HEALTH CARE POLICY
HEALTH CARE POLICY
Exercise 1.1
Define the following terms correctly
• Actors
• Content
• Context
• Policy
• Policy elites
• Policy makers
• Policy process
Answer:
• Actor
o Short-hand term used to denote individuals, organizations or even the state and their actions that affect policy.
• Content
o Substance of a particular policy which details its constituent parts.
• Context
o Systemic factors – political, economic, social or cultural, both national and international– which may have an effect on health policy.
• Policy
o Broad statement of goals, objectives and means that create the framework for activity. Often take the form of explicit written documents, but may also be implicit or unwritten.
o 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. The people who make policies are referred to as policy makers. Policy may be made at many levels – in central or local government, in a multinational company or local business, in a school or hospital.
o Policies are made in the private and the public sector.
o In the private sector, multinational conglomerates may establish policies for all their companies around the world, but allow local companies to decide their own policies on conditions of service. For example, corporations such as Anglo-American and Heineken introduced anti-retroviral therapy for their HIV-positive employees in Africa in the early 2000s before many governments did so. However, private sector corporations have to ensure that their policies are made within the confines of public law, made by governments.
o Public policy refers to government policy. For example, Thomas Dye (2001) says that public policy is whatever governments choose to do or not to do. He argues that failure to decide or act on a particular issue also constitutes policy. For example, successive US governments have chosen not to introduce universal health care, but to rely on the market plus programmes for the very poor and those over 65 years, to meet people’s health care needs.
• Policy elites
o Specific group of policy makers who hold high positions in an organization, and often privileged access to other top members of the same, and other, organizations.
o For example, policy elites in government may include the members of the Prime Minister’s Cabinet, all of whom would be able to contact and meet the two executives of a multinational company or of an international agency, such as the World Health Organization (WHO).
• Policy makers
o Those who make policies in organizations such as central or local government, multinational companies or local businesses, schools or hospitals.
• Policy process
o The way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated.
Exercise 1.2
a. Define the term policy
b. State and explain private and public policies with examples
Answer:
a. Definition of policy
o Broad statement of goals, objectives and means that create the framework for activity. Often take the form of explicit written documents, but may also be implicit or unwritten.
o 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.
o Policies may be expressed in a whole series of instruments: practices, statements, regulations and laws.
o They may be implicit or explicit, discretionary or statutory.
b. Explanation for private and public policy with examples.
o The people who make policies are referred to as policy makers. Policy may be made at many levels – in central or local government, in a multinational company or local business, in a school or hospital.
o Policies are made in the private and the public sector.
o In the private sector, multinational conglomerates may establish policies for all their companies around the world, but allow local companies to decide their own policies on conditions of service. For example, corporations such as Anglo-American and Heineken introduced anti-retroviral therapy for their HIV-positive employees in Africa in the early 2000s before many governments did so. However, private sector corporations have to ensure that their policies are made within the confines of public law, made by governments.
o Public policy refers to policies made by the state or the government, by those in the public sector. Hence, are also referred to as government policy
o For example, Thomas Dye (2001) says that public policy is whatever governments choose to do or not to do, which is in contrasts with the more formal assumptions that all policy is made t achieve a particular goal or purpose. He argues that failure to decide or act on a particular issue also constitutes policy. For example, successive US governments have chosen not to introduce universal health care, but to rely on the market plus programmes for the very poor and those over 65 years, to meet people’s health care needs.
Exercise 1.3
Explain why the study of health policy is important to you as a student nurse
Answer:
In many countries, the health sector is an important part of the economy. Some see it as a sponge – absorbing large amounts of national resources to pay for the many health workers employed. Others see it as a driver of the economy, through innovation and investment in bio-medical technologies or production and sales of pharmaceuticals, or through ensuring a healthy population which is economically productive.
Most citizens come into contact with the health sector as patients or clients, through using hospitals, clinics or pharmacies; or as health professionals – whether as nurses, doctors, medical auxiliaries, pharmacists or managers. Because the nature of decision making in health often involves matters of life and death, health is accorded a special position in comparison to other social issues.
