AGP Summary - Health Policy Framework PDF

AGP -- Summary **Chapter 1. The health policy framework.** ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Actor** Any pa...

AGP -- Summary **Chapter 1. The health policy framework.** ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Actor** Any participant in the policy process that affects policy, including individuals ------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Content** The specific objectives of policy **Context** Factors which can influence health policy (e.g. political, economic, social or cultural, both national and international) **Epistemic community** Policy community with shared political values, shared understanding of a problem and its causes **Ideas** What shapes policy (e.g. values, evidence, including the way a policy problem or solution is presented) **Interest** What an actor or group can gain or lose from a policy change **Institutions** They determine how government and other parts of the state operate. Including formal and informal guidelines.\ Formal: official structures, laws and procedures.\ Informal: unwritten norms and behaviours that people follow. **Policy** Broad statement of goals, objectives and means that create a framework for activity. Often takes the form of explicit written documents, but may also be implicit or unwritten **Policy elite** Specific group of policy makers who hold high positions in a policy system and often have privileged access to other top members of the same, and other, organizations **Policy process** The way in which policies are initiated, formulated, developed, negotiated, communicated, implemented and evaluated. **Public policy** Policies made by the state or the government and/or by the public sector **Health policy** Policies that affect the health system (e.g. institutions, organisations, services and funding arrangement, both public and private) ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Policy analysis triangle** - **Content**: what is the policy about? - **Context**: what factors influence the policy? - **Actors**: who play a role, or are affected by the policy? - **Process**: how does the policy take shape? **Content:** can be anything. What is the problem deserving of a solution where it comes to. **Context**: Four types of contextual factors affect the policy making. 1. **Situational factors**: focusing event, violent events (wars, coup), earthquake 2. **Structural factors**: political system, type of economy (planned vs. 'free'), technology, GDP, demography, migration. 3. **Cultural factors**: religion, traditions, social values. 4. **International (exogenous) factors**: interdependence among states, bilateral/multilateral aid and agreements. ***An example -- mpox*** 1. Emergence of mpox + if there is already a war happening it has effect on the government 2. Lack of healthcare facilities, political systems has challenges so that makes it difficult to make a policy, presence of vulnerable groups, lack of health education. 3. Values and beliefs about vaccines or how contagious a disease can be. 4. International depended on other countries. **Actors**: minister of health, leaders of political parties, patients, international travel, healthcare professionals, healthcare institutions. - They can be individuals, organizations, groups, states. - Inside government: members of parliaments, ministers, bureaucrats. - Outside government: groups that do not seek political power but influence those who do have the power. *Stakeholders (always suggest that there is something at stake).* **Processes**: how does policy take shape - To understand the question we need to: - Understand relations between actors - Understand power, values, perspectives, roles and interest of different actors - Understand procedures and rules that are in place **The processes of policy making** - **Problem identification and issue recognition**: explores how some issues get on to the policy agenda, while others do not even get discussed - **Policy formulation**: explores who is involved in formulating policy, how policies are arrived at, agreed upon, and how they are communicated. - **Policy implementation**: arguably the most important phase of policy making because, if policies are not implemented then something might be going wrong - **Policy evaluation**: identifies what happens once a policy is put into effect. **\ Chapter 10. Doing policy research** **Crowdsourcing** Gathering suggestions from the public via Social media to help decide a course of action ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Social network analysis** Methods used for mapping, measuring and analysing the social relationships between people, groups and organizations **Stakeholder** An individual or group with a substantive interest in an issue, including those with some role in deciding or its execution. *Used synonymously with actor and interest group* **Stakeholder analysis** Identifying who is involved in making policy or who will be impacted by it. Then, understanding what their opinions, interests and influences are. **There are 2 types of analysis:** - **Retrospective**: to understand how policy works or does not work and why (analysis **of** policy) - **Prospective**: to inform (future) policy about what might work in addressing a problem (analysis **for** policy) **Stakeholder analysis** - Identify the actors - Assess the power relationships - Assess interest, position and commitment - Assess the opposition (power) **Actor analysis** - Asses decision makers and media - Assess public relations (e.g. victim status/hero nature) **Power strategies**\ used to affect the distribution of political assets of the players involved to strengthen supportive groups and undermine opposition groups. - **Providing supportive actors with**: funds, information, access to decision makers, links to supportive networks - **Limiting opponents with**: challenging their legitimacy, reducing their access to decision makers, refusing to cooperate or share information **Player strategies**\ attempt to impact on the number of actors involved in a policy arena, in particular to mobilize those that are neutral and to demobilize those groups who are opposed. **Perception strategies\ **a variety of techniques used to alter perceptions. - Data, arguments, the importance of a problem or the practicality of a policy solution can be questioned. - The appropriateness of public or private action can be attacked using economic theory or philosophy to shift players' perceptions on an issue. - Associations can also be altered to give an issue a greater chance of political and social acceptability. **Chapter 3. State and the private sector** **Decentralization** The transfer of authority and responsibilities from central government to local levels ------------------------------- --------------------------------------------------------------------------------------------- **New public management** An approach to government involving the application of private sector management techniques **Private sector** That part of the economy which is not under direct government control **Privatisation** Sale of publicly owned property to the private sector **Regulation** Government intervention enforcing rules and standards (e.g. in the private sector) **Transnational corporation** Business which owns branch companies in more than one country \ Focused on: two important **actors** in the health policy triangle: state and private sector **Health systems reform -- Problems** - Technological developments increase costs and make choices necessary - Rise in chronic disease (diabetes, obesity) put pressure on services - Demographic development (rise in number of elderly) increase demand **Health system reform -- Ideology**\ Current ideology slimmed down state through - Introduction of market pressures for public services -- 'new public management' - Competition for contracts from public purchasers - Competitive tendering of support services - New financial mechanisms: - Introduction of out-of-pocket fees for service use **Health system reform -- Decentralisation**\ Taking service elements away from the ministry and to the community. - **Functions** of ministry of health (MoH) new executive agencies - **Authority** of MoH district or local levels - **Autonomy** for hospitals control over own budget **Influence on public health policy** - **Financial support** of political parties and campaigns. ([Money]) - **Participation** in governmental committees and working groups. ([Knowledge]) - **Establishment** of sectional interest group of joint companies, for example the Netherlands' Federation of Pharmaceutical Companies (NEFARMA). ([Power]) The elements money, knowledge and power and the elements that connect the private sector in itself as well as the private sector with the government. - Financial support to research organisations - Establishment of scientific organisations (by the private sectors) - Financial support to patient organisations - Employment of PR firms that use media **Private sector & norms** Self-regulation -- substitutes public policy: - Market standards: facilitate trade - Social standards: - **Types**: Corporate social responsibility (CSR, voluntary codes and reporting initiatives and corporate philanthropic programmes - **Why?** Concerns raised by consumer and shareholders, threat of public regulation **Social standards, but evaluation studies show:** - Lack of transparency and accountability -- no involvement of public in M&E - Lack of timely and effective sanctions - Erodes universal right - Only concerns selected issues and groups of workers **New relationships** Public -- Private partnerships - Co-regulation: public and private sectors negotiate on an agreed set of policy or regulatory objectives private sector implements - Joint planning and funding of health programmes private sector implements **Chapter 4. Agenda setting** **Agenda setting** Process in which certain issues come onto the policy agenda (from the much larger number of issues potentially worthy of attention by policy makers) --------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Feasibility** A characteristic of those issues for which there is a practical solution **Legitimacy** A characteristic of those issues which policy makers see as appropriate for government to act on **Policy agenda** List of subjects or problems to which government officials and people outside government pay serious attention **Policy stream** The set of possible policy solutions or alternatives developed by experts, politicians, bureaucrats and interest groups, together with the activities of those interested in these options (e.g. debates between researchers) **Policy windows** Points in time when the opportunity arises for an issue to come onto the policy agenda and be taken seriously with a view to action **Politics stream** Political events such as: shifts in the national mood or public opinion, elections and changes in the government, social uprisings, demonstrations and campaigns by interest group **Problem stream** Indicators of the scale and significance of an issue which give it of visibility **Support** A characteristic of those issues to which the public and other key political interests want to see a response **Politics-as-Usual or the Rational model\ **What is important will be taken up by policy makers and politics. However, what is important may differ among people, political parties, cultures, etc. **Hall model (Politics-as-Usual)** - **Legitimacy**: issues with which governments feel they should be concerned with and in which they have a right to intervene. (Have to) - **Feasibility**: refers to potential for implementation, recourses, personnel, infrastructure. (Can we) - **Support**: refers to public support for, or public 'trust' in, government. (Will we) When an issue is low concerning one or more of these concepts, it will be low on the policy agenda. **Kingdon model -- Why issues get on the agenda, or not (Politics-as-Usual)\ **Approach focuses on the role of policy 'entrepreneurs' inside and outside government who take advantage of agenda setting opportunities -- known as policy windows -- to move items onto the government's formal agenda. **Three separate stream of processes** - **Problem stream**: defining certain condition as problem - **Political stream**: visible participants -- politicians in power, interest groups -- and hidden participants -- specialist/experts. - **Policy stream**: selecting from problems and possible solutions using criteria such as legitimacy, support, feasibility, etc. Sometimes the three streams are joined and a policy window (of opportunity) opens because of\ individual (policy entrepreneur), media attention, focusing events (crisis) or feedback **Policy under crisis** - Differs from politics-as-usual, e.g. easier to get radical policies seriously considered - Crisis exists when important policy makers perceive that one exists - Real and threatening circumstances - Failure could lead to even more disastrous consequences - Events that do not have all these characteristics are not likely to be considered a crisis - If the gravity of the situation is confirmed by pressure from outside the government (e.g. fall in price of an essential exported crop) and the government has access to information from its own experts, then the chances are that the government will see the problem as a crisis, and pay it serious attention **Non-decision making** - The power to keep things off the policy agenda is as important as the power to push certain issues onto the government's agenda - For instance, those with enough power (e.g. economic elites) are not only capable of stopping items reaching the agenda; they are also able to shape people's wishes so that only issues deemed acceptable and non-threatening to their interests are discussed, never mind acted on. **Government as agenda setter**\ Hogwood & Gunn approach -- 'issue search' -- anticipate before they turn into crisis - Government is the most powerful agenda setter - Policy makers need to anticipate problems before crisis occur - External environment (climate change) - New technologies (ICT, biotechnology, nano) - Demographics (aging, multicultural, urban) - Information and needs change - New problems arise, new solutions become available - Attitudes change **Interest groups as agenda setters** - Civil society organisations, pressure / interest groups, non-governmental organisations, private sector companies, international organisations and social movements **Media as agenda setter\ **Responsive to less powerful groups - Many groups see the media as a way of reaching both the general public and policy makers - Media do not treat not everyone and every situation equally and fairly (teams are not there, issue not considered newsworthy) - Issue attention cycle  **Chapter 5. Government and the policy process** **Unicameral legislature** There is only one 'house' or chamber --------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Bicameral legislature** There is a second or upper chamber, the role of which is to critique and check the quality of draft legislation promulgated by the lower house. Normally, only the lower house can determine whether draft legislation becomes law **Bureaucracy** Compromises the public officials, often known as civil servants, whose job it is to advise ministers (the executive) on how best to take forward their policy goals and then to manage the process of policy implementation **Executive** Leadership of a country (the president and/or prime minister and other ministers). The prime minister/president and senior ministers are often referred to as the cabinet **Federal system** The sub-national, state or provincial level of government is not subordinate to the national government but has substantial powers of its own which the national