Summary Analysis of Governmental Policy (MPA 2012)
http://books.google.nl/books?id=LL1M4lOzXtwC&pg=PA186&lpg=PA186&dq=making+health+policy+ward&source=bl&ots=AyrKOUd3VD&sig=QQ5vMEdhJI_sWJ51vijvS6RhU4E&hl=nl&sa=X&ei=dZV2UPOwD8fK0QWS_4GYAQ&ved=0CCgQ6AEwAA#v=onepage&q&f=false Chapter 1 The health policy framework

Health policy and other policies (economical, political) have an impact on health. Policies are made by policy makers/policy elite in the private sector (non-governmental) and in the public sector (governmental). Health policy can be both private and public. When making health policies, it is important to keep external determinants in mind such as transport of food, pharmaceuticals and tobacco. Programs are the embodiment of policies. The health policy triangle is a simplified representation of inter-relationships that may help to think systematically about different factors affecting policy.

Actors influence the policy process at the local, national, regional and/or international level. Context refers to systemic factors which may have an effect on health policy. They can be categorized (Leichter, 1979) in: Situational factors: transient situations (epidemic, earthquake) Structural factors: unchanging element of society (economical, political) Cultural factors: relatively unchanging element (religion, ethnicity) International or exogenous factors: international cooperation (WHO, programs) Process refers to the way in which policies are initiated, developed, implemented and evaluated. They can be categorized (Sabatier and Jenkins-Smith, 1993) in: Problem identification and issue recognition

Policy formulation: who/how
Policy implementation
Policy evaluation: effectiveness, monitoring, consequences
Additional notes (lecture)
Health policy: steering the health system in a direction.
Parliament: yes/no to laws. Cabinet: enforces laws, puts them into practice

Chapter 2
Power is the ability to achieve a desired result irrespective of the means. Power in relation to policy making often thought of as “power over” others. Three dimensions of power (Lukes, 1974): Power as decision making: voting is an important form of power in this dimension. They indirectly influence decisions, while few people directly influence these decisions. Power as non-decision making: dominant groups may influence the policy agenda? they manipulate values and procedure to limit the scope of actual decision making. Example: tobacco companies that divert attention from public health issues to other diseases. Approaches for (non)-decision making: hard (intimidation or exchanges) versus soft (loyalty/commitment). Authority is having the right to make someone do what you want; it is considered legitimate when it is based on trust and acceptance and lies between intimidation and exchange. Three types of authority: Traditional: established way of doing things (queen)

Charismatic: commitment to leader
Rational-legal: hospital director, not necessarily a doctor but still the authority over other doctors. Power as thought control: power can be a function of the ability to influence other by shaping their initial preferences. Processes involved can be socialization, use of mass media and control of information. The shaping of preferences includes letting people believe there are no alternatives/situation is unchangeable. Distribution of power is influenced by the differences in policy content and context; they make it difficult to create a general theory of power distribution. State and society are the focus in these theories, although theorists do not agree whether the state is independent of society or a reflection of power distribution is society and whether the state serves the common good or the interests of a privileged group. Several theories: Pluralism: power is dispersed from society. It is characterized by open competition, neutral state, individuals are free, pressure groups may air their views. Health policy emerges of deliberation between groups; the best option is put forward by the state. Public choice: competing groups pursuing self-interested goals. The state itself is an interest group that makes policy in pursuit of interests of those who run it. By doing this, they try to keep their support, while the public try to get more support in order to
gain more power. Elitism: policy is dominated by a privileged minority. Public policy reflects the interests of this elite, instead of “the people” (pluralists). Health policy loses power in this group. Only the few who have power can be policymakers; non-elites may only govern if they accept the elite; public policy does not necessarily includes a conflict of interest of elite and public (power of thought may manipulate the public). Examples of elitist frameworks are Marxism and Professionalism. Critiques, methodological constraints and new empirical evidence has lead to modification and updating of the separate approaches: theorists admit there is overlap. Additionally, the models may be applied to different types of policy: international policy is more elite, while more local policy may be more pluralistic/public choice. The political system is concerned with deciding which goods, rights and freedoms to grant and to whom. Input in Easton’s model (1965) take the form of demands (e.g. in health care more affordable care or convenient services) and support (of the public). Then policy is made based on these inputs, which result in outputs, the impact: when the policy leads to unwanted and unanticipated consequences, there is a feedback loop to input because the demand and support has changed. Five political systems:

