communication poor

short duration long

clearly policy goals conflicting

skilful implementers weak

limit participation extensive

yes legitimacy No

Policy implementation : Policy characteristics

see Hogwood and Gunn (1984) -10 elements of ideal implementation model

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Further reading list• Green, A. 1999. An Introduction to Health Planning in Developing Countries. Second edition. Oxford

University Press.• Keeley, J., and Scoones, I. 1999. Understanding Environmental Policy Processes: A Review. Rep. IDS

Working Paper 89, Environment Group, Institute of Development Studies, University of Sussex, Sussex

• Kingdon, JW. 1995. Agendas, alternatives, and public policies. 2 ed. Boston: Little, Brown & Co.• Leichter, H.M. 1979. A comparative approachto policy analysis: health care policy in four nations.

Cambridge: Cambridge University Press.• Lukes, S. 1974. Three distrinctive views of power compared, in Power: A Radical View,

London:Macmillan. Reprinted. In The Policy Process: A Reader (1993), edited by Hill, M. London: Harvester Wheatsheaf.

• Marsh, D. 1998. The Development of the Policy Network Approach. In Comparing Policy Networks, edited by Marsh, D. Buckingham: Open University Press.

• Mooij, J., and Vos, V. 2003. Policy processes: An Annotated Bibliography on Policy process, with Particular Emphasis on India. London: Overseas Development Institute. July 2003.

• Parsons, W. 1995. Public policy: An introduction to the theory and practice of policy analysis. Glos: Edward Elgar.

• Sutton, R. 1999. The Policy Process: An Overview. Rep. 118, Overseas Development Institute, London

• Walt, G. 1994. Health Policy: An Introduction to Process and Power. London: Zed Books.• Walt, G., and Gilson, L. 1994. Reforming the Health Sector in Developing-Countries - the Central

Role of Policy Analysis. Health Policy and Planning 9 (4):353-370.