Module 5: Understanding Health Policy Processes: Previous page | 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23

Introduction

Table of contents Contents Introduction The policy making environment Reviewing stated policies Matching stated policies to field realities Policy contents and allocative patterns Features of strong policy proposals Sustainability of chosen policies Looking at some concrete examples of policy implementation Actors: roles, perceptions, agendas Government (central and peripheral) Rebel groups Transitional (UN) authorities, UN agencies Development banks Donors The European Humanitarian Aid Office (ECHO) Non-Governmental Organisations (NGOs) New actors in the humanitarian field, Professional associations Understanding Coordination Recommended Reading References Annex 5a: Establishing a Policy Intelligence Unit Annex 5b: Sector-Wide Approaches in Disrupted Health Sectors

Disrupted health sectors confront actors with the awkward dilemma of deciding whether

• to struggle to maintain the system’s basic functions, mending cracks as they emerge and, if feasible, cautiously introducing novelties at the margin and at a pace the system can absorb, or conversely
• to declare the system irreparably wrecked, abandon it to its fate and start from scratch designing a totally new one.

The policy discussion during and after the crisis is permeated by this dilemma, at all levels of decision making.

A thorough appraisal of the system’s strengths and weaknesses should provide precious clues to decision-makers. Such an appraisal is by definition difficult for both insiders and outsiders. The former, grown within established settings and taking most of them for granted, have problems in conceiving different organisational features. Thus, they tend to favour conservative approaches. The latter, lacking in most cases an intimate knowledge of the health sector, may react to the shambles they face concluding that nothing valuable has survived the crisis and that aggressive restructuring is the only sensible option on offer.

In this respect, disrupted countries present a wide range of situations. At one end of the spectrum, the preservation of basic functions (and the ability of the MoH to present the situation under a favourable light to outsiders) of the Mozambican health sector explains the prevailing conservative approach adopted during and after the war by most actors. There, the occasional call for radical change, usually unsupported by convincing arguments, was largely ignored. At the other end of the spectrum, the total disarray of Afghanistan or Somalia, or the birth of new state entities, such as Kosovo or East Timor, encourage innovative, start-from-the-basics approaches. Whether aggressive postures will pay out in some forbidding environments remains to be seen.

In any case, conservative approaches incur the risk of missing valuable opportunities for change and of wasting efforts and resources in maintaining alive a system already beyond recovery. Conversely, radical change may dismantle surviving functions and hurt fragile capacity, adding damage to that brought by conflict. In this way, the health sector hastily considered beyond repair will become beyond repair, to fulfil the original (and wrong) diagnosis.

The term ‘policy’ encompasses a broad range of laws, approaches, prescriptions, guidelines, regulations, habits. Some ‘macro’ policies have implications across most or all areas, including the health sector, whose actors have limited influence over those policies. Fiscal or civil-service policies fall in this category. Within the health sector, policies can be of broad or narrow scope. Macro policies with far-reaching implications tend to have a robust political character, even when they are advocated for their supposed technical merits. Examples of such policies are Primary Health Care, decentralisation and Health Sector Reform, new financing mechanisms, etc., which affect (or should affect) most aspects of health service delivery. Other policies, of strictly technical nature, address narrower issues, such as the control of a communicable disease, or drug quality control. This module focuses mainly on macro and sector policies, whose implications affect the whole health sector or substantive aspects of it.

Health policies are (or better, should be) recognisable even in the absence (or despite the content) of written statements. The ways services are delivered, allocative decisions are made, information is produced and used, actors interact, old practices are followed and new ones are introduced, all these elements sum up into the ‘policies’ governing a health sector during a given period of time. Therefore, countless, dispersed decisions shape a specific way of running operations.

Policies evolve over time, under multiple pressures. In unstable situations, this evolution may accelerate. Due to sudden turnarounds, policy processes may be reverted. As the crisis deepens, the policy frame that previously governed a battered health sector may melt down. Unwritten working methods, usually transferred by senior colleagues to junior ones, are particularly exposed to oblivion. Newcomers ignorant of practices enforced before the crisis may accelerate this trend. Against this disrupted backdrop, policy documents become the sole reference available to actors, who may vocally complain about their absence or advocate for their development.

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