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Summary HPI4009: Case 3 Health Policymaking: a matter of evidence or power struggle?
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Complete summary of case 3 of HPI4009 Health Systems Governance
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Case 3 Health Policy: a matter of evidence or power 25-11-20221. What is health policy and how can it be described in terms of content, process, actors and
context?
Health systems governance versus health policy (making)
- Health systems governance: how things are done.
- Health policy (making): what should be done.
Health policy (making)
Policy is not a precise of self-evident term. The definition of health policy we use in this course is:
“Health policy is assumed to embrace course of action (and inaction) that affect the set of
institutions, organizations, services and funding arrangement of the health and healthcare system”
(Buse et al., 2012).
Another definition states: “A collective and more or less deliberate effort to achieve health goals (or
policy objectives) by means of policy instruments.
(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.
These definitions are really on: “what should be done”? You make choices on when, where, how
many times, to change or not to change something.
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.
Health policy
- Health
There is a new paradigm for health:
o We witness a shift from a pure biomedical model to a bio psycho social model: “it is
more important to know what sort of patient has a disease than what sort of a
disease a patient has” (William Osler).
o We pay more attention to how to keep people healthy.
- Policy
A decision that is taken by those with responsibility for a given policy area.
o Public policy : government policy or the policies of government agencies (whatever
the government choose to do or not to do).
o Private policy: policy for companies. However, private sector corporations have to
ensure that their policies are made within the confines of public law that is made by
the government.
The only important difference between public and private policies is that public policies
can often take longer to implement, especially in liberal democratic political systems because
of the larger number of actors necessary to agree to putting the policy into effect.
So, health policy encompasses:
- Health care policy
, - Public health policy
Health policy triangle (Walt & Gilson, 1994)
- Actors:
o Actors are influenced by the context within they live and work.
o Actors can be:
Individuals (Nelson Mandela)
Organizations (World Bank)
Multinational companies (Shell)
State/ government
o Actors can influence the policy process at the local, national, regional or international
level. Often, they become parts of networks to consult and decide on policy at all of
these levels.
o The extent to which actors will be able to influence policy depends on their
perceived or actual power. Power is characterized by a mixture of individuals wealth,
personality, level of access to knowledge or authority, but is also strongly tied up
with the organizations and structures (including networks) within which the
individual actor works and lives as well as the position or office that the individual
holds.
- Context
o The context is affected by systematic factors (political, economic and social, local,
regional, national and international) which may have an effect on health policy.
Different kind of factors include:
Situational factors: are more or less transient or idiosyncratic conditions
which may influence policy. In other words; focusing events (e.g., an
earthquake or the HIV epidemic).
Structural factors: relatively unchanging elements in the society (e.g., type of
economy, the opportunity to participate in policy discussions and type of
employment).
Cultural factors: (e.g., formal hierarchies or religious factors). In societies
where formal hierarchies are important, it may be difficult to question high
officials or elder statesmen
International or exogenous factors: factors leading to greater cooperation
between states, and influencing sovereignty and international cooperation in
health may also affect health policy. Although many health problems are
dealt with by national governments, some demand cooperation between
national, regional or multilateral organizations (e.g., polio and climate
change).
All the contextual factors are complex and unique in time and setting.
- Process
, o The policy making (how issues get on the policy agenda) is affected by actors andt he
position, values and expectations of these actors.
o Process is the way in which policies are initiated, developed/formulated, negotiated,
communicated, implemented and evaluated.
o The most common approach is the “stages heuristic” : breaking down the policy
process in different steps:
Agenda setting: problem identification and issue recognition explores how
some issues get on the policy agenda, while others do not even get
discussed.
Policy formulation: explores who is involved in formulation policy, how
policies are arrived at, agreed upon and how they are communicated.
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.
Policy evaluation: identifies what happens once a policy is put into effect,
how it is monitored, whether is achieved its objectives and whether it has
unintended consequences.
The stages heuristic approach shows a pretty linear process. However, the policy process
is almost never that clear or obvious. Policy making is seldom a fully rational process it is
iterative and affected by interests.
- Content
o The content of policy reflects a combination of all these factors.
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.
The (health) policy cycle
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
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