Liberal democratic: stable political institutions with opportunities to participate via elections, parties, interest groups and media. Health policy varies from market-oriented to welfare. USA, Western Europe, India, Israel. Egalitarian-authoritarian: ruling elite, state-managed popular participation, bureaucracy. Health care is a fundamental human right and is financed by the state. Traditional-inegalitarian: monarchs, few participation opportunities. Health policy relies on private sector. Saudi-Arabia. Populist: dominant political party, elite only has influence when they are part of or linked to this party. Attempt to make health care a basic right. Africa. Authoritarian-inegalitarian: military governments as reaction to populist and liberal democratic governments. Health care for small elite (military mainly). Simon (1957) developed a stepwise rational approach to make decisions and policies: Identify the problem

Goals, values and objectives need to be clarified and ranked Alternative
strategies should be listed.
Analysis of impact of strategies
Choose strategy that effectively achieves the goal.
Several critiques are that problem definition is not black-and-white and what values and aims should be adopted (never homogenous). It is also impractical (considering all options). Some even say you cannot look at problems rationally: policy makers view something as a problem while others may not and vice versa. Some argue that the interests of the decision makers should be valued, while others say the value of the status quo (all stakeholders) is more important. These are incremental descriptions of decision making. They do not take into account radical decisions and state strategies that run into vested interests may not be used, although it may reach its goal. Path dependency: the influence of previous decisions/steps in making policy Additional notes (lecture)

Models: policy triangle, power, evaluation? apply them to your research, either one or a combination. Power is defined by the observers (mainly the ones who experience it). Media is a way to mobilize minorities/weaker groups to influence decision making (e.g. facebook revolutions in Egypt). Rational decisions (decisions that are quite radical) are made by academics. Incremental decisions are made by administrations (most used).

Chapter 3
State in health system:
Regulates quantity/distribution of services: licensed providers and facilities, control on number and size of medical schools, number of doctors per area, incentives for health professionals in rural areas; Regulates prices: salaries, charges, reimbursement rates;

Regulates quality: licensed practitioners, training/education, procedures for monitoring and complaints, accredited facilities. Economists say that the state has a big role in controlling health care because the health care system is not suitable for the market: 1) cost/benefits are not very important to consumers or producers, 2) market cannot produce this many public goods (non-rival consumption/non-excludable) and 3) monopolies may
lead to overcharging. Some economists disagree with the theory of market failure leading to state control, because markets can be regulated. Then again, private sectors have much more information than consumers which may lead to over-treatment and charging and private insurance markets have proven to not work well in the past? state involvement is better. The expanded role of the state (during the twentieth century) was not accepted by everyone and led to a reassessment of its role in the health care sector. Reforms included liberalizing trade, deregulating utilities and private industry and curbing public expenditure. Service provision was privatized. Anti-state, pro-market was the new philosophy in the 80s. This led to political pressure that resulted in public finance of health services which were not cost-effective. Political demands of the elite resulted in disproportionate allocation of resources to urban areas at the expense of basic services to the majority of the population. The radical changes clearly were not the answer, but the opinion that the role of the state had to be slimmed down remained: the private sector kept their bigger role, the state a smaller role and health provision was more efficient by introducing competition and decentralized decision making. This neo-liberal thinking was based on two theories: Public choice: politicians and bureaucrats have their own interests which do not maximize efficiency. Property rights: private property owners want to maximize efficiency of resource use which is not the case in the public sector. Civil servants have few reasons to do well because they cannot benefit personally from goal performance. State officials are motivated in a certain way which influences their pursue of policy. This gave rise to new public management: public services were exposed to market pressures (internal markets: more competition among caregivers). New finance mechanisms such as restrictions on private providers, accountability of providers to consumers and diversity of provider ownership were implemented. Functions of the ministry of health were transferred to executive agencies so the ministry could focus on policy and oversight. So the state retained some power: they should safeguard the public health by developing policy and standards and enable health care, e.g. mandatory insurance in high income countries and targeting public expenditure in low/middle income countries. Although these reforms seemed to be accepted, it was still difficult to implement them, or at least with the
right consequences: in some countries it led to fewer people being insured or services were used less frequently. Some of the reforms had to be reversed which resulted in a higher coverage rate of insured people. The private sector had an increasingly important role in health care during the 80s and 90s. It is characterized by profit making but may vary in type of organization; this can be multinational or small for example. There are also some non-profit organizations but they are mostly established to support the interests of a profit organization and lobby for them, e.g. tobacco company Philip Morris established the Institute of Regulatory Policy. Besides establishing non-profit organizations, they also organize and support patient groups to steer health policy decisions of governments and to create a positive reputation. Governments have interest in profits of pharmaceutical companies because of their tax revenues and these companies have specialist knowledge on which the governments relies when making policy. Self-regulation of private companies concerns establishing own rules and policies. Self-regulation then either concerns market standards (products/practice) or social standards (response to issues of stakeholders). Social standards include implementation of codes: Benefits:

Cover corporate practices that might determine health
PR & image
Differentiation from competitors? increased market share
Codes in response to issues of consumers/shareholders? boosts sales and investment by listening Letting other lagging forms see what standards they should use Codes of companies may be better for market share than statutory codes Problems:

Consumers feel not involved due to lack of transparency
Governs only select issues? societal commitment to universal rights erodes The private sector is often influenced by public policy and as a result, tries to influence the content of this policy by e.g. lobbying or executives taking place in office. Co-regulation: public and private sectors negotiate an agreed set of policy or regulatory objectives and work in partnership. Additional notes (lecture)

State not efficient provider of health services:
Public choice: own interests? more and more…
Survival is not at stake for the state while with market pressure there is. Implementation of market pressure: law states that the lowest priced products must be used. Side-effects are that when one product is chosen which people have bought, but a few years later another product is even lower priced, this product must be bought. People with the old product are stuck with that or have to buy new ones? not cost-effective while this was the intention of applying market pressure. Market pressure: “the strongest survive”? second best will not survive, meaning that there are a lot of losers in market. High priced pharmaceutical products? profits go to the companies and the government. A lot of this money goes to lobbying. Helsinki declaration: not allowed to do experiments on people unless there is a written consent after explanation of the research. (WO II: a lot of cruel experiments, led to the Helsinki Declaration). “Me too” drugs: very similar to other drugs (e.g. paracetamol), so no real benefits over other drugs. However, billions are spent to market them because there is a big target market (everyone needs it). Private sector needs to live up to social standards such as responsibility, being philanthropic, to show that they are not merely focused on profits and sales. They organize it themselves which is cost-effective and there is no external manager. However, there is no transparency (public cannot see what goes on inside the company), no effective sanctions.

Chapter 4
Agenda: list of subjects or problems to which attention is paid by government officials and people closely related to them. Theories of agenda setting in “politics-as-usual” (day-to-day): Long-term changes in socio-economic conditions, e.g. ageing

Power and ideas influence whether issues are put on the agenda, e.g. media can make people afraid of mentally ill patients. Three frames in which issues can be put: archaic, metaphorical or medical scientific. Theoretical models on agenda setting:

Hall
Legitimacy: should we do it? Obligation
Feasibility: can we do it? Technical/theoretical knowledge
Support: do we want to do it? Authoritorian leaders do not depend on popular support, but still support of key groups is necessary. Kingdon: a policy window is created with three streams
Problem stream: officials learn about problems through indicators (e.g. statistics), feedback of programs, pressure groups or sudden events such (crisis). Policy stream: solutions (feasible, consistent with social values, acceptable, etc). Politics stream: will