Health is also affected by many decisions that have nothing to do with health care: poverty affects people’s health, as do pollution, contaminated water or poor sanitation. Economic policies, such as taxes on cigarettes or alcohol may also influence people’s behaviour. Current explanations for rising obesity among many populations, for example, include the promotion of high calorie, inexpensive fast food, the sale of soft drinks at schools, as well as dwindling opportunities to take exercise.
Understanding the relationship between health policy and health is therefore important so that it is possible to tackle some of the major health problems of our time – rising obesity, the HIV/AIDS epidemic, growing drug resistance – as well as to understand how economic and other policies impact on health. Health policy guides choices about which health technologies to develop and use, how to organize and finance health services, or what drugs will be freely available.
Exercise 1.4
What is health policy?
Answer:
Health policy is assumed to embrace / covers courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements of the health system (both public and private)
It includes policy made in the public sector (by government) as well as policies in the private sector about health.
But 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 (for example, the food, tobacco or pharmaceutical industries).
An economist may say health policy is about the allocation of scarce resources for health; a planner sees it as ways to influence the determinants of health in order to improve public health; and for a doctor it is all about health services (Walt 1994).
For Walt, health policy is synonymous with politics and deals explicitly with who influences policy making (actors), how they exercise that influence (process), and under what conditions.
Exercise 1.5
Describe the health policy framework
Answer:
The health policy framework focuses on content, context, process and actors. It helps to explore systematically the somewhat neglected place of politics in health policy. This framework can be applied to high, middle and low income countries.
The health policy triangle (framework) is a highly simplified approach to a complex set of inter-relationships, and may give the impression that the four factors can be considered separately. However, this is not so! In reality,
• Actors are influenced (as individuals or members of groups or organizations) by the context within which they live and work.
• Context is affected by many factors such as instability or ideology, by history and culture
• The process of policy making – how issues get on to policy agendas, and how they fare once there – is affected by actors, their position in power structures, their own values and expectations.
• The content of policy reflects some or all of these dimensions.
So, while the policy triangle is useful for helping to think systematically about all the different factors that might affect policy, it is like a map that shows the main roads but that has yet to have contours, rivers, forests, paths and dwellings added to it
The policy analysis triangle
Source: Walt and Gilson (1994)
Exercise 1.6
Make a list of the different actors who might be involved in health policy on HIV/AIDS in your own country. Put the actors into different groups.
Answer:
Actors are at the centre of the health policy framework. Actor may be used to denote individuals (a particular statesman –Nelson Mandela, the ex-President of South Africa, for example), organizations such as the World Bank or multinational companies such as Shell, or even the state or government.
Therefore, the different actors who might be involved in health policy on HIV/AIDS in Ghana
o Government (Ministry of Health, Ministry of Education, Ministry of Employment)
o International non-governmental organizations (Médecins Sans Frontières, Oxfam)
o National non-governmental organizations (People-Living-With-AIDS, faith-based organizations)
o Pressure/interest groups (Treatment Action Campaign)
o International organizations (WHO, UNAIDS, the World Bank)
o Bilateral agencies (DFID, USAID, SIDA)
o Funding organizations (the Global Fund, PEPFAR)
o Private sector companies (Anglo-American, Heineken, Merck)
Exercise 1.7
Consider HIV/AIDS policy in your own country. Identify some contextual factors that might have influenced the way policy has (or has not) developed. Bear in mind the way context has been divided into four different factors.
Answer:
Context refers to systemic factors – political, economic and social, both national and international – which may have an effect on health policy. There are many ways of categorizing such factors, but one useful way is provided by Leichter (1979):
• Situational
a new prime minister/president coming to power and making AIDS policy a priority.
the death of a famous person acknowledged publicly to be due to AIDS
• Structural
the role of the media or NGOs in publicizing, or not, the AIDS epidemic – relating to the extent to which the political system is open or closed
evidence of growing mortality from AIDS made public – perhaps among a particular group such as health workers
• Cultural
The actions of religious groups – both negative and positive – with regard to those with HIV/AIDS or towards sexual behaviour
• International
The role of international donors – the extra funds brought in by global initiatives such as the Global Fund to Fight AIDS, TB and Malaria.
Exercise 1.8
Discuss the policy making process
Answer:
The policy making process refers to the way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated.
The most common approach to understanding policy processes is to use what is called the ‘stages heuristic’ (Sabatier and Jenkins-Smith 1993).
