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 s 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 (Lighter, 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 operation (WHO, programs) Process refers to the way in which policies are initiated, developed, implemented and evaluated.
They can be categorized (Sybarite 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 (Likes, 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 Nan-decision making: dominant groups may influence the policy agendas they manipulate values and procedure to limit the scope of actual decision making. Example: 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 colonization, use of mass media and control of information.
The shaping f 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 tot a privileged group. Several theories: Pluralism: power is dispersed from society.
It is characterized by open competition, neutral Tate, individuals are tree, 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 fifths 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 Stetson’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 IA elections, parties, interest groups and media, Health policy varies from market-oriented to welfare. LISA, 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-negotiating: 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-negotiating: military governments s 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 homogeneous). It is also impractical (considering all options). Some even say you cannot look at problems rationally: logic 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 tooth 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 en or a combination. Power is defined by the observers (mainly the ones who experience tin Media is a way to immobile minorities/weaker groups to influence decision making (e. G. Casebook revolutions in Pet). 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, hares, 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 (Nan-rival consumption/non-clubbable) 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 such more information than consumers which may lead to over-treatment and charging and private insurance markets have proven to not work well in the pasta 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 ass.
This led to political pressure that resulted in public finance of health services which ere 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 examine 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 tot 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 ere implemented. Functions of the ministry of health were transferred to executive agencies 50 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. . 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 ass and ass.
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 tenant 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 isles:: 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. . 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 o buy new ones not cost-effective while this was the intention of applying market pressure. Market pressure: ‘the strongest survive”IS 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. (WOO II: a lot of cruel experiments, led to the Helsinki Declaration). “Me too” drugs: very similar to other drugs (e. G. Paramedical), so no real benefits ever 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 tot 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? Authoritarian leaders do not depend on popular support, but still support of key groups is necessary. Kingdom: 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 o 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. Hoosegow & Gun: government is an important generated because they can be found in the politics and policy stream. Policy makers need to anticipate: information and needs changed new problems and new solutions. Public choice on government as agenda setter: “the Tate is a interest group thus not neutral, but it tends to follow what the public wants on the agenda[l populist approach”.
To set their own agenda, they “create a crisis” to push issues on the agenda, e. G. Route 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 cerement_ Its functions are colonization (society 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. Kauffman and Smith: conceptual model of agenda setting. Resembles the policy triangle: Actor power Ideas Characteristics Context Chapter 5 Mennonites: trials political Legislative: enacts laws (el/e gamer), 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.
Majorities: 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 separates 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 (KICK, US) you vote for the program; if they win they will (likely) implement what they remised. In liberal democracies (multiple parties in government), not only policies, but also other measures of the program are important for voters. Federal: federation “Resolutely” 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 ELI would hue been a Step towards a federation. Tweed gamer suggests new laws, the Rest gamer then checks whether they are feasible (rest gamer consists of professors). They may edit and send it back and the tweed gamer 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 changed 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 he 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 statically_ 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 overspent and interest groups have power and the elite has none.
High politics, however, are often executed by a small elite, In the ass’s and says 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 tot 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 f 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. Giddiness (2001) states there are civil society groups, cause groups (interest groups that fall under civil society), No’s (mainly civil society or cause groups), interest groups and market-related interest groups (self-interested). No’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 an weaken the ability to resist of certain sectional groups by splitting up the protections; in this way more minorities are created, resulting in tailor 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, hut 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 the rules”. They are closely involved in testing policy ideas, e. G. Deiced 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 articulate. 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.
Manipulation: new policies 6. Monitoring 7. Provision: deliverance of services with(out) governmental funding A network in policy area consists tot organizations that have resources such as information ND 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 lath policy. The iron triangles are small, stable and highly exclusive Sets Of relationships between politicians, bureaucrats and commercial interest. Marsh & Rhodes (1 992): 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).
Alfred (1975) argued that there are three fundamental interests that influence health care politicos: professional monopolists: doctors a. o. Are served why economic, social and political structure Corporate rationalizes: implement strategies to challenge professionals and save costs, e. G. Facilities, protocols, management ethos. 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. He global response to AIDS. Additional notes (lecture) Examples of No’s: Cordial, Arties gender Green 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 overspent (relevant voice Of society; Federation Of Patient groups). Outsider: relevant voice, but not invited to discuss vivid government (Greenback).
Recognition by government Health Council a border group: they are an independent advisory organ of the government. Thresholds groups: “on the edge Of change”, sometimes insider sometimes outsider In the ass’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. Greenback; sectional insider e. G. Medical refashions; cause insiders e. G. Patient organizations Chapter 7 Implementation: what happens between policy expectations and (perceived) policy results (Deletion, 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 & Williwaws (1984) suggested that a system that linked goals to actions should be designed: failure was caused by wrong strategies and machineries. Sybarite & Amazonian (1979) came up with criteria for good implementation: I) clear objectives; 2) adequate causal theory; 3) a structured implementation process; 4)skiff officials; 5)support from interest groups and legislature; 6) no changes in socioeconomic conditions.
Deontological; difficult to fulfill criteria (especially the first One); too much distinction between policy and implementation; extent of policy change is not taken into account. Hoosegow & Gun (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. Lipids’ (1980) tidied street level bureaucrats, which included social workers, teachers, local government, doctors and nurses.