government cannot take away (like in the US) **Judiciary** Comprises judges and courts which are responsible for ensuring that the government of the day (the executive) acts according to the laws passed by the legislature **Legislature** Body that enacts the laws that govern a country and oversees the executive. It is normally democratically elected to represent the people of the country and commonly referred to as the parliament or assembly. Often there will be two chambers or 'houses' of parliament **Parliamentary system** The executive are also members of the legislature and are chosen on the basis that most of the legislature supports them **Presidential system** The president or head of state is directly elected in a separate process from the election of members of the legislature **Proportional representation** Voting system designed to ensure that the proportion of votes received by each political party equates to their share of the seats in the legislature **Unitary system** The lower levels of government are constitutionally subordinate to the national government, and receive their authority from central government **\ Theory of Trias politica**: The three branches of government - Legislative (make laws) - Executive (enforces laws & governs the states) - Judiciary (ensures executive acts in accordance with the law) **Two features of government systems have a major effect on their ability to make and implement policy:** - **Autonomy**: ability of government to resist self-interested groups and to act as arbiter of social conflict from perspective of welfare of the whole country - **Capacity**: ability of government to make and implement policy Only then will an accountability structure work. **Governmental systems** **Unitary:** - Clear **chain** **of** **command**, lower levels being subordinate to higher levels - National government has **potentially all decision-making powers**, may delegate more rapid policy change - *European countries, New Zealand, Japan\ * **Federal**: - At least two separate levels of government with powers shared between them - Sub-national level has high levels of freedom - Levels may have different political parties - *USA, Canada, India, Brazil, Nigeria\ * **Parliamentary system:** - Executive is chosen by legislative among its members - Executive remains in office as long as it has majority support among legislatures - Executive can normally rely on majority in legislature for policy change **Presidential system**: - Executive and legislature and separately elected by public - No need to have majority support among legislatures - President regularly has to offer concessions **Election of legislature: political parties & party policy** - In **liberal** **democracies** political parties produce **policy** **statements** before each election to demonstrate intended policies - Policy statements are often done in **sufficiently general terms**, catering for broad front of opinions - Only when in power may they actually formulate policy **governance agreement** (will divert from intentions) - In **single-part systems** the political party formulates all policies, and it is the task of the government to find the best way of implementation -- the part is the supreme policy-making body **Types of electoral systems** **Majoritarian** (first-past-the-post) - Candidates from different political parties compete in individual districts - The candidate who gets the most votes in each district wins the set in parliament - Political parties aim to win as many induvial district contests as possible because winning more districts means securing more seats in parliament - Parties often focus on specific local issues that affect particular groups of voters (constituencies) to tailer their policies and maximize votes within each district - Used in the **US** **Proportional Representation (PR)** - The number of seats a political party gets in parliament depends on its overall share of the national vote. - For example, if a party winds 30% of the national vote, it might get roughly 30% of the seats in parliament - Here the focus for political parties is to maximise their total vote count across the country - This systems encourages parties to appeal to a broader range of voters by addressing more universal or national issues - Used in **the** **Netherlands** **Bureaucracy / ministers** - Civil servants may have considerable **power** because of their **expertise**, **knowledge** and **competence** - In those systems where **civil servants stay** in position when politicians change frequently, politicians may be highly **dependent** on civil servants (and endorse whatever they say) - Civil servants may **control policy** by **manipulating** info to keep ministers at a disadvantage  **Chapter 7. Policy implementation** **Advocacy coalition** A group within a policy sub-system sharing common norms, beliefs, and resources, including politicians, civil servants, interest groups, journalists, and academics who align on policy goals and, to some extent, solutions. ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Bottom-up approach (implementation)** An approach to policy analysis that highlights how local actors and context shape implementation, acknowledging that lower-level implementers have discretion and may produce outcomes different from the original plan **Implementation** Process of turning a policy into practice or action **Implementation gap** Difference between what the policy architect intended and the end-result of a policy **Policy instrument** One of the range of options at the disposal of the policy maker in order to give effect to a policy goal (e.g. privatisation, regulation, subsidy, etc) **Principal-agent theory** Theory or organisational and government behaviour that focuses on the relationship between principals (e.g. purchasers) and their agents (e.g. providers), together with the contracts or agreements that enable the purchaser to specify what it to be provided and check that this has been accomplished **Street-level bureaucrats** Front-line staff involved in delivering public services to members of the public who have some discretion in how they apply the objectives and principles of policies handed down to them **Top-down approach (implementation)** A linear, rational approach to policy analysis that tracks how higher-level policies (e.g., national government) are executed at lower levels, focusing on how policy design impacts local implementation and separating policy formulation from implementation. **'Top down' policy implementation\ **A more traditional view of implementation 1. Clear and logical objectives 2. Adequate causal theory (i.e. a valid theory as to how particular actions would lead to the desired outcomes) 3. Appropriate incentives and sanctions to steer the subordinates 4. Committed, skilful implementing officials 5. Support from interest groups and legislature 6. No changes in socio-economic conditions **Challenges in a 'top down' policy implementation\ **The world is much more complex - **Implementation gap**: difference between what the policy architect intended and the end result of a policy Criticism of 'top down' implementation: too 'uniform' goal perceptions and too much focus on central decision maker Lipsky (1980): the role of street-level bureaucrats\ Officials 'interpret' policies, and have freedom to implement them in different ways. This can be good (context-specific solutions) or bad (confusion, conflict) **'Bottom up' policy implementation** - Bottom up approaches start from local actors & stakeholders policy implementation - Better tailored to local needs/conditions - Using the knowledge and expertise of those who implement the policies - Importance of relationships and trust **Challenges in 'bottom up' policy implementation** - Is there still distinction between policy formulation and policy implementation? - How to evaluate policies, if there are no clearly separated 