What this means is breaking down the policy process into a series of stages but acknowledging that this is a theoretical device, a model and does not necessarily represent exactly what happens in the real world.
It is nevertheless, helpful to think of policy making occurring in these different stages:
o Problem identification and issue recognition:
This explores how issues get on to the policy agenda, why some issues do not even get discussed.
o Policy formulation:
This explores who is involved in formulating policy, how policies are arrived at, agreed upon, and how they are communicated.
o Policy implementation:
This is often the most neglected phase of policy making and is sometimes seen as quite divorced from the first two stages. However, this is arguably the most important phase of policy making because if policies are not implemented, or are diverted or changed at implementation, then presumably something is going wrong – and the policy outcomes will not be those which were sought.
o Policy evaluation:
This 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. This may be the stage at which policies are changed or terminated and new policies introduced. Chapter 9 covers this stage.
Exercise 1.9
The following extract on the rise and fall of policies on tuberculosis by Jessica Ogden and colleagues (2003) describes the different stages of the policy process, looking at context and actors as well as process.
As you read it, apply the health policy triangle:
1. Identify and write down who were the actors.
2. What processes can you identify?
3. What can you discern about the context?
4. What part did content play in determining policy?
Getting TB on the policy agenda and formulating the DOTS policy
1970s: the era of neglect and complacency
Throughout the 1970s TB control programmes were being implemented in many low and middle income countries, with only modest success. Only one international NGO, the
International Union Against Tuberculosis and Lung Disease (IUATLD), explored ways of improving TB programmes, largely through the efforts of one of its public health physicians,
Karel Styblo. From the early 1980s, Styblo and the IUATLD tried to develop a control strategy using a short-course regimen (six months) that would be feasible and effective in developing countries. At the time most TB programmes were using much longer drug regimens, and the public health community disagreed about best practice in treatment of TB. Also, the international health policy context in the 1970s militated against support for the development of the IUATLD’s vertical approach to TB control. This was the period when
WHO, and in particular it’s then Director-General, Halfdan Mahler, espoused the goal of ‘Health for All by the Year 2000’. This was to be achieved through concerted action to improve and integrate basic primary health care in poor countries. Health concerns therefore focused on integrating family planning and immunization in health services, rather than establishing vertical (specialized) disease control programmes.
The late 1980s: resurgence and experimentation
Interest in and concern over TB re-emerged from the mid-1980s as increasing numbers of cases, and alarming rises in multi-drug-resistant disease, were seen in industrialized countries, where most people had believed TB was a disease of the past. It was increasingly evident that TB and HIV/AIDS were linked, and many of the deaths from TB were linked to
HIV.
Several international agencies initiated a process to get TB back on the international health policy agenda. The World Bank undertook a study of different health interventions as part of a health sector priorities review, and highlighted TB control as a highly cost-effective intervention. The Ad Hoc Commission on Health Research (made up of distinguished public health experts, with a secretariat at Harvard University) also identified TB as a neglected disease. Members of the Commission met Styblo, and were impressed with his approach. WHO expanded its TB Unit, and appointed Arata Kochi, an ex-UNICEF official, as its new head. One of his first appointments was an advocacy and communications expert.
The 1990s: advocacy opens up the window of opportunity
The WHO TB programme switched from a primarily technical focus to intensive advocacy in 1993. One of the first signs was a major media event in London in April 1993 declaring
TB a ‘Global Emergency’. The second was the branding of a new TB policy – DOTS –
Directly Observed Therapy, Short-course. DOTS relied on five components: directly observed therapy (where health workers watched patients taking their drugs); sputum smear testing; dedicated patient recording systems; efficient drug supplies; and political commitment.
This branding process sent a tremor of shock waves through the academic and scientific communities. A rift developed between the political and operational experts who wanted to push the new strategy (which downplayed the importance of new vaccine and drug developments for TB) and the technical and scientific experts (including many in the academic community) who were concerned that the new WHO strategy not only oversimplified
TB control measures, but would mean even less funding to research and development.
Others objected to what was perceived initially as a very autocratic policy, with little room for discussion of alternative ways of controlling TB.