A policy entrepreneur is necessary (he recognizes the clash of the streams). Coincidence therefore is an important aspect for this model. Perceived crisis is one of the reasons a policy window opens. A crisis exists when important policy makers perceive that one exists and that these circumstances may lead to disastrous consequences. Non-decision making can explain why agenda setting fails: the power to keep issues of the agenda is just as important as the power to push certain agendas. Issues may remain latent (e.g. against interests of those in power), status quo may seem more important, ethnic minorities are ignored and use of force may be absent. Hogwood & Gunn: government is an important agendasetter because they can be found in the politics and policy stream. Policy makers need to anticipate: information and needs change? new problems and new solutions. Public choice on government as agenda setter: “the state is a interest group thus not neutral, but it tends to follow what the public wants on the agenda? populist approach”. To set their own agenda, they “create a crisis” to push issues on the agenda, e.g. Rutte says he needs to make budget cuts due to the financial crisis, while research data shows that there actually is no real crisis situation in the Netherlands that requires budget cuts. Media is an important catalyst to let issues get noticed by the government. Its functions are socialization (society’s culture), information, legitimacy (“people talk about it so we have to publish it”) and propaganda (persuasion of public). Bill and Melinda Gates foundation contribute to global health agenda setting since their funding is often essential in global health policies. Printed media sends a message that is influenced by the owner
(e.g. Berlusconi) and requirements of advertisers. The influence of the media on policies is not as great as some might say though: policy makers have other sources of information, the media highlights what issues already exist (they do not create issues) and policy makers are usually not moved to action by a single media account. Content, context and process of debate are determinants of the influence of media on policy. In low income countries, media is often closely related to the government. Shiffman and Smith: conceptual model of agenda setting. Resembles the policy triangle: Actor power

Ideas
Characteristics
Context

Chapter 5
Montesqieu: trias politica
Legislative; enacts laws (1e/2e kamer), oversees executive. Executive; leadership of a country/cabinet, chosen by legislature in parliamentary systems, but separate of legislature in presidential systems. Judiciary; court

Two features of government systems:
Autonomy: all factors are autonomous and neutral;
Capacity: government can make and implement policy.
Governmental systems:
Unitary: chain of command, all decision making power, delegation? rapid policy change; Federal: at least two levels of government that share powers? compromise. The levels may have different political party distribution. In Canada the health system is the responsibility of provinces, but the government contributes to funding.

Majoritarian: candidate with the most votes represents the district in parliament Proportional electoral: number of seats gained by each party is proportional to the share of the national vote

Parliamentary: legislature and executive are closely related? members of the executive are chosen of the parties with a majority in the legislature. Rapid policy change because policy is made by executive that usually is supported by legislature. Presidential: legislature and executive are separate? executive (president) has to make concessions on policies. More room for interest groups and it is more open. Political parties have their own policy statements and try to relate what is “buzzing” in the public to gain support; when they have power they may try to formulate and implement policies. In single party-systems (UK, US) you vote for the program; if they win they will (likely) implement what they promised. In liberal democracies (multiple parties in government), not only policies, but also other measures of the program are important for voters. Federal: federation “overkoepelt” different states. Each state is a small federation which may consists of a different political party distribution. The constitutional law that would maybe be implemented in the EU would have been a step towards a federation.

Tweede kamer suggests new laws, the Eerste kamer then checks whether they are feasible (eerste kamer consists of professors). They may edit and send it back and the tweede kamer can do the same? back and forth, may take some time (sometimes it is correct initially) before it is implemented. In some countries, the bureaucrats that advise the executives change when the executive change? no clear distinction. In other countries, the bureaucrats are more neutral, because they are permanent. Bureaucrats: civil servants. Executives delegate tasks to bureaucrats. The power of bureaucracy depends on its internal organization: e.g. they can be quite influential when there are few institutions and official that have decision power. They also have more influence on day-to-day issues (low politics) than on major policies with high profile (high politics). Different ministries relate to different policy networks. The ministry of health shape and maintain the policy and regulatory framework within which health services are paid for and delivered. Other ministries also influence the policy making of health, although often not consciously, most policies are pursued sectorally. They may come together eventually, e.g. children’s health and education influence each other. Governments often consult external (non-governmental) groups to see what they think about issues. Groups are not only used for information,
but they try to influence ministers and civil servants through the formation of interest groups. They use the media, discussions, etc. In the medical field, pharmaceutical-, insurance- and food companies exert significant influence. The cooperation of government with non-governmental actors is called a shift from government to governance. Governance: the rules of collective decision-making in setting where there are a plurality of actors or organizations and where no formal control system can dictate the terms of the relationship between these actors and organizations. Pluralism: mainly applicable to low politics, where both government and interest groups have power and the elite has none. High politics, however, are often executed by a small elite. In the 80’s and 90’s the number of interest groups increased. Before that time, non-governmental pressure was mainly of personal or family nature. Interest or pressure groups are defined as voluntary, try to achieve goals and do not want to become part of the governmental machinery to influence the decision making process. Interest groups are part of the civil society group, but civil society groups also include sport clubs and religious groups that do not often take a position on an issue of public policy (religious groups more often than sport clubs though). Some argue that not all interest groups fall under civil society group, since some interest groups try to influence policy. Giddens (2001) states there are civil society groups, cause groups (interest groups that fall under civil society), NGO’s (mainly civil society or cause groups), interest groups and market-related interest groups (self-interested). NGO’s can act as interest groups because they desire to influence public policy. Social movements are defined as a large number of interest groups involved with the same issue, e.g. “Arab Spring” in Tunisia and Egypt. Social media played a big role in this by spreading videos of the first protests. A distinction in interest groups:

Sectional groups: protect and enhance interests of their members. Government listens but only to the extent they think their role is important politically/economically. Interest groups that are produces tend to have the most influence because their cooperation is more central to policy implementation than consumer groups. Medical professionals controlled and regulated their own work and even shaped policy for the larger part of the
twentieth century. Politics can weaken the ability to resist of certain sectional groups by splitting up the professions; in this way more minorities are created, resulting in failure to form one opposition group. Cause groups: promote a particular issue, anyone that wants to promote the issue can become a member. Sometimes these groups are formed spontaneously, but it also occurs these groups are “front” groups of corporate interests to get their view in the civil society. Examples are the food industry that funds the World Sugar Research Organization or tobacco industry that support libertarian organizations devoted to promoting rights of smokers. In the past 35 years it has become popular to become a member of a interest group rather than a political party because the perceived remoteness of representatives in political party has grown. A distinction in interest groups:

Insider groups: not officially part of the government, but are consulted and expected to play “by the rules”. They are closely involved in testing policy ideas, e.g. medical and nursing associations are consulted in an early stage. Outsider groups: organizations that either reject close involvement in government processes or have an illegitimate reputation making them unsuitable to participate. Examples are anti-abortion and anti-vivisection organizations that take direct actions against clinics, laboratories and sometimes even the people that work there. Functions of interest groups

1. Participation: alternative to voting
2. Representation: policy makers take into account multiple interest groups 3. Political education
4. Motivation: new issues, more information
5. Mobilization: new policies
6. Monitoring
7. Provision: deliverance of services with(out) governmental funding A network in policy area consists of organizations that have resources such as information and skills, but are dependent on others in the networks for other resources such as money. They have to exchange resources to achieve a goal. Government becomes part depending on the degree to which it depends on interest groups to develop and implement policies. Policy networks reduce
the ability of the governments to act alone and requires politicians that can work with interest groups. Policy sub-system: a recognizable sub-division of public policy-making comprising the individuals and groups most often involved in decisions in that field. Mental health policy includes different actors than environmental health policy. The iron triangles are small, stable and highly exclusive sets of relationships between politicians, bureaucrats and commercial interest. Marsh & Rhodes (1992): policy communities are highly integrated and stable networks involving a limited number of participants that interact through formal and informal relationships. In contrast, issue networks are loosely inter-dependent and unstable networks with a large number of members that have different levels of power inhibiting the level of bargaining. Policy community bargains over policy developments while issue networks draw attention to certain issues. Because both capital and labor are vital to the economy, business and worker interest group are the most powerful interest groups. There are industrial and commercial interests involved in health policy, but also governmental (public finance) and professionals (medical monopoly over a body of knowledge). Alford (1975) argued that there are three fundamental interests that influence health care politices: Professional monopolists: doctors a.o. are served by economic, social and political structure Corporate rationalizers: implement strategies to challenge professionals and save costs, e.g. facilities, protocols, management methods. Equal health advocates: patients’ rights, fair access

Interest groups play a more influential role in health policy in low and middle income countries where they have traditionally been weak or absent, e.g. the global response to AIDS. Additional notes (lecture)

