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Module 5

Understanding health policy processes

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ContentsThis module explores the foggy field of policy-making, non-making and unmaking in troubled health sectors, drawing from documented situations as diverse as Afghanistan, Angola, the Democratic Republic of the Congo, Kosovo, Mozambique, Sudan and Uganda. Analysing existing policies and the process of their formulation says much about the sector and the forces that shape it. The analysis can provide clues on the directions taken by the sector and on the constraints that have affected decision-making and implementation. It can help avoid old traps and mistakes and identify fields and avenues that have proved encouraging. The module discusses common patterns and suggests approaches to policy analysis. The main features of the most influential actors interacting in the policy arena are briefly described. The coordination of external resources, usually a key issue in protracted crises, concludes the module.Annex 5 discusses the value of a Policy Intelligence Unit in a troubled environment, and suggests the features it may have, the products it may deliver, and the institutional position it should take to function effectively. Closely-related modules: No 3. Understanding the broader country context: past, present and future No 6. Analysing health financing and expenditure No 7. Analysing patterns of healthcare provision No 8. Studying management systems No 12. Formulating strategies for the recovery of a disrupted health sector

IntroductionDisrupted health sectors often confront actors with the dilemma of deciding whether a. to struggle to maintain the systems basic functions, mending cracks as they

emerge and, if feasible, cautiously introducing novelties at the margin and at a pace that the system can absorb, or conversely

b. to declare the system irreparably wrecked, abandon it to its fate and design a new system from scratch.

At all levels of decision-making, policy discussion during and after the crisis is permeated by this dilemma, even if it is not explicitly recognized. A thorough appraisal of the systems strengths and weaknesses should provide precious clues to decision-makers. Such an appraisal is by definition difficult for both insiders and outsiders. The former, grown within established settings and taking most of them for granted, have problems in conceiving alternative organizational features. Thus, they tend to favour conservative approaches. The latter, lacking in most cases an intimate knowledge of the health sector, may react to the shambles that they observe by concluding that nothing valuable has survived the crisis and therefore that aggressive restructuring is the only sensible available option.In this respect, disrupted countries present a wide range of situations. At one end of the spectrum, the preservation of basic functions (and the ability of the MoH to present the situation under a favourable light to outsiders) of the Mozambican health sector explains the prevailing conservative approach adopted by most actors during and after the war. There, the occasional call for radical change, usually unsupported by convincing arguments, was largely ignored. At the other end of the spectrum, the total disarray of Afghanistan or Somalia, or the birth of new political entities, such as Kosovo or Timor-Leste, encourage innovative, start-from-the-basics approaches. Whether aggressive strategies pay off in certain forbidding environments remains to be seen. See True Story No. 7 and Exercise 6 in Module 15 for a short discussion of the Kosovo experience.

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Conservative approaches incur the risk of missing valuable opportunities for change and of wasting efforts and resources in maintaining a system already beyond recovery. Conversely, radical change may dismantle surviving functions and hurt fragile capacity, adding damage to that brought by conflict. In this way, the health sector hastily considered beyond repair will become beyond repair, to fulfil the original (and wrong) diagnosis.The term policy encompasses a broad range of laws, approaches, prescriptions, guidelines, regulations and habits. Some macro-policies have implications across most or all areas, including the health sector, whose actors have limited influence over them. Fiscal or civil-service policies fall in this category. Within the health sector, policies can be of broad or narrow scope. Macro-policies with far-reaching implications tend to have a robust political character, even when they are advocated for their supposed technical merits. Examples of such policies are Primary Health Care, decentralization, Health Sector Reform, and new financing mechanisms, which affect (or should affect) most aspects of health service delivery. Other policies, of strictly technical nature, address narrower issues, such as the control of a communicable disease or drug quality control. This module focuses mainly on macro- and sector policies, whose implications affect the whole health sector or substantive aspects of it.Health policies are (or better: should be) recognizable even in the absence (or despite the content) of written statements. The ways services are delivered, allocative decisions are made, information is produced and used, actors interact, old practices are followed and new ones are introduced: all these elements sum up into the policies governing a health sector during a given period of time. Therefore, countless, dispersed decisions shape a specific way of running operations. Policies evolve over time, under multiple pressures. In unstable situations, this evolution may accelerate. Due to sudden turnarounds, policy processes may be reverted. As the crisis deepens, the policy frame that previously governed a battered health sector may melt down. Unwritten working methods, usually passed on by senior colleagues to junior ones, are particularly exposed to oblivion. Newcomers ignorant of practices enforced before the crisis may accelerate this trend. Against this disrupted backdrop, policy documents become the sole reference available to actors, who may vocally complain about their absence or advocate for their development.

The policy-making environmentDuring protracted crises, virtually all factors conspire against effective policy-making. The state authority is contested, top managers are removed from their posts or move to other jobs, the public sector is crippled, instability and uncertainty discourage long-term initiatives, the information base is poor, actors multiply and are replaced, memory is weak, the policy discussion easily takes political overtones, and accountability and transparency are difficult to enforce. Unsurprisingly, documented examples of successful policy-making practice are scarce.The health sector is part of a broader picture, which affects the choices made within it. For instance, free market, new public management, and decentralization are all part of worldwide processes that impact on the sector according to political and economic rationales not necessarily desirable from the health sectors exclusive point of view (Reich, 2002). In the political deals between governments, rebels, UN agencies, donors, development banks, private companies and providers, foreign armies, and peacekeepers, important decisions that affect the health sector and shape the decision space of its actors are taken. As in a true theatre, the actors on the crisis stage must conform to a certain extent to pre-written scripts, obey the instructions of directors and producers, and take into consideration the reaction of critics and audience.The idealised strong state, with its functioning Ministry of Health firmly in control of policy-making, resource allocation and regulation of the sector, is increasingly absent

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in many parts of the Third World. Instead, many developing countries, particularly in Africa, are characterised by states which lack the capacity, and in some cases the political will, to function as sovereign states. The weakness of public policy in these countries, together with the current preference of officials aid organisations for policy-based lending means that the locus of health-policy making is increasingly internationalised with decisions regarding major elements of the content of health policy in recipient countries frequently being made in Washington, Copenhagen and London, rather than in national capitals (Lanjouw, Macrae and Zwi, 1999). The health sector itself is often the object of political bargaining, as in Angola, where the ministers post was given to the rebels, as part of the negotiated settlement of that conflict. Health, often perceived as a technical field of limited political significance, may count among the areas where weakened governments are more amenable to concede grounds. Further, the health sector may offer to former rebels the first experience of formal governance. And at the end of a liberation struggle, healthcare delivery may be used to demonstrate the commitment of the new rulers to social welfare and to win hearts and minds.The policy discussion is often kept within a narrow circle of health professionals, who may be remarkably unaware of the influence of political, economic, legal and administrative determinants on health developments. Health officials from the MoH, health international agencies and NGOs are joined by health authorities from academia, business or professional bodies to debate the shape the health sector should assume. The broader country context, and the decisions being taken that strongly impact on the health arena, are reluctantly if at all considered,