political processes/actors initiating or sustaining health systems reform
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Political Processes/Actors Initiating or Sustaining Health Systems Reform. Presented on 1 June 2006 at the Health Systems Strengthening Seminar Belize City, Belize By Marilyn Entwistle Advisor, Health Services Administration PAHO/WHO Trinidad and Tobago. - PowerPoint PPT PresentationTRANSCRIPT
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Political Processes/Actors Initiating or Sustaining Health Systems Reform
Presented on 1 June 2006 at theHealth Systems Strengthening Seminar
Belize City, Belize
ByMarilyn Entwistle
Advisor, Health Services Administration
PAHO/WHO Trinidad and Tobago
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By the mid-1990s, virtually every Latin American & Caribbean country had either embarked upon health sector reform or was considering to do so
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PATHWAY TO HEALTH REFORM
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REFORM IS LIKE A PUZZLE
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FROM WHICH PERSPECTIVE
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HEALTH REFORM CONTENTS ARE:
• the result of the political process surrounding reform process
• the epidemiological, economic & organizational considerations embedded in its content
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Health reforms have varied in content & scope but they share certain common features
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Most involve changes in the:
• institutional configuration of the health care system
• role of the public & the private sector
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Health reforms involving institutional change have included:
• decentralization of decision making & resource management
• institutional changes involved in the modernization of the State
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Health reform is a highly political process mobilizing many groups within the State & in society, whose interests may be affected by the envisioned reform
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Reformers have based re-configuration of their health care systems on two major changes
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1. Creation of new actors or organizations that are to assume roles & responsibilities, such as the provision & articulation of health care services under a new scheme of collaboration
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2. Transformation of the old actors, or existing public institutions, so they may operate under the new rules of the game
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The political process has to deal with:
• the interplay of the different actors involved
• their potential to influence the process
• the strategies used by reformers to pursue their reform agenda
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When a health reform initiative reaches the public agenda, the country’s political process is unleashed presenting a series of opportunities and obstacles for its successful implementation
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Those interested in promoting reform may follow a series of political strategies in order to enhance the State’s capacity to bring about reform
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But What To DO?
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INTEREST GROUPS
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DOES THE POWER OF THE INTEREST GROUP MAKE A DIFFERENCE?
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Interest groups who perceive that their interests may be affected by reform may try to influence the process
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Health reform outcomes can be expected to reflect the interests of the most powerful interest groups and/or the weightiest political coalition
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STAKEHOLDER FATIGUE
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What about reforms that will benefit some groups while negatively affecting others?
Decision-makers will take into consideration the interests and power of stakeholders who might step up in favour of or against the reform
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Powerful interest groups can “capture” the State, leading reformers to redesign the reform initiative & even to stop reform in spite of its technical soundness & potential for enhancing the common good
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However what about when policy makers decide to continue to support a reform in spite of visible resistance from powerful social groups?
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LOOKING BEYOND THE OBVIOUS
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INSTITUTIONAL CONTEXT
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A country’s institutional setting sets the group rules for political competition, thereby determining the degree of access that interest groups have to influence the reform agenda
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By the same token, institutions determine the room for maneuver available to reformers & thus the degree of autonomy the State counts on to promote reform
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For example, in a democratic regime there is a higher possibility of powerful interest groups capturing the State & perpetuating an inequitable status quo
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However, the same democratic institutions might give greater access to politically weak groups able to influence reform in their favour to confront more powerful interest groups resisting reform
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It has been argued that political systems with a strong executive power are better able to isolate reform formulation from interest group politics.
This would seem to enhance the political feasibility of the reform initiative & speedier implementation
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Circumventing the channels for interest representation & limiting the access of actors may not necessarily enhance the chances of the reform's survival
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Politics that are suppressed by these means at one stage of reform may simply resurface at another stage requiring consensus-building & the pursuit of coalition strategies to ensure the political feasibility of the reform
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Important to take into consideration at what stage of the reform process any opposition to reform may peak & how “reformers” will deal with it
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Interest groups opposing reform may choose the most opportune moments in which to voice opposition
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Political & economic consequences of health reform are of such magnitude that the determining factors – and determinant actors – are beyond the Ministry of Health.
They may lie in the core ministries in control of the economy
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CHANGE TEAMS
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The act of creating a change team, empowering it & placing it in a position to lead a reform process can be considered as a strategy in & of itself
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A government may use this strategy as a means of augmenting its autonomy from interest group pressure with the intent of enhancing its changes of bringing about reform
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Change teams can be
• located in different points of the policy context &
• active at several stages of reform process
For example:– an advisory committee/group– congressional commission– planning commission– ad hoc inter-agency task force– health reform unit/secretariat
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The change team needs to:
– win the or, at the very least,
– neutralize the resistance of other factions within the government and/or interest groups
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Their capacity for strategic political maneuvering during reform process will prove as much a determinant to its accomplishment as the team’s technical capacity
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POINTS TO THINK ABOUT
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As the reform process develops, reform will pass through a number of points in which its content may be altered & even the very chance of it begin implemented at all may be put at risk
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Reform will be affected by those actors who have access to these points & can influence the policy process during that particular stage
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Actors that participate in decision-making at each point, as well as those who manage to influence them, are not the same at each stage
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The same actors may have different roles at the different stages of the reform process
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Their agenda & power will be different at each point & their potential to influence the content of reform will vary
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So as the final note …
Political Processes and Actors may end up changing your vision … or health reform puzzle
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WASTHIS
YOURGOAL?
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MERCI
GRACIAS