'decision moments'? **Comparing 'top down' and 'bottom up'** **Top down** **Bottom up** -------------------------------- -------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ Starting point **Central** government decision **Local** actors and networks Identification of major actors **Top down**, starting from the government **Bottom up**, including both government and non-government View of the policy process **Rational**, from problem identification policy at higher levels implementation at lower levels **Interactive**, involving policy makers and implementers at all levels, policy may change during implementation Evaluative criteria Formal objectives; **outcome criteria**, less the unintended consequences Much less clear; **process criteria** take into account local influences Overall focus **Intention** of central policy makers (structure) **Strategic** **interaction** of multiple actors in a policy network (agency) **Bridging the gap between 'top down' and 'bottom up'** **Strengths**: - Top-down: focus on government capacity - Bottom-up: focus on system complexity and networks **Bridging the gap:** - Advocacy coalition framework - If the boundaries between policy formulation and policy implementation are vague in reality, why do we need them in theory? **Advocacy coalition framework** - Advocacy coalition: a group within a policy sub-system distinguished by a **shared set of norms, beliefs and resources**. Can include politicians, civil servants, members of interest groups, journalist and academic who **share ideas** about policy goals and to a lesser extent about solutions  **Principle agent theory**\ Sub-optimal policy implementation is unavoidable because decision-makers ('principals') must delegate tasks to officials and agents (e.g., civil servants, doctors) they can\'t fully control or monitor. These \"agents\" have their own priorities and discretion, which may lead to ineffective policy outcomes. The amount of discretion and the complexity of the principal--agent relationships are affected by: - **The nature of the policy problem**: simple vs complex, ill-defined vs clear, many causes vs a single cause and costly versus inexpensive. - **The context of circumstances surrounding the problem**: the political situation, whether the economy is growing or not, the availability of resources and pace of technological change. - **The organisation of the machinery required to implement the policy**: the number of formal agencies and informal relationships involved in making the desired change, and the skills and resources. **New public management**\ Governments shifted from directly providing services to contracting out to private or nonprofit providers, aiming for greater efficiency. Policymakers were also encouraged to explore a range of policy tools to improve service delivery. The policy instruments or tools at the disposal of governments to implement their policies are: - **Information and persuasion**: encouraging behaviour change by providing information such as health education programmes, clinical guidelines, training, research and evaluation, but without associated compulsion to act in a particular way. - **Regulation**: requiring behaviour change through sanctions for non-compliance, using tools like legislation, licensing, minimum standards, taxation, subsidies, and resource reallocation (e.g., clinical workforce). - **Public provision**: the government provides key public services directly, especially for public goods that benefit everyone and require broad participation, like defence and immunization. - **Markets and market-like incentives:** encouraging behaviour change by introducing competition and user choice in public services or creating new markets (e.g., carbon trading to combat climate change). **Bridging the gap -- transition governance\ **combines 'top down' and 'bottom' up insights. **Key characteristics of governing transitions** 1. **System analysis** and **visioning** to formulate 'problems' and 'future systems' 2. **Building multi-stakeholder** networks around the vision 3. Learning and **reflection** play key roles 4. **Implementation** focuses on **experiments** (doing, thinking and organising differently) 5. **Implementation** focuses on **scaling up** of sustainable initiatives 6. **Implementation** focuses on **phasing out** unsustainable elements **Chapter 2. Power and the policy process** **Authority** Whereas power concerns the ability to influence others, authority concerns the right to do so ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Bounded rationality** Theory that policy makers intend to be rational but make decisions that are satisfactory as opposed to optimal **Elitism** Theory that power is concentrated in a minority group in society **Government** The institutions and procedures for making and enforcing rules and other collective decisions. Government is a narrower concept than the state since the state also includes the judiciary, military and other public bodies **Incrementalism** Theory that decisions are not made through a rational process but by small adjustment to the status quo in the light of political realities **Path dependency** The process by which decisions taken in one period shape and limit the range of policy choices available to decision makers later **Pluralism** Theory that power is widely distributed in society **Political system** The processes through which governments transform 'inputs' from citizens into 'outputs' in the form of policies **Power** The ability to influence people, and to control resources **Punctuated equilibrium** Theory which explains why long periods of policy stability are upset by abrupt adjustment, policy reversals and reforms **Rationalism** Theory that decisions are made (and should be) made through a rational process by considering all the options and then consequences and then choosing the best **Sectional group** Interest group whose main goal it is to protect and enhance the interests of its members and/or the section of society it represents **Sovereignty** Entrails rule or control over a geographical area that is supreme, comprehensive, unqualified and exclusive **State** A set of institutions that enjoy legal sovereignty over a fixed territorial area. The state comprises a wide set of institutions than the government and includes the parliament, judiciary, military as well as other bodies **What is power\ **The ability to influence people to control resources **Easton's model -- 'How it should work'** **Three dimensions of power** - Power as **decision making:** few actors have or realise direct influence on key decisions (Dahl) - Power as **non-decision making:** dominant groups exert influence to delineate the policy agenda (agenda setting) (Bachrach & Baratz) - Power as **thought control:** compliance through subtle means (e.g. mass media or socialisation) (Lukes) **Weber's three origins of power** *(plus a fourth)* 1. **Traditional authority**: where obedience is based on custom and the established way of doing things (for example, a king or sultan has traditional authority) 2. **Charismatic authority**: based on intense commitment to a leader and their ideology or other personal characteristics. Those exercising authority on the basis of charisma, for example, some religious leaders, statesmen (e.g. Nelson Mandela) 3. Rational-legal authority: based on rules and procedures, where authority comes from the office, not the person holding it. For example, in many former British colonies, the most senior health official is a Permanent Secretary, usually a manager, not a doctor. Doctors follow their orders based on the office\'s legal authority, not the individual\'s personal traits or expertise. 4. *Technical authority: patients respect the advice of their doctors (for the most part) on the basis of the technical knowledge that doctors are thought to possess* Authority is considered legitimate if the personal judgment to accept someone (or some institution) is based on trust and acceptance. **Who has power in society?