Answer:
1. You may have named the following as actors:
a. Karel Styblo, Halfdan Mahler, Arata Kochi (and the organizations within which they worked, which provided the base for their influence: IUATLD, WHO, UNICEF)
b. An un-named advocacy and communications expert
c. The World Bank; the Ad Hoc Committee on Health Research
d. Networks: of public health community, TB specialists; technical and scientific experts interested in new drugs and vaccines research for TB.
2. Processes
o The story is divided into decades that suggest a stage of neglect in the 1970s (with TB programmes being implemented in many countries but with no special attention to improving their impact); a stage when a problem was recognized in the 1980s as connections were made between the HIV/AIDS epidemic and increasing TB cases through research and experience. Then came the agenda-setting 1990s when concerted action put TB back on the international policy agenda.
3. Context
o Some of the points you might make under context would be: complacency in the industrialized world up to the end of the 1980s, because TB was thought to be conquered.
o This was not true in low income countries, partly because of the relationship between TB and poverty. You might mention that WHO was promoting its ‘Health for All’ policy, which subscribed to integrated health care, and rejected special, vertical programmes, which was how TB programmes had been designed.
4. Content
o You may have noted references to the technical content of TB policy such as short course drug regime. You may also have noted what DOTS stood for and differences over what it should be.
Exercise 2.0
Discuss the uses of the health policy framework or triangle
Answer:
The health policy triangle or framework can be used to
o Help analyze or understand a particular policy or
o Apply or plan a particular policy.
The former can be referred to as analysis of policy, the latter as analysis for policy.
Analysis of policy is generally retrospective – it looks back to explore the determination of policy (how policies got on to the agenda, were initiated and formulated) and what the policy consisted of (content). It also includes evaluating and monitoring the policy – did it achieve its goals? Was it seen as successful?
Analysis for policy is usually prospective – it looks forward and tries to anticipate what will happen if a particular policy is introduced. It feeds into strategic thinking for the future and may lead to policy advocacy or lobbying. For example, before the UK government introduced legislation on compulsory use of car seatbelts to decrease mortality on the roads, it ran a national education campaign to persuade people of the evidence that seatbelts reduced deaths and it consulted the police and motor industry before introducing legislation that made it mandatory to have seatbelts in cars and for the police to enforce the law.
Therefore, the policy triangle can be used both retrospectively – to analyze past policy, and prospectively – to help plan how to change existing policy
Exercise 2.1
Define the following terms correctly
a. Bounded rationality policy makers
b. Elitism
c. Government
d. Incrementatism
e. Pluralism
f. Political system
g. Power
h. Rationalism theory
i. Sovereignty
j. State
Answer:
a. Bounded rationality Policy makers
These are people who intend to be rational but make decisions that are satisfactory as opposed to optimum, due to imperfect knowledge.
b. Elitism theory
The theory that power is concentrated in a minority group in society.
c. Government
The institutions and procedures for making and enforcing rules and other collective decisions. A narrower concept than the state which includes the judiciary, military and religious bodies.
d. Incrementatism Theory
This theory states that decisions are not made through a rational process but by small adjustments to the status quo in the light of political realities.
e. Pluralism Theory
The theory that power is widely distributed in society.
f. Political system
The processes through which governments transform ‘inputs’ from citizens into ‘outputs’ in the form of policies.
g. Power
The ability to influence, and in particular to control, resources.
h. Rationalism Theory
This theory states that decisions are made through a rational process by considering all the options and their consequences and then choosing the best among alternatives.
i. Sovereignty
This entails rule or control that is supreme, comprehensive, unqualified and exclusive.
j. State
A set of institutions that enjoy legal sovereignty over a fixed territorial area.
Exercise 2.2
Differentiate power from authority base on what they concern
Answer:
Authority concerns the right to do so whereas power concerns the ability to influence others.
Exercise 2.3
a. What is power?
b. Describe how power can be exercise in simple terms
c. Outline and explain the three faces or dimensions of power
Answer:
a. Power is generally understood to mean the ability to achieve a desired outcome – to ‘do’ something.
In policy making, the concept of power is typically thought of in a relational sense as in having ‘power over’ others. Hence, it is considered as the ability to influence, and in particular to control, resources
b. Power is said to be exercised when “A” ask “B” to do something that B would not have otherwise done.
c. “A” can achieve this end over “B” in a number of ways, which have been characterized as the three ‘faces’ or ‘dimensions’ of power:
o Power as decision making
o Power as non-decision making
o Power as thought control.
