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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