\ **Theories about the distribution of power in society: pluralism, public choice, elitism and bounded pluralism **Pluralism:** - **Equality** protected by political rights to vote and to free speech (lobbying, demonstration, strike, free mass media) - Individual citizens have the right to and the **ability to organise groups** and associations - State does not defend the interests of one class or group, nor shows marked bias towards particular interests - There is a plurality of elites: power is diffused throughout society **Public** **choice**: - State is in itself an interest group - Wields power over policy process in interest of those who run it**: politicians and civil servants** - Politicians tend to give **favours to be re-elected** - Civil servants try to expand their **bureaucratic empires** - State has **inbuilt dynamic** to its further growth and power - Leads to policy captured by **narrow interest groups** and not in public's interest **Elitism**: - Political elite is only open to members of **dominant economic classes** - **Interest groups** are not equally powerful (resources) - Considerable power outside areas of state activity by **transnational companies** and international organizations - Policy choice is dominated by few elites and primary function of state is **to ensure continuing dominance of these elites** **Alternative: incrementalist model (Lindblom)\ **Describes the way policy is actually made: - **Selection** of goals/objectives and means of implementation are closely allied -- often avoidance of specifying objectives clearly - Policy makers look at small numbers of alternatives that differ marginally from existing policies ('**path dependency**') - Of each alternative only **most important costs and benefits** are considered - '**Best decision**' is the option for **which there is agreement among policy makers** - Policy making is serial - Policy as a process of 'muddling through' - Result of negotiation, bargaining and adjustment between different interest groups to influence policy **Criticism**: - Picture of policy as inherently conservative - Reinforces inertia and status quo and cannot explain radical change **Punctuated equilibrium -- Baumgartner and Jones (1991)** - Policy change often occurs in long periods of stability, interrupted by sudden, major reforms. - Policy monopolies---elites or interest groups---maintain this stability by controlling the narrative and institutions. - However, external shocks, like new political coalitions or economic shifts, can disrupt this equilibrium, leading to rapid change. **Mixed-scanning -- Amitai Etzioni's model** - Combines the idealism of rational decision-making with the realism of incrementalism. It involves broad analysis of major decisions and detailed focus on smaller steps. - Overcomes rationalism\'s complexity and incrementalism\'s conservative nature. - In health policy, this might mean ministries assess the overall burden of disease to set priorities, while specific program managers focus on detailed interventions. **Chapter 9. Research evaluation and policy** **Audit** Examination of the extent to which an activity corresponds with pre-determined standards or criteria ----------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Dissemination** Process by which research findings are made known to key audiences, including policy makers **Evaluation** Research designed specifically to assess the operation and/or impact of a programme or policy to determine whether the programme or policy is worth pursuing further **Evidence** Any form of knowledge including, but not confined to research of sufficient quality to be used to inform decisions **Evidence-based medicine** Movement within medicine and related professions to base clinical practice on the most rigorous scientific basis, principally informed by the results of randomized controlled trials of effectiveness of intervention **Evidence-based policy** Movement within public policy to give evidence greater weight in shaping policy decisions, better described as 'evidence-informed' policy than 'evidence-based' since it is obvious in public policy that evidence is only one factor influencing policy making **Formative evaluation** Evaluation designed to assess how a programme or policy is being implemented with a view to modifying or developing the programme or policy in order to improve its implementation **Knowledge transfer** Strategy usually incorporating a variety of 'linkage' and 'exchange' activities designed to reduce the social, cultural and technical 'gap' between researchers and policy makers **Monitoring** Routine collection of data on an activity usually against a plan or contract **Research** Systemic activity designed to generate rigorous new knowledge and relate it to existing knowledge to improve understanding of the physical social world **Summative evaluation** Evaluation designed to produce an overall verdict on a policy or program in terms of the balance of costs and benefits **Formative evaluation** - An evaluation designed to contribute directly to assisting those responsible for a programme to shape the programme while it is being designed or implemented. Formative evaluations generally take place during the early stages of a programme and focus on activities and processes with a view to providing advice directly to the policy makers that can be used to modify and develop the programme **Summative evaluation** - Designed to try to provide a verdict on a policy or programme. In other words, they focus on measuring the impact or outcome and costs as well as, the extent to which a programme has met its objectives. They tend to produce their findings later and to use quantitative methods. Formative evaluations tend to use qualitative methods such as observation and semi-structured interview **Evidence-based policy:\ **From evidence medicine towards evidence based policy (emerged as response to politics by 'conviction') 'what counts is what works'. - **Engineering model**: linear process from policy problem to solution - **Enlightenment model**: acknowledges an indirect application of research insights towards policy solutions - **Strategic model**: views research as ammunition to support predetermined positions or to delay or obstruct politically uncomfortable decisions - **Elective affinity model**: policymakers accept insights of research faster when they participated (in focus groups, expert groups, analysis, etc.) **Differences between the 'engineering' and 'enlightenment' models** **Engineering or problem-solving model** **Enlightenment model** ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Sees the relationship between research and policy as rational and sequential Sees the relationship as indirect and not necessarily logical, predictable or neat A problem exists because basic research has defined it Problems are not always recognised, or at least not immediately Applied research is undertaken to help solve the problem There is often a long gap between research and its policy impact, as most research shapes new ways of thinking rather than solving specific problems Research is then applied to help solve the policy problem. Research produces a preferred policy solution. The way in which research influences policy is complex and hidden. Policy makers may not want to act on results or may use findings in ways that researchers do not approve of Rarely or never describes how the relationship between research and policy works in practice. Assumes that this happens in a straightforward, uncontroversial manner Research influences policy generally indirectly and the process is frequently obscure and hard to explain **Two communities model\ **emphasizes the idea that researchers and policy makers live in different cultures based on different assumptions about what is important and how