Exercise 1.1
Define the following terms correctly
• Actors
• Content
• Context
• Policy
• Policy elites
• Policy makers
• Policy process
Answer:
• Actor
o Short-hand term used to denote individuals, organizations or even the state and their actions that affect policy.
• Content
o Substance of a particular policy which details its constituent parts.
• Context
o Systemic factors – political, economic, social or cultural, both national and international– which may have an effect on health policy.
• Policy
o Broad statement of goals, objectives and means that create the framework for activity. Often take the form of explicit written documents, but may also be implicit or unwritten.
o 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. The people who make policies are referred to as policy makers. Policy may be made at many levels – in central or local government, in a multinational company or local business, in a school or hospital.
o Policies are made in the private and the public sector.
o In the private sector, multinational conglomerates may establish policies for all their companies around the world, but allow local companies to decide their own policies on conditions of service. For example, corporations such as Anglo-American and Heineken introduced anti-retroviral therapy for their HIV-positive employees in Africa in the early 2000s before many governments did so. However, private sector corporations have to ensure that their policies are made within the confines of public law, made by governments.
o Public policy refers to government policy. For example, Thomas Dye (2001) says that public policy is whatever governments choose to do or not to do. He argues that failure to decide or act on a particular issue also constitutes policy. For example, successive US governments have chosen not to introduce universal health care, but to rely on the market plus programmes for the very poor and those over 65 years, to meet people’s health care needs.
• Policy elites
o Specific group of policy makers who hold high positions in an organization, and often privileged access to other top members of the same, and other, organizations.
o For example, policy elites in government may include the members of the Prime Minister’s Cabinet, all of whom would be able to contact and meet the two executives of a multinational company or of an international agency, such as the World Health Organization (WHO).
• Policy makers
o Those who make policies in organizations such as central or local government, multinational companies or local businesses, schools or hospitals.
• Policy process
o The way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated.
Exercise 1.2
a. Define the term policy
b. State and explain private and public policies with examples
Answer:
a. Definition of policy
o Broad statement of goals, objectives and means that create the framework for activity. Often take the form of explicit written documents, but may also be implicit or unwritten.
o 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.
o Policies may be expressed in a whole series of instruments: practices, statements, regulations and laws.
o They may be implicit or explicit, discretionary or statutory.
b. Explanation for private and public policy with examples.
o The people who make policies are referred to as policy makers. Policy may be made at many levels – in central or local government, in a multinational company or local business, in a school or hospital.
o Policies are made in the private and the public sector.
o In the private sector, multinational conglomerates may establish policies for all their companies around the world, but allow local companies to decide their own policies on conditions of service. For example, corporations such as Anglo-American and Heineken introduced anti-retroviral therapy for their HIV-positive employees in Africa in the early 2000s before many governments did so. However, private sector corporations have to ensure that their policies are made within the confines of public law, made by governments.
o Public policy refers to policies made by the state or the government, by those in the public sector. Hence, are also referred to as government policy
o For example, Thomas Dye (2001) says that public policy is whatever governments choose to do or not to do, which is in contrasts with the more formal assumptions that all policy is made t achieve a particular goal or purpose. He argues that failure to decide or act on a particular issue also constitutes policy. For example, successive US governments have chosen not to introduce universal health care, but to rely on the market plus programmes for the very poor and those over 65 years, to meet people’s health care needs.
Exercise 1.3
Explain why the study of health policy is important to you as a student nurse
Answer:
In many countries, the health sector is an important part of the economy. Some see it as a sponge – absorbing large amounts of national resources to pay for the many health workers employed. Others see it as a driver of the economy, through innovation and investment in bio-medical technologies or production and sales of pharmaceuticals, or through ensuring a healthy population which is economically productive.
Most citizens come into contact with the health sector as patients or clients, through using hospitals, clinics or pharmacies; or as health professionals – whether as nurses, doctors, medical auxiliaries, pharmacists or managers. Because the nature of decision making in health often involves matters of life and death, health is accorded a special position in comparison to other social issues.
Health is also affected by many decisions that have nothing to do with health care: poverty affects people’s health, as do pollution, contaminated water or poor sanitation. Economic policies, such as taxes on cigarettes or alcohol may also influence people’s behaviour. Current explanations for rising obesity among many populations, for example, include the promotion of high calorie, inexpensive fast food, the sale of soft drinks at schools, as well as dwindling opportunities to take exercise.
