d epartment of p ublic h ealth d epartment of i nternational d evelopment i nternational h ealth and...
TRANSCRIPT
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DEPARTMENT OF PUBLIC HEALTHDEPARTMENT OF INTERNATIONAL DEVELOPMENT
INTERNATIONAL HEALTH AND DEVELOPMENT
HILARY TERM 2010
THE POLITICAL NATURE OF POLICIES & POLICY PROCESSES
PROOCHISTA ARIANA
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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?
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OUTLINE
What is Policy Theory of Policy Making Practice of Policy Making Disciplinary Approaches to Policy Case Example
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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
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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
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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)
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LINEAR MODEL
Source: Sutton 1999
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POLICY PROCESS
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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)
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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
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BARRIERS TO CHANGE
Source: Sutton 1999
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INVESTED INTERESTS
Source: Sutton 1999
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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“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)
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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.
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“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
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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
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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.
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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.
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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
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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
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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?
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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
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US UNIVERSAL HEALTHCARE
Problem: 45 million Americans without health
insurance Quality concerns Efficiency problems Recognition of need for more prevention
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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
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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?
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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)
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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
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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
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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?
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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