the world works ***University teachers*** ***Government policy makers*** -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Work** Planned research projects using scientific methods to produce clear, generalizable results; highly specialized and reported in technical language. Continuous, unplanned tasks involving negotiation, compromise, and feasibility assessment; focused on specific decisions and often addressing multiple issues simultaneously. **Attitudes to research** Justified by contributing to valid knowledge; findings often lead to further research due to remaining uncertainty. One of many inputs; valued for relevance and practical use in decision making; sceptical of research compared to personal experience, favouring research that supports their policies and views. **Accountability** To scientific peers primarily, but also to funders. To politicians primarily, but also the public, indirect. **Priorities** Expansion of research opportunities and influence of experts in the world Maintaining a system of 'good governance' and satisfying politicians; may wish to protect or expand the role of their agency **Careers/rewards** Built largely on publication in peer reviewed scientific journals and peer recognition rather than practical impact though this varies by discipline Built on successful management of complex political processes (as well as relationships) and involvement with 'successful' policy initiatives rather than use of research findings for policy **Training and knowledge** High level of training, usually specialized within a single discipline; little knowledge about policy making processes Often, though not always, generalists expected to be flexible; often little or no scientific training **Organisational constraints** Relatively few (except resources); high level of discretion, e.g. in choice of research focus focus Embedded in large, inter-dependent bureaucracies and working within political limits, often to short timescales; such organizations likely to be highly risk-averse **Values/orientation** Place high value on independence of thought and action; belief in unbiased search for generalizable knowledge Oriented to providing high quality advice, but attuned to a particular political and economic context and to informing specific decisions **Barriers to the use of research** - **Political and ideological factors:** external evaluations often diminish the perceived value of research in low- and middle-income countries, as they are typically conducted by foreign experts for external donors. This can lead national governments and program workers to disregard the findings, despite their quality. Additionally, underinvestment in health research for low-income countries limits the use of research in addressing local health issues. - **Policy and scientific uncertainty**: Evaluating findings is challenging due to broad program goals, small effects compared to other factors, and uncertainty in outcomes. Policy makers often can\'t tell if a program\'s failure stems from its design or external influences. Competing objectives, like equity versus efficiency, add to the complexity. Additionally, the relevance and generalizability of research are frequently disputed, leading policy makers to downplay findings that contradict their agenda. - **Different conceptions of risk**: people often overestimate risks from environmental hazards while underestimating risks from lifestyle factors like alcohol and poor diets. Media can amplify this issue by focusing on dramatic but rare events, pressuring politicians to act without solid evidence. - **Perceived utility of research:** the challenge researchers face when their work extends into advocacy, as it requires them to engage in political lobbying and potentially jeopardizes their status as disinterested experts. If key policy audiences do not align with the values and goals of the research, it may be ignored. - **Timing:** Recommendations may be ignored if the political context isn\'t favourable, such as during \"windows of opportunity\" or government changes. Researchers often face criticism for slow findings, risking missed chances to influence policy. Even high-quality research may be overlooked if it contradicts existing narratives or decision-makers\' pressures. - **Communication and reputation:** Complex or unclear research is less likely to be noticed by policymakers. Proposals for radical changes are often ignored, regardless of communication quality. The perceived quality of the research and the reputation of the researchers and their institutions greatly influence the attention it receives. **(Not) bridging the gap -- Linkage and exchange model\ ***Practical steps advocated to reduce the 'gap' between research and policy* **Academic** **Governmental** --------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- Produce various forms of reports, newsletters, summaries, rent a journalist Set up a policy community Invite policy makers to join in analytical steps of focus groups, interview data Do not consider 'evaluation' as wasting time looking backwards Stay in close contact with policy makers during the project Ensure evaluation studies, in the budgets of policy implementation Connect the real world: use a range of research methods such as, action research, participative, practical, involving all relevant subjects Establish intermediate policy/science institutes (Health Council) Devote more time to media briefing **Enhance academic influence on policy process** - Identify relevant advocacy coalitions and study their core values and perception of problems - Engage with the advocacy coalitions - Realise that 'research evidence' only counts when it is recognised as arguments and advocacy by the actors - By providing a solid knowledge base, influence reflection on values and believes **Chapter 6. Interest groups and the policy process** **Cause group** Interest or pressure group whose main goal is to promote a particular issue or cause ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Civil society** The part of society between the private sphere of the family or household and the sphere of government **Civil society organisation (CSO)** A group or organisation which is outside government. It may or may not be involved in public policy (e.g. sports clubs are civil society organisations, but not primarily pressure groups) Private sector groups involved in the market (e.g. industry groups) are sometimes defined as in civil society, but are generally treated separately **Governance** Refers to the rules of collective decision-making among multiple actors or organizations without formal control. Health governance has shifted from being solely a government responsibility to include non-governmental organizations in decision-making. **Insider group** Interest group that pursues a strategy designed to win themselves the status of legitimate participants in the policy process **Interest (pressure) group** Any group outside the state including market and some civil society groups that attempts to influence policy to achieve specific goals **Iron triangle** Small, stable and exclusive policy community usually involving executive agencies, legislative committees and interest groups (e.g. around defence procurement) **Issue network** Loose network comprising many diverse members who usually come together to try and draw attention to an issue, address a specific problem or promote a particular solution **Non-governmental organisation (NGO)** Any not-for-profit organisation outside government, often used to refer to structured organisations providing services **Outsider group** Interest groups that have either failed to attain insider status or have deliberately chosen a path of confrontation **Policy community (and sub-system)** Relatively stable network of organisations and individuals involved in a recognisable field of wider public policy such as health policy. Within each of these