Understanding the relationship between health policy and health is therefore important so that it is possible to tackle some of the major health problems of our time – rising obesity, the HIV/AIDS epidemic, growing drug resistance – as well as to understand how economic and other policies impact on health. Health policy guides choices about which health technologies to develop and use, how to organize and finance health services, or what drugs will be freely available.
Exercise 1.4
What is health policy?
Answer:
Health policy is assumed to embrace / covers courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements of the health system (both public and private)
It includes policy made in the public sector (by government) as well as policies in the private sector about health.
But 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 (for example, the food, tobacco or pharmaceutical industries).
An economist may say health policy is about the allocation of scarce resources for health; a planner sees it as ways to influence the determinants of health in order to improve public health; and for a doctor it is all about health services (Walt 1994).
For Walt, health policy is synonymous with politics and deals explicitly with who influences policy making (actors), how they exercise that influence (process), and under what conditions.
Exercise 1.5
Describe the health policy framework
Answer:
The health policy framework focuses on content, context, process and actors. It helps to explore systematically the somewhat neglected place of politics in health policy. This framework can be applied to high, middle and low income countries.
The health policy triangle (framework) is a highly simplified approach to a complex set of inter-relationships, and may give the impression that the four factors can be considered separately. However, this is not so! In reality,
• Actors are influenced (as individuals or members of groups or organizations) by the context within which they live and work.
• Context is affected by many factors such as instability or ideology, by history and culture
• The process of policy making – how issues get on to policy agendas, and how they fare once there – is affected by actors, their position in power structures, their own values and expectations.
• The content of policy reflects some or all of these dimensions.
So, while the policy triangle is useful for helping to think systematically about all the different factors that might affect policy, it is like a map that shows the main roads but that has yet to have contours, rivers, forests, paths and dwellings added to it
The policy analysis triangle
Source: Walt and Gilson (1994)
Exercise 1.6
Make a list of the different actors who might be involved in health policy on HIV/AIDS in your own country. Put the actors into different groups.
Answer:
Actors are at the centre of the health policy framework. Actor may be used to denote individuals (a particular statesman –Nelson Mandela, the ex-President of South Africa, for example), organizations such as the World Bank or multinational companies such as Shell, or even the state or government.
Therefore, the different actors who might be involved in health policy on HIV/AIDS in Ghana
o Government (Ministry of Health, Ministry of Education, Ministry of Employment)
o International non-governmental organizations (Médecins Sans Frontières, Oxfam)
o National non-governmental organizations (People-Living-With-AIDS, faith-based organizations)
o Pressure/interest groups (Treatment Action Campaign)
o International organizations (WHO, UNAIDS, the World Bank)
o Bilateral agencies (DFID, USAID, SIDA)
o Funding organizations (the Global Fund, PEPFAR)
o Private sector companies (Anglo-American, Heineken, Merck)
Exercise 1.7
Consider HIV/AIDS policy in your own country. Identify some contextual factors that might have influenced the way policy has (or has not) developed. Bear in mind the way context has been divided into four different factors.
Answer:
Context refers to systemic factors – political, economic and social, both national and international – which may have an effect on health policy. There are many ways of categorizing such factors, but one useful way is provided by Leichter (1979):
• Situational
a new prime minister/president coming to power and making AIDS policy a priority.
the death of a famous person acknowledged publicly to be due to AIDS
• Structural
the role of the media or NGOs in publicizing, or not, the AIDS epidemic – relating to the extent to which the political system is open or closed
evidence of growing mortality from AIDS made public – perhaps among a particular group such as health workers
• Cultural
The actions of religious groups – both negative and positive – with regard to those with HIV/AIDS or towards sexual behaviour
• International
The role of international donors – the extra funds brought in by global initiatives such as the Global Fund to Fight AIDS, TB and Malaria.
Exercise 1.8
Discuss the policy making process
Answer:
The policy making process refers to the way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated.
The most common approach to understanding policy processes is to use what is called the ‘stages heuristic’ (Sabatier and Jenkins-Smith 1993).