Examples of NGO’s: Cordaid, Artsen zonder Grenzen
Pluralist societies: interest groups have a lot of influence. Countervailing power: they draw attention to issues they find important and ministers take this into account. Sectional: sections of society, based on profession gender race etc. Cause: based on issue. Membership/goals Insider: work together with government (relevant voice of society; Federation of Patient groups). Outsider: relevant voice, but not invited to discuss with
government (Greenpeace). Recognition by government. Health Council a border group: they are an independent advisory organ of the government. Tresholder groups: “on the edge of change”, sometimes insider sometimes outsider In the 80’s, the sectional group of medical professionals moved from a privileged position to a less centered stage. Internal/external: insider/outsider. Sectional outsider e.g. minorities/mafia; cause outsider e.g. greenpeace; sectional insider e.g. medical professionals; cause insiders e.g. patient organizations

Chapter 7
Implementation: what happens between policy expectations and (perceived) policy results (DeLeon, 1999). Approaches to explain policy implementation:
Top-down: clear division between policy formulation (political) and execution/ implementation (technical) through a linear sequence of activities. Pressman & Wildavsky (1984) suggested that a system that linked goals to actions should be designed: failure was caused by wrong strategies and machineries. Sabatier & Mazmanian (1979) came up with criteria for good implementation: 1) clear objectives; 2) adequate causal theory; 3) a structured implementation process; 4)skilful officials; 5)support from interest groups and legislature; 6) no changes in socioeconomic conditions. Too analytical; difficult to fulfill criteria (especially the first one); too much distinction between policy and implementation; extent of policy change is not taken into account. Hogwood & Gunn (1984) came up with pre-conditions that made it possible to follow the top-down approach but not all pre-conditions could realistically be met. Bottom-up: awareness that implementers play an important role in implementation. Lipsky (1980) studied street level bureaucrats, which included social workers, teachers, local government, doctors and nurses. He saw the implementation process as a more interactive, political process characterized by negotiation and conflict of interests. To this day this approach is useful to see whether policies can be implemented effectively. How do you deal with divergence of goals of actors at the “bottom”? How much influence should they have on policy? Principal agent theory: institutions have to delegate responsibility for implementation of policies to officials and “agents” who they cannot completely control or monitor? sub-optimal implementation is inevitable.
Principals (decision makers) delegate their tasks to agents, but agents have their own views and loyalties which may hinder policy implementation. Three factors influence the principal-agent relationship: Nature of the problem: macro-micro, simple-complex, etc. Complex problems that concern a lot of people are more difficult to deal with than simple problems. Context/circumstances of the problem

Organization of the machinery required to implement policy: number of agencies and relationships The principal-agent model and related theories led to more defined organizations in the 80s: contracts of agents were defined, principal’s objectives were clarified, agencies with a small number of policy objectives were set up, etc. The government as direct provider of public services was re-organized so some of the public services were now delegated to private sectors. Governments used the following ways to implement policy: Information and persuasion: encourage certain behavior

Regulation: sanctions for those who do not follow rules
Public provision: public goods are still provided by government or publicly owned agencies Markets and market-like incentives
This is also called New Public Management (NPM) and it still used this day. Changes to instruments (market-like systems, new persuasion techniques) and processes (decentralization of decision making, making agents more responsible/principals more objective towards judging performance) took place during the 90s. Linder & Peters (1989) identified factors in shaping policy implementation choices of governments: Features: features of instruments vary in resource intensiveness, targeting, political risk and degree of coerciveness, meaning some instruments are more demanding than others. Policy style and political culture;

Organizational culture;
Context;
Administrative decision makers’ subjective preferences.
This model highlights the extent of the government capacity (top-down) and the complexity of the particular policy field (bottom-up). Sabatier sees policy change as a continuous process that takes place within sub-systems
and is shaped by external events. Within networks there are advocacy coalitions that consist of different people (from politician to researcher) that share beliefs and ideas. They agree on fundamental policy positions but may disagree on what means should be used to reach their goals. Policy brokers want to find feasible compromises between the advocacies. This model is more applicable to low politics than high politics, where policy decisions are normally made within a small elite.

Chapter 8
Health policy experiences pressure from transnational corporations, e.g. donor organization in low and middle income countries or tobacco companies that refuse to put warnings on their cigarette packs. Globalization is used in at least five different ways:

Internalization: increased cross border movement of goods
Liberalization: removal of barriers
Universalization: homogenization of cultures

McDonaldization: convergence around Western values and policies Emergence of transworld geography: increased connections through technological advancements The impact of globalization on health is most evident in the area of infectious diseases: microbes can cross the world in less than 24h. Outbreaks of eradicated diseases is an indication of a poor national health system, since it has spread to other countries. IHR: International Health Regulations accepted by all members of the WHO. However, the WHO could not do anything about the fact the IHR are not always followed: in 2005 new rules stated that members have to report to the WHO when international public health may be endangered.