fields, there will be identifiable sub-systems, such as for mental health policy, with their own policy communities **Policy network** Generic term for inter-dependent organisations involved in an area of policy that exchange resources and bargain to varying degrees to attain their specific goals **Sectional group** Interest group whose main goal is to protect and enhance the interest of its members and/or the section of society it represents **Social movement** Loose grouping of individuals sharing certain views and attempting to influence others but without a formal organisational structure **From government to governance** - The government cannot act alone - Many actors, interest groups (non-government), are involved in policy process to influence government thinking - Shift from government tot governance: - Shift from traditional hierarchical and directive mode towards adoption of networks of government, civil society and private sector - More participatory relation between state and society - More flexible forms of regulation **Interest groups (or pressure groups)** - Are voluntary: people or organisations choose to join them - Aim to achieve some desired goals - Generally do not attempt to infiltrate the process of decision making to the extent of becoming part of the formal government machinery. **Different types of interest groups\ **Walt, Mays & Kent (2012) distinguishes between different types of 'groups' **Sectional groups** - Protect interest of their members and political pressure is secondary aim - Often very influential (e.g. trade unions) - In the health sector, medical professionals are/were in dominant positions with control over training and regulation **Cause groups** - Exist primarily to pressurise on particular issues - Draw their membership from a wide range of people within society - Examples are for instance environmental organisations, consumer groups, etc **Potential resources of interest groups are**: their members, level of funding, level of knowledge, persuasive skills, sanctions **Insider groups** - Accepted and respected by the government policy makers - Part of the governmental decision-making arena: - Government may turn to such groups for information or to test ideas for policy changes - May be invited to join particular government committees - Often subtle lobbying **Outsider groups:** - Not perceived as legitimate by governmental policy - Difficulty in penetrating policy process - May resort to direct action trying to get media coverage and to mobilize public opinion - May try to persuade individual politicians to take up their cause in legislature **Thresholder groups:** - Can shift strategies over time, from outsider to insider groups (and vice versa). When delivering services is seen as relevant **Function of interest groups** Peterson (1999) - **Participation**: alternative way for voters - **Representation**: widens range of options - **Political** **education**: learn about political process - **Motivation**: bring in new issues, more information, new views, new policy options - **Mobilization**: build pressure for action - **Monitoring**: assessing performance of government and private corporations - **Provision**: deliver services **Structural interests (example of healthcare reform)** - **Professional monopolists**: the doctors and to a lesser extent the other health professionals whose dominant interests are served by the existing economic, social and political structures of government and the health system - **Corporate rationalisers**: who challenge the professional monopolists by attempting to implement strategies such as rational planning of facilities, efficient methods of health care delivery and modern management methods over medical judgement. These can be private insurers, governments as payers, health planners, employers wanting to curb the cost of insuring their workers, commercial hospital chains, etc - **Equal/community health advocates**: the wide range of relatively repressed cause and sectional interest groups lobbying for patients' rights, fairer access to health care for poor and marginalized groups and more attention to be given to the views of patients and populations in health care decision making **Iron triangle**: politicians, bureaucrats and the industry **Chapter 8. Globalizing the policy process** **Global civil society** Civil society groups which are global in their aims, communication or organisation -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- **Global public goods** Good which are undersupplied by markets, inefficiently produced by individual states and which have benefits which are strongly universal **Globalization** Complex set of processes which increases interconnectedness and interdependencies between countries and peoples **Globalisation** - **Internationalisation**: the increasing extent of cross-border movement of goods, people, ideas, finances or infectious pathogens. - e.g. more people flying around the world; the ability to buy 'seasonal' fruits all year around - **Liberalisation**: the removal of barriers to trade, to make greater movement possible - e.g. removal of protection for domestic production of cigarettes - **Universalisation**: the homogenization of cultures - e.g. same shops and brands found around the world or the same words used on signs (STOP) - **McDonaldisation**: the coming together of Western, modern and particularly US values and policies - e.g. Starbucks in Beijing and Burma - **Super territoriality**: people and organizations have increasing connections to others in ways that transcend territorial boundaries - e.g. buying airline tickets over the internet from a third country - **Spatial dimensions**: we are increasingly 'overcoming' distance - **Temporal dimensions**: through telecommunications and transport activity, the world has speeded up - **Cognitive dimensions**: the thought processes that shape perceptions of events and phenomena - Support groups for people who have a condition and they share their feelings with people across the globe. **Globalisation and health** - **Globalisation's impact on infectious diseases**: rapid spread due to increased travel and trade - E.g. SARS outbreak, causing both health and economic damage or the spread of polio facilitated by globalisation from Nigeria to polio-free regions - **National health systems' role in epidemic control**: the inability to detect or contain outbreaks can turn them into global threat - **Global health risks beyond infectious diseases**: global food production, marketing, and behaviours contribute to health risks - E.g. smoking or alcohol - **Global health worker shortage**: demand for health workers in high-income countries, leading to recruitment from low-income countries causing shortages - **Migration of health workers**: poor working conditions driving emigrations from countries like Nigeria and South Africa As a result of globalisation, countries will not be able to directly control all the determinants of ill-health of their populations, therefore having to cooperate with other actors outside their borders to protect the health of those within them. **Traditional inter-state cooperation for health** - **International Health Regulations (IHR)**: established by the WHO to control the spread of infectious diseases internationally (in 1969) - **Limits of cooperation**: states failed to comply with the IHR in the reporting requirements, and the WHO had limited enforcement power - In 2005, the IHR expanded reporting requirements for public health and authorised the WHO to consider unofficial reports **The United Nations\ **The UN includes organisations like WHO, which coordinates international health activities. WHO is governed by the World Health Assembly (WHA), where member states make health policy decisions, though the WHO lacks enforcement power over these policies. The World Bank also influences global health, particularly through financial support