What this means is breaking down the policy process into a series of stages but acknowledging that this is a theoretical device, a model and does not necessarily represent exactly what happens in the real world.
It is nevertheless, helpful to think of policy making occurring in these different stages:
o Problem identification and issue recognition:
This explores how issues get on to the policy agenda, why some issues do not even get discussed.
o Policy formulation:
This explores who is involved in formulating policy, how policies are arrived at, agreed upon, and how they are communicated.
o Policy implementation:
This is often the most neglected phase of policy making and is sometimes seen as quite divorced from the first two stages. However, this is arguably the most important phase of policy making because if policies are not implemented, or are diverted or changed at implementation, then presumably something is going wrong – and the policy outcomes will not be those which were sought.
o Policy evaluation:
This 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. This may be the stage at which policies are changed or terminated and new policies introduced. Chapter 9 covers this stage.
Exercise 1.9
The following extract on the rise and fall of policies on tuberculosis by Jessica Ogden and colleagues (2003) describes the different stages of the policy process, looking at context and actors as well as process.
As you read it, apply the health policy triangle:
1. Identify and write down who were the actors.
2. What processes can you identify?
3. What can you discern about the context?
4. What part did content play in determining policy?
Getting TB on the policy agenda and formulating the DOTS policy
1970s: the era of neglect and complacency
Throughout the 1970s TB control programmes were being implemented in many low and middle income countries, with only modest success. Only one international NGO, the
International Union Against Tuberculosis and Lung Disease (IUATLD), explored ways of improving TB programmes, largely through the efforts of one of its public health physicians,
Karel Styblo. From the early 1980s, Styblo and the IUATLD tried to develop a control strategy using a short-course regimen (six months) that would be feasible and effective in developing countries. At the time most TB programmes were using much longer drug regimens, and the public health community disagreed about best practice in treatment of TB. Also, the international health policy context in the 1970s militated against support for the development of the IUATLD’s vertical approach to TB control. This was the period when
WHO, and in particular it’s then Director-General, Halfdan Mahler, espoused the goal of ‘Health for All by the Year 2000’. This was to be achieved through concerted action to improve and integrate basic primary health care in poor countries. Health concerns therefore focused on integrating family planning and immunization in health services, rather than establishing vertical (specialized) disease control programmes.
The late 1980s: resurgence and experimentation
Interest in and concern over TB re-emerged from the mid-1980s as increasing numbers of cases, and alarming rises in multi-drug-resistant disease, were seen in industrialized countries, where most people had believed TB was a disease of the past. It was increasingly evident that TB and HIV/AIDS were linked, and many of the deaths from TB were linked to
HIV.
Several international agencies initiated a process to get TB back on the international health policy agenda. The World Bank undertook a study of different health interventions as part of a health sector priorities review, and highlighted TB control as a highly cost-effective intervention. The Ad Hoc Commission on Health Research (made up of distinguished public health experts, with a secretariat at Harvard University) also identified TB as a neglected disease. Members of the Commission met Styblo, and were impressed with his approach. WHO expanded its TB Unit, and appointed Arata Kochi, an ex-UNICEF official, as its new head. One of his first appointments was an advocacy and communications expert.
The 1990s: advocacy opens up the window of opportunity
The WHO TB programme switched from a primarily technical focus to intensive advocacy in 1993. One of the first signs was a major media event in London in April 1993 declaring
TB a ‘Global Emergency’. The second was the branding of a new TB policy – DOTS –
Directly Observed Therapy, Short-course. DOTS relied on five components: directly observed therapy (where health workers watched patients taking their drugs); sputum smear testing; dedicated patient recording systems; efficient drug supplies; and political commitment.
This branding process sent a tremor of shock waves through the academic and scientific communities. A rift developed between the political and operational experts who wanted to push the new strategy (which downplayed the importance of new vaccine and drug developments for TB) and the technical and scientific experts (including many in the academic community) who were concerned that the new WHO strategy not only oversimplified
TB control measures, but would mean even less funding to research and development.
Others objected to what was perceived initially as a very autocratic policy, with little room for discussion of alternative ways of controlling TB.
Answer:
1. You may have named the following as actors:
a. Karel Styblo, Halfdan Mahler, Arata Kochi (and the organizations within which they worked, which provided the base for their influence: IUATLD, WHO, UNICEF)
b. An un-named advocacy and communications expert
c. The World Bank; the Ad Hoc Committee on Health Research
d. Networks: of public health community, TB specialists; technical and scientific experts interested in new drugs and vaccines research for TB.
