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Case 3 Health systems governance
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Case 3 of health systems governance
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Case 3 What is health policy and how can it be described in terms of content, process, actors and context?
Overall health policy: Triangle model + actors
Policy is often thought of as decisions taken by those with responsibility for a given policy area – it
may be in health or the environment, in education or in trade.
Health policy may cover public an private policies about health. Health policy is assumed to embrace
courses of action that affect the set of institutions, organizations, services and funding arrangements
of the health and health care system.
(Broad) Policy: broad statement of goals, objectives and means that create the framework for
activity. Refers to the decisions taken or not taken by those with responsibility for a particular policy
area. The set of institutions: rules of the games. Organisation services and funding arrangements:
hospital/health care institutions + the way how they deliver the healthcare.
You make choices on when, where, how many times, to change or not to change something.
Health policy: may cover public and private policies about health. It embraces courses of action (and
inaction) that affect the set of institutions, organizations, services and funding arrangements of the
health and health care system.
Because health is influenced by many determinants outside the health system, health policy analysts
are also interested in the actions and intended actions of organizations external to the health system
which have an impact on health.
To understand how a decision is made you need to know something about the political context; the
power of the president to introduce change and the role of evidence in influencing the decision,
among other things.
‘’ the framework used in this book acknowledges the importance of looking at the content of policy,
the processes of policy making and how power is used in a particular health policy context. This
means exploring the role of nation state, international organizations, the groups making up national
and global civil society as well as the private sector to understand hwo they interact and influence
health policy. It also means understanding the processes through which such influence is played out
and the context in which these different actors and processes interact’’.
The four factors influence each other.
- Actors are influenced by the context within which they live and work.
- Context is affected by many factors such as political instability or ideology, by history and culture.
- The process of policy making is affected by actors, their position in power structures, their own
values and expectations.
- The content of policy reflects some or all of these factors.
,Actors Individuals (e.g. the minister of Health), organizations (e.g. WHO, Shell, government). Non-
state actors and state actors.
Actors may seek to influence policy, but the extent to which they will be able to do so will depend
on their perceived or actual power. The organisation in which the actor is involved also decides how
much influence the actor has. This actor is more broad than the last one (case 2); it is more focused
on the policy within the health system, not only the health care (as in case 2). Here you also have
power, so not everybody has the same amount of power.
Examples of actors:
Government
National non-governmental organizations
Interest groups
International organizations such as the WHO
Funding organizations
Private sector companies
The role of actors all differ. Someone In the government has more power to influence. Or research if
there is a big organization they could influence the political agenda.
Context Factors that affect policy – systemic factors (political, economic and social, local, regional,
national and international, which may have an effect on health policy. There are many ways of
categorizing such factors:
Situational factors Transient (voorbijgaand) or unusual conditions which may influence policy
(e.g. wars).
Structural factors Relatively unchanging elements of the society (e.g. political
system(open/closed), type of economy). Or for example the demographic features or technological
advance.
Cultural factors In societies where formal hierarchies are important, it may be difficult to
question high officials or elder statesmen. Religious for example, ethnic minorities.
International or exogenous factors Factors leading to greater inter-dependence between states
and influencing sovereignty and international cooperation in health may affect health policy.
, Example:
Situational: a new prime minister president to power and making aids policy a priority
Structural: the role of the media or NGO in publicizing or not the AIDS epidemic relating to the extent
to which the political system is open or closed
Cultural: the actions of religious groups both negative and positive with regard to people living with
HIV or towards sexual behaviour
International: the role of international donors, the extra dungs brought in by global initiatives such as
the global fund to fight AIDS.
Content
Substance of specific policy. What the policy entails.
Process How the policy is made.
The way in which policies are initiated, formulated, developed, negotiated, communicated,
implemented and evaluated. Stages heuristic= breaking down the policy process into a series of
steps, (not necessarily reality and not linear)
1. Problem identification and issue recognition Explores how issues get on to the policy agenda,
while others do not even get discussed.
2. Policy formulation Explores who is involved in formulating policy, how policies are arrived at,
agreed upon, and how they are communicated.
3. Policy implementation Often the most neglected, but most important phase: if policies are not
or wrongfully implemented, the policy outcomes may not be those which were sought.
4. Policy evaluation Identifies what happens once a policy is put into effect. How it is monitored,
whether it achieves its objectives and whether it has unintended consequences.
These stages all occur, but not in the linear way.
Stages of the process
1. Recognition that the problem must be known and that solutions must be available to
engender prioritisation.
Problem
Local level indicators: the health care issue is globally noted, but not locally and that is why is does
not get on the agenda.
No resources: knowledge alone is not enough to prevent/treat patients, especially in low- and
middle-income countries there are no resources to provide treatment.
Infrastructural and training challenges
High costs: vaccination for prevention does not require infrastructural development, but for
example HPV vaccines are expensive. In summary, policy frameworks commonly note the necessity
of both a clear problem and a viable solution to raise the priority of an issue
CONNECTION WITH MODELS feasibility + problem stream and policy stream + issue
characteristics.
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