Health System Governance Case 3: Health Policy
making: a matter of evidence or power struggle?
1.What is health policy and how does health policymaking work?
In the early 2000s: HIV/AIDS received more than one-third of all major donor funding for health,
despite representing only around 5% of the mortality and morbidity burden in low-and middle-
income countries. Also, severe acute respiratory syndrome (SARS) attracted enormous resources
despite causing the deaths of only several hundred people.
Meanwhile: other communicable diseases (e.g. pneumonia) that kill millions of people each year and
for which cost-effective interventions exist, attract minimal donor resources (Shiffman, 2009).
How can such seemingly irrational policy choices be explained? In other words, why do some health
issues receive priority from (inter)national policymakers whereas others receive little attention?
To answer this question, it is important to understand how policy, and particularly health
policy, is made.
Difference health systems governance vs health policy making:
Health systems governance: about how things are done?
Health policy making: what should be done?
Health policy consists of two words: health and policy
A new paradigm for health:
1. We witness a shift from a pure biomedical model to a biopsychosocial model: ‘’It is more
important to know what sort of patients has a disease than what sort of a disease a patient
has’’ (William Osler)
2. We also pay more attention to how to keep people healthy
So health policy encompassed: healthcare policy as well as public health policy
Public Health policy: refers to government policy or policies of government agencies
Health policy:
The healthcare policy sector has specific characteristics which, logically, also affect the policy
environment:
Health care policy environments are increasingly populated by complex networks of public
and private actors with different roles in policymaking
Governments may be both provider and purchaser of services, as well as being involved in
regulation and other functions
Health policy (Buse et al, 2012): is assumed to embrace courses of action (and inaction) that affect
the set of institutions, organizations, services and funding arrangements of health and health care
system. (‘’What should be done’’)
It includes policy made in the public sector (by government) as well as policies in the
private sector
Because health is influenced by many determinants outside the health system,
policymakers are also interested in (intended) actions of external organizations which
have an impact on health (e.g. Ministry of Transport, food/tobacco/pharma industries)
Health Policy Triangle is important in what should be done
1
, Health Policy Triangle:
Policy actors: any participant in the policy process
that affects policy (e.g. individuals, groups,
organizations and the government). They define a
policy content
Policy content: objectives and instruments are
formulated for your policy (has to be seen together
with policy context)
Policy context: situation (earthquake), structural
(unchanging elements of the society: type of
economy of a country), cultural (e.g. position of
women) and international factors (e.g. purchasing
vaccines together with other EU countries)
have an effect on policy
Policy process: we have this, if you have
established the policy actors, the policy
content and the policy context
Gives highly simplified representation of
complex set of relationships and that the
four factors can be considered separately
(which is not the case!)
Some analysts have criticized these stages
of policy making: in reality they tend to
be messy and often unobservable to
outsiders
Can be particularly difficult to unpack and
explain (Walt et al, 2008)
E.g. in reality: actors are influenced by the
context in which they live and work
Health policy cycle (=describes the policy process):
1. Agenda setting: problem identification and issue
recognition (what comes on the agenda)
2. Formulation: policy development (how is it developed
after this issue is prioritized)
3. Implementation: how is policy implemented after
prioritizing and development
4. Evaluation: learn from agenda setting, formulation and
implementation (what should be adjusted in new cycle or
what other problems should be looked at?)
In the second part of the lecture: we look at theoretical frameworks and theories regarding agenda
setting and formulation
2
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