2. Processes
o The story is divided into decades that suggest a stage of neglect in the 1970s (with TB programmes being implemented in many countries but with no special attention to improving their impact); a stage when a problem was recognized in the 1980s as connections were made between the HIV/AIDS epidemic and increasing TB cases through research and experience. Then came the agenda-setting 1990s when concerted action put TB back on the international policy agenda.
3. Context
o Some of the points you might make under context would be: complacency in the industrialized world up to the end of the 1980s, because TB was thought to be conquered.
o This was not true in low income countries, partly because of the relationship between TB and poverty. You might mention that WHO was promoting its ‘Health for All’ policy, which subscribed to integrated health care, and rejected special, vertical programmes, which was how TB programmes had been designed.
4. Content
o You may have noted references to the technical content of TB policy such as short course drug regime. You may also have noted what DOTS stood for and differences over what it should be.
Exercise 2.0
Discuss the uses of the health policy framework or triangle
Answer:
The health policy triangle or framework can be used to
o Help analyze or understand a particular policy or
o Apply or plan a particular policy.
The former can be referred to as analysis of policy, the latter as analysis for policy.
Analysis of policy is generally retrospective – it looks back to explore the determination of policy (how policies got on to the agenda, were initiated and formulated) and what the policy consisted of (content). It also includes evaluating and monitoring the policy – did it achieve its goals? Was it seen as successful?
Analysis for policy is usually prospective – it looks forward and tries to anticipate what will happen if a particular policy is introduced. It feeds into strategic thinking for the future and may lead to policy advocacy or lobbying. For example, before the UK government introduced legislation on compulsory use of car seatbelts to decrease mortality on the roads, it ran a national education campaign to persuade people of the evidence that seatbelts reduced deaths and it consulted the police and motor industry before introducing legislation that made it mandatory to have seatbelts in cars and for the police to enforce the law.
Therefore, the policy triangle can be used both retrospectively – to analyze past policy, and prospectively – to help plan how to change existing policy
Exercise 2.1
Define the following terms correctly
a. Bounded rationality policy makers
b. Elitism
c. Government
d. Incrementatism
e. Pluralism
f. Political system
g. Power
h. Rationalism theory
i. Sovereignty
j. State
Answer:
a. Bounded rationality Policy makers
These are people who intend to be rational but make decisions that are satisfactory as opposed to optimum, due to imperfect knowledge.
b. Elitism theory
The theory that power is concentrated in a minority group in society.
c. Government
The institutions and procedures for making and enforcing rules and other collective decisions. A narrower concept than the state which includes the judiciary, military and religious bodies.
d. Incrementatism Theory
This theory states that decisions are not made through a rational process but by small adjustments to the status quo in the light of political realities.
e. Pluralism Theory
The theory that power is widely distributed in society.
f. Political system
The processes through which governments transform ‘inputs’ from citizens into ‘outputs’ in the form of policies.
g. Power
The ability to influence, and in particular to control, resources.
h. Rationalism Theory
This theory states that decisions are made through a rational process by considering all the options and their consequences and then choosing the best among alternatives.
i. Sovereignty
This entails rule or control that is supreme, comprehensive, unqualified and exclusive.
j. State
A set of institutions that enjoy legal sovereignty over a fixed territorial area.
Exercise 2.2
Differentiate power from authority base on what they concern
Answer:
Authority concerns the right to do so whereas power concerns the ability to influence others.
Exercise 2.3
a. What is power?
b. Describe how power can be exercise in simple terms
c. Outline and explain the three faces or dimensions of power
Answer:
a. Power is generally understood to mean the ability to achieve a desired outcome – to ‘do’ something.
In policy making, the concept of power is typically thought of in a relational sense as in having ‘power over’ others. Hence, it is considered as the ability to influence, and in particular to control, resources
b. Power is said to be exercised when “A” ask “B” to do something that B would not have otherwise done.
c. “A” can achieve this end over “B” in a number of ways, which have been characterized as the three ‘faces’ or ‘dimensions’ of power:
o Power as decision making
o Power as non-decision making
o Power as thought control.
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