The United Nations (UN) was established after WOII to maintain peace and security and save generations of war. UN organizations (e.g. UNICEF and the WHO) promote exchange and contact among member states and provide a platform to resolve common problems. Besides member states, some NGOs are allowed to participate in governing the organization. The WHA consists mainly of the ministers of health and also governs the WHO. The WHO is best respected for technical norms and standards, but is criticized for lack of leadership, management and accountability.

Other UN organizations include the World Bank, UNICEF, UNAIDS and UNDP. As they grew, they not only served their members’ needs but also pursued their own organizational interests in policy debates on (inter)national levels. The World Bank is unique in that the voting rights in the World Bank are linked to capital subscriptions of its members. For quite some time it was the largest external financier of health development in low and middle income countries. Its influence derived from the loans it disbursed, the perceived objectivity and authority of its economic analysis and its relationships with powerful finance ministries in borrowing countries. It acquired a central role in the health arena, often as coordinator at country level due to its image as apolitical, neutral and successful. World Bank: long term support, policy is decided by management. IMF: short term balance of payment deficits. Core funding was reduced in the 90s while program funding increased. The WTO administers and enforces a series of international trade agreements with the goal of facilitating trade, which may impact health through trade in medicine and health services/workers. When becoming a member of the WTO, you must alter policies and statues to the WTO agreements (no reservations). Bilateral relationship (government to government) are often financiers of health programs in low and middle income countries and of health programs in UN organization, e.g. USAID. Bilateral donors are often closely involved in setting the health policy agenda and in policy formulation. Rich, industrialized countries have significant influence over policy inside and outside UN agencies.

Developing countries play only a limited role in policy making in the international arena and use formal channels to vote for/against policies but have limited financial contribution. Bill and Melinda Gates Foundation: central actor in international health and has played a catalytic role in changing the organizational landscape in international health, mainly by supporting NGOs that are global public-private partnerships. They primarily financed research, development and product access for a range of neglected conditions. By handing out grants, is has supported evidence-informed policy making. Global civil societies (group of people that communicate via Internet to communicate a shared vision) try to influence the policy groups as (chapter 6) insiders, global communities (MSF/AZG), outsiders (Occupy), or tresholder groups. Persuasion and socialization are methods used by global civil society networks and coalitions to change procedures and policies. The internet plays a big role in communicating views and drawing attention to issues. A lot of global public-private health partnerships (GHPs) were launched in the 90s as a result of globalization. It brings actors from public, commercial and civil society organizations together that share goals and objectives. Some aim to research and develop new medicines, while others want to increase access to existing products. GHPs represent important actors in global and national health policy and have become powerful advocates for particular health issues and policy responses. Golden Pentangle (Cerny, 2001) consists of domestic bureaucrats, elected officials, interest groups, international institutes and transnational civil societies/market activities. It visualizes the range of interests involved in policy processes.

