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The policy making environment

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

During protracted crises, virtually all factors conspire against effective policy making. The state authority is contested and its top managers can be removed from their posts or move to other jobs, the public sector is crippled, instability and uncertainty discourage long-term initiatives, the information basis is poor, actors multiply and are replaced, memory is weak, the policy discussion easily takes political overtones, accountability and transparency are difficult to enforce. Unsurprisingly, documented examples of successful policy practice are scarce.

The health sector is part of a broader picture, which affects the choices made within it. For instance, free market, new public management, decentralisation are all part of worldwide processes that impact on the sector according to political and economic rationales not necessarily desirable from the health sector’s exclusive point of view. In the political deals between governments, rebels, UN agencies, donors, development banks, private companies, foreign armies, peacekeepers, important decisions that affect the health sector and shape the decision space of its actors are taken. As in a true theatre, the actors on the crisis stage must follow to a certain extent already-written scripts, follow the instructions of directors and producers, and take into consideration the reaction of critics and audience.

“The idealised ‘strong state’, with its functioning Ministry of Health firmly in control of policy-making, resource allocation and regulation of the sector, is increasingly absent in many parts of the Third World. Instead, many developing countries, particularly in Africa, are characterised by states which lack the capacity, and in some cases the political will, to function as sovereign states (..). The weakness of public policy in these countries, together with the current preference of officials aid organisations for policy-based lending (..), means that the locus of health-policy making is increasingly internationalised – with decisions regarding major elements of the content of health policy in recipient countries frequently being made in Washington, Copenhagen and London, rather than in national capitals (..) (Lanjouw et al., 1999). The health sector itself is often the object of political bargaining, as in Angola, where the minister’s post was given to the rebels in one of the many ill-fated attempts of negotiated settlements of that conflict. Health, often perceived as a technical field of limited political significance, may count among the areas where weakened governments are more amenable to concede grounds. Further, the health sector may offer to former rebels the first experience of formal governance. And at the end of a liberation struggle, health care delivery can be used to demonstrate the commitment of the new rulers to social welfare and to win ‘hearts and minds’.

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