and health policy reforms. - **United Nations (UN)**: established to maintain global peace and promote cooperation, with organisations like WHO and UNICEF - **World Health Organisation (WHO)**: founded to lead international health efforts, with technical authority but limited enforcement power - **Functions**: articulating evidence-based policies, setting norms and catalysing change in global health - **World Health Assembly (WHA)**: WHO's governing body, where member states shape global health policy - **The World Bank**: significant player in health policy through financial support and reform initiatives, especially in low- and middle-income countries. **The World Trade Organisation** - **World Trade Organisation (WTO)**: founded to facilitate and regulate global trade, with binding agreements in affecting member states - **Impact on health**: WTO rules influence access to medicines, health services, and trade-related health risks - **Domestic policy constraints**: Countries must align policies with WTO agreements, limiting their autonomy on health-related issues **Bilateral cooperation** - **Bilateral relationships**: government-to-government cooperation, often influencing health policy and aid distribution - **Major bilateral organisations**: the United States Agency for International Development (USAID), the UK Department for International Development (DfID) and the Swedish International Development Agency (SIDA). - **Political influence**: donors often pursue diplomatic and strategic interest in their aid policies - E.g.: US aid to Egypt and Israel, UK support to ex-colonies - **Health-policy influence**: external donors play a role in shaping the health agendas of recipient countries through financial support and technical assistance - New players like China, India, and Brazil are shifting the traditional aid landscape with increased South-South cooperation and new aid models **Global civil society** - **Diverse actors and issues**: civil society organizations focus on issues like reproductive health, HIV rights, humanitarian relief, and landmine bans. These organisations range from small internet-based groups to large influential foundations. - **The bill and Melinda gates foundation**: a major player in global health, funding research, driving public-private partnerships, and influencing health policy with substantial resources - **Civil society strategies**: these organizations influence policy as insiders (through formal relationships with organizations like the UN) or as outsiders (using confrontational tactics) - **Influence on global health**: civil society groups shape health priorities, engage with international organizations, and mobilize around issues like AIDS drug prices. - **Advocacy role of civil society networks**: coalitions aim to change state and international policies through persuasion and socialisation - **Influence on policy**: civil society groups, like ACTUP, have successfully shaped corporate and policy responses, particularly around health issues like HIV - **Use of the internet**: the internet is an essential tool for organising support and influencing policy - **Civil society's growing influence**: welcomed for its role in democratizing decision-making, improving communication, and providing expertise - **Criticisms** **of global groups**: - **Legitimacy**: can be questioned because most funds and members come from the Global North and the agenda is set accordingly - **Elitism**: some organisations draw their membership from, or are funded by, elites - **Lack of democratic credentials**: many organizations have not considered the extent to which they involve and truly represent the individuals and groups that they claim to advocate for, and how to do so better - **Lack of transparency**: many groups fail to identify clearly who they are, what their objectives are, where their funds originate and how they make decisions. Some are fronts for industry and would be better described as being market actors - **'Uncivil' civil society**: global civil society is a catch-all phrase for a diverse group of entities. Transborder criminal syndicates and pro-racist groups both have a place in this sector **Transnational corporations** - **Commercial sector influence**: the role of transnational corporations (TNCs) and commercial associations in influencing domestic and international health policies. - **Global market rules**: the push for a global framework of market rules, as articulated by the International Chamber of Commerce (ICC). - **Global compact**: An initiative that connects large TNCs with the United Nations (UN), facilitating collaboration without binding regulations - **Strategies of influence**: various methods the commercial sector uses to impact intergovernmental organisations - **Agenda setting**: influencing the agendas of organizations like WHO through industry roundtables and advisory roles - **Delaying Legal Instruments**: hindering the introduction of international legal frameworks (e.g., dietary guidelines) - **Lobbying**: successfully advocating for favourable positions in international agreements (e.g., tobacco policy) - **Challenging Authority**: questioning the competence of organizations like WHO to address certain health issues **Global public-private partnerships** - **Global Public-Private Health Partnerships (GHPs)**: collaborative efforts among public, commercial, and civil society actors aimed at addressing health issues. - **Diverse actors**: participation from various sectors, including governmental, commercial, and non-governmental organizations, working towards shared health goals. - **Independent legal identities**: some GHPs, like the International AIDS Vaccine Alliance, operate as separate entities, while others are housed within larger organizations, such as WHO. - **Functions of GHPs**: - **Research and Development**: Initiatives to create health products (e.g., Medicines for Malaria Venture). - **Access to Medications**: Programs to distribute donated medicines to underserved populations (e.g., International Trachoma Initiative). - **Fund Mobilization**: Channels for funding specific health interventions, exemplified by the Global Fund to Fight AIDS, TB and Malaria. - **Advocacy**: Efforts to promote awareness and action for particular health issues (e.g., International Partnership for Microbicides). - **Policy influence**: GHPs set agendas, influence health priorities, and engage in policy formulation, filling roles traditionally held by governments or intergovernmental organizations. - **Political resources**: GHPs leverage political access, diverse knowledge, and collaborative strengths, enabling them to advocate effectively for health policies. - **Collaboration and unity**: the ability of GHPs to unite various policy actors enhances their influence and advocacy power in the health sector. **Globalising the policy process** - **Golden pentangle**: an expanded model reflecting the inclusion of global actors, consisting of: - Domestic bureaucrats - Elected officials - Interest groups - Formal international organizations (e.g., World Bank, WTO) - Informal entities (e.g., public-private partnerships, transnational civil society) - **Policy complexity**: the involvement of multiple actors makes the policy process intricate, especially in low and middle-income countries where ministries of health struggle to manage diverse inputs. - **Sector-Wide Approaches (SWAPs)**: initiatives aimed at creating coherent policy frameworks and expenditure plans that harmonize funding from various donors within a unified strategy. - **Challenges of Coordination**: many donors continue to pursue separate projects, undermining efforts for coherent policy-making and causing confusion within health ministries. - **Global Public-Private Partnerships (GHPs)**: these partnerships introduce new dynamics by implementing vertical health programs, leading to competition for attention and resources.