DEPARTMENT OF PUBLIC HEALTHDEPARTMENT OF INTERNATIONAL DEVELOPMENT

INTERNATIONAL HEALTH AND DEVELOPMENT

HILARY TERM 2010

THE POLITICAL NATURE OF POLICIES & POLICY PROCESSES

PROOCHISTA ARIANA

POINTS FOR REFLECTION

Is there a distinction (linguistically or conceptually) between policy and politics?

Whose interests are involved in the process of generating policies? Whose interests are left out?

How evidence-based is policy? What kind of data are used?

OUTLINE

What is Policy Theory of Policy Making Practice of Policy Making Disciplinary Approaches to Policy Case Example

POLICY

Course of action, or principles that govern action

Policies can shift and mutate May entail unintended and unexpected

consequences which can end up harming intended beneficiaries

All policies have normative content

THEORY & PRACTICE

In theory policy frequently presented as de-politicised, rational and/or inevitable

In practice it is interested, economically costly and heavily politically contested

In development studies, particularly development economics, emphasis tends to be placed on the discursive realm to the detriment of the process of implementation

POLICY PROCESS

Agenda formation: the politics whereby statements of intention are announced (manifestoes, project proposals, five year plans, mission statements, etc) and their elements are prioritised

Procedure: the power relations giving rise to laws, rules, informal norms etc. together with the politics of access to these legal resources

Access: the politics of contact (eligibility, counter, queues and their rules, exit options and the deployment of voice); interface between state and society

The politics of resource mobilisation (without which the state cannot proceed with a developmental project); money trail (extremely sensitive & at heart of policy process)

LINEAR MODEL

Source: Sutton 1999

POLICY PROCESS

SCHAFFER’S CRITIQUE

Those who implement policies and those who create them generally have different status and power

Rarely have monitoring and evaluation Data scarcity problems and its

implications Process often de-politicised Constraints in linear model (versus

contextualising policy in societies)

WINNERS & LOSERS Experts have political roles as advocates or

opponents Politicians Business Donors Trade unions Civil societies Media NGOs

Who gets excluded in this process

BARRIERS TO CHANGE

Source: Sutton 1999

INVESTED INTERESTS

Source: Sutton 1999

DISCIPLINARY PERSPECTIVE

Disciplines see policy in a range of different ways

Economic Political Science Anthropological Legal

Understanding of such perspectives can encourage analysis of policy which is more self- aware and more critical

ECONOMIC APPROACH

Modeling the impact of policy in terms of prices and quantities on markets

Residualisation of policy Inclusion of policy/political conditions as

a dummy in regression analyses Invasion of politics to model it in quasi-

market terms with voters or lobbies as demand, policies as commodities and votes as prices.

Applied applications as the rational missing link in a linear and rational conception of policy

POLITICAL APPROACH

Rational choice: the state made up of a congeries of self seeking interest groups and self serving leaders, of politicians and officials maximising gains from office; all harming social welfare unless restricted

Marxist analysis of policy Policy as an epiphenomenon (a by-product of existing power relations)

Policies as the expression in the state of interests of the ruling class/of the accommodations between fractions of property owning coalitions

Policy within the institutions of capital and labour

RATIONAL CHOICE

From the perspective of societies (2 sorts of analysis):

1) Economic agents using political markets for economic power. State action is analysed inferentially to reflect social interests

2) Political agents used economic markets for political gaina. the “predatory state” - inferences made from the maximisation of short term revenue and pursuit of taxation policies which increase the state’s size and wealthb. Modelled constraints are political, technical, and resource-based

RATIONAL CHOICE

Individuals within the state (3 sorts of analysis):

1) Politicians and the electorate where staying in power is the maximand

2) Politicians and officials and their power structures : using position in power structure to benefit kin, neighbours etc: clientelism

3) Officials, bureaucratic conduct and efficiency in the face of a range of (dis)incentives.

ANTHROPOLOGICAL

Discourse creating structure of knowledge entrenchment of bureaucratic power

Labelling labels as an instrument of power through which fields of power are created,

Ethnographies The nature of the state links between discourse and outcome creation and evolution of political and

developmental categories

LEGAL

Policy cannot be implemented without laws

Legal pluralism: in which law and custom are shown to be intertwined and deployed strategically but at times with competing interests

Legal pluralism cannot be avoided in implementation of policies (people deploy systems to suit own interests)

Systems of power and authority and power of knowledge

LAW & DEVELOPMENT

Law and legal engineering to determine the course of development

Notion that if have ‘right’ legal framework, will achieve development

Unexpected outcomes if customary and religious rules and interpretations of laws not considered

CASE EXAMPLE

Health for All by 2000: The 1978 Alma-Ata Declaration and the call for primary health care in developing countries

Alma Ata Declaration of Health for All

“The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector” (Alma-Ata Declarlation, 1978)

PRIMARY HEALTHCARE

• In the 1960s and 1970s, China, Tanzania, Sudan, Venezuela and Papua New Guinea initiated successful programs to deliver a basic but comprehensive program of primary care health services covering poor rural populations. From these programs came the name “primary health care”

• This new methodology for healthcare service delivery incorporated a questioning of top-down approaches and the role of the medical profession in healthcare provision.

“Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.” - Alma Ata Declaration, 1978

WHAT HAPPENED NEXT

Almost as soon as the Alma-Ata Conference was over, PHC came under attack

Politicians and aid experts from developed countries could not accept the core PHC principle that communities in developing countries would have responsibility for planning and implementing their own healthcare services

SELECTIVE PHC

A new concept of Selective Primary Health Care (SPHC) advocated providing only PHC interventions that contributed most to reducing child (<5 years) mortality in developing countries. The advocates of SPHC argued that comprehensive PHC was too idealistic, expensive and unachievable in its goals of achieving total population coverage. By focusing on growth monitoring, oral rehydration solutions, breastfeeding and immunisation, greater gains in reducing infant mortality rates could be achieved at reduced cost.

SELECTIVE PHC

• In effect, SPHC took the decision-making power and control central to PHC away from the communities and delivered it to foreign consultants with technical expertise in these specific areas. These technical experts, often employed by the funding agencies, were subject to the policies of their agencies, not the communities.

• SPHC reintroduced vertical programs at the cost of comprehensive PHC. The PHC versus SPHC debate continued throughout the 1980s.

HEALTH SECTOR REFORMS (1993 WDR)

• It considers the delivery of healthcare services in terms of the economic benefit that improved health could deliver, and sees health improvement mainly in terms of improvement of human capital for development, rather than as a consequence of development

• Heralded an emphasis on using the private sector to deliver healthcare services while reducing or removing government services

• User fees, cost recovery, private health insurance, and public-private partnerships became the focus for delivery of healthcare services

SUMMARY• Access to basic health services was affirmed as a

fundamental human right by the ‘78 Declaration of Alma-Ata

• The model formally adopted by all WHO member states for providing healthcare services was Primary Health Care (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement

• PHC did not achieve its goals for several reasons• refusal of experts and politicians in developed countries

to accept the principle that communities should plan and implement their own healthcare services

• Changes in economic philosophy led to the replacement of PHC by Health Sector Reform, based on market forces and the economic benefits of better health

WHAT WAS THE POLICY PROCESS

What was the international agenda? Whose interests were involved Who were excluded What information was used

How were policies formulated at the national level?

How were the policies implemented? What were the effects of the policies?

ALMA ATA POLICY PROCESS

International consensus achieved- health for all through primary health care

National policy formulation- confronted by obstacles leading to a shift in national policies adopted to GOBI (SPHC)

Implementation- vertical programmes by ‘technical experts’

Evaluation- immunisation rates increased, infant mortality decreased but ‘health for all’ not achieved

US UNIVERSAL HEALTHCARE

Problem: 45 million Americans without health

insurance Quality concerns Efficiency problems Recognition of need for more prevention

POLICY FORMULATION ATTEMPTS

Popular consensus of problem but no consensus of solution or role of government

Obstacles: drug companies, insurance companies, HMOs

Drug and insurance companies spent over 10 billion USD over the past ten years to lobby against universal coverage plans

WHAT WAS THE POLICY PROCESS

What is the problem? How are policies being formulated?

Whose interests are involved Who are excluded What information is being used

Why does the policy get stuck in the procedure phase?

What could advance formulation of such a policy within the US context?

USER FEES IN VIETNAM

Collapse of the socialist system in the Soviet Union and Eastern Europe

Cut in foreign aid Socio-economic crisis in 1980s to 1990s Compromised government’s ability to provide free

healthcare 1986 Economic Reform Programme (Doi Moi)

ECONOMIC REFORMS

User fees for health services at higher level public health facilities (i.e. Hospitals)

Legalization of private medical practice Liberalisation of pharmaceutical industry De-regulation of the retail trade in drugs and medicines

IMPACT OF USER FEES

Raise revenues for public health services Increase in health workers’ wages Improved healthcare management and finance No evidence that user fees increased the quality of care Created barriers to healthcare services Pushed the poor and the marginalized further into poverty

WHAT WAS THE POLICY PROCESS

What was the problem identified? How were policies formulated?

Whose interests were involved Who were excluded What information was used

How were the policies implemented? What were the effects of the policies?

POLICY PROCESS

Problem: Financial constraints in provision of healthcare

Policy Formulation: Policy for user fees Implementation: introduction of user fees Evaluation:

Utilisation among poor decreased Poor got poorer Increase in poverty gap