SWAPs: introduced to improve coordination since many actor (see pentangle) influence policy making. Mixed success was the result: many donors continued to fund off-plan projects, new GHPs needed to agree with policies. Country-level coordination needed to be supported by global-level coordination? Millennium Development Goals (IMF/WB/G8/OECD). Formative evaluation: qualitative research to optimize policy implementation in an early phase. Summative evaluation: quantitative outcome evaluation, to assess the goals promised after five or more years. Cost-benefit evaluation. Audit: examination of the extent to which an activity corresponds with predetermined standards or criteria (e.g. checking that facilities and staffing at a clinic are adequate). Monitoring: continuous tracking of data and process to ensure everything is going as planned. Regular surveys, focus groups, stakeholder analysis are examples of methods used to monitor. Evidence-based medicine was a movement that advocated for greater and more direct use of research evidence in clinical practice decisions. This movement later broadened into evidence-based policy driven by conviction. “What counts is what works”. Engineering model: a problem defined by policy makers and solved by new knowledge or research. Very rational/direct/linear model that is not very realistic. Enlightenment model: concepts and ideas derived from research filter into policy networks and have a cumulative, indirect effect on policy (Weiss, 1979). Strategic model: research is ammunition to support predetermined positions or delay uncomfortable
decisions (ibid). Elective affinity model: policymakers accept insights more quickly when they participated in the research, if there are results during decision making and if the findings coincide with values and beliefs of the policy audience (Short, 1997). This model emphasizes the importance of ideological compatibility between policymakers and researchers; if this is not the case, researcher fit more in the enlightenment model. Two communities: researchers and policy makers live in different cultures based on different assumptions about what is important and how the world works. Examples: researchers find unambiguous, generalizable results important, as well as valid knowledge, training, independency. Policy makers have less planning, have to take multiple opinions into account (government, public, NGOs), want successful management and usually have little scientific training. Donor organizations find it important to evaluate programs in low and middle income countries and usually hire foreign experts to do this? national government or program staff take these evaluations less seriously. Not only politicians shape research by ideology, but private and public sources of funds as well since they select which research they will fund. Health research for low and middle income countries is still under-resourced. If there is little agreement to what the main goals of a program are and how progress towards them should be measured, then an evaluation is open to a variety of interpretations in policy terms. Different conceptions of risk also shapes the way that evidence influences health policies and timing also affects whether or not research is used in policy making (see Kingdon model). Weiss 1991: three types of research output

Data and findings: most useful as support for consensus
Ideas and criticism: most useful in an open, pluralistic system when there is a wide range of possible response Arguments for action
Since the mid-90s in the health field, there has been interest in closing the gap between the two communities (researchers and policy makers) by making compromises in their habits, e.g. researchers should produce more “user-friendly” summaries and draw out the policy implications of their work while policy makers should give more opportunities for this type of research:

Lomas (2000) suggests that policy makers and researchers should work together to plan an develop research projects through using “cross-boundary techniques”.

Enhancing academic influence on policy process (Gibson, 2003): Identify relevant advocacy coalitions and study their core values and perception of problems Engage with the advocacy coalitions
Realize that research evidence only counts when it is recognized as arguments and advocacy by the actors Influence values and beliefs by providing a solid knowledge base

Chapter 10
Analysis for policy: prospective
Analysis of policy: retrospective
Stakeholder analysis:

Identifying stakeholders: discover independent actors who wield considerable influence while keeping the number small to make analysis manageable. Relevant actors will include those who are affected by the policy and who might take action? pay attention to those who may block policy adoption or implementation. Assess power relationships: tangible (votes, members, finance) and intangible (expertise, access to media/networks/political decision makers) assets? more assets equals more power. Doctors, for example, have considerable power because they are both experts and have high social status and relationships with decision makers? influence on health policy. Assess interests, position and commitment: the expected economic effect on an actor’s interests often determines their position on a policy.

However, defining interests may not necessarily give away the position of the actor because they may conceal it in public. Commitment is whether actors are devoted to successfully implement policies; a powerful actor may be opposed to the policy, but the issue is of marginal importance so he will not block or adopt this policy. Assess the opposition (power): see interests/position/commitment? make a policy map with on the y-axis position and the x-axis power (p198). Roberts (2004) suggests that political feasibility of policy change is determined by these strategies:

Position: 1) making deals with opposition to get their support; 2) making concessions to get some support; 3) making promises; 4) making threats. Power: strengthen supporting actors by giving them funds/personnel/facilities, information, access to decision makers/media, supportive networks, PR material. Or limit resources of opposing actors by challenging their legitimacy/expertise/integrity, reducing access to decision makers, refusing to cooperate/give information. Player: mobilizing neutral and demobilizing opposing actors through persuasion. Perception: either through data and theories or making associations with similar issues Data for policy analysis

Policy documents: books, journals. If possible, internal document (emails, unpublished reports), statistical sources. ? evidence that explains or predicts policy change. Quantitative content analysis: quantify content to predetermined categories Qualitative content analysis: uncover underlying themes in content People: surveys for basic information in relation to actor’s position, semi-structured interview more in-depth information on the position, elite interviews for powerful actors. Social media

Policy triangle or analytical narrative (time-line: background, problem identification, agenda setting, policy formulation and implementation). Impossible to be a completely neutral analyst, as long as you are clear on the values that shaped your approach. Powerful politicians may influence who will be the analyst.