International Health Systems Program  
Department of Global Health and Population
Harvard School of Public Health
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RESEARCH


Politics of the Policy Process

Background
Analysis and understanding of the political context in which health policies are envisioned and/or made are crucial to understanding the chances of success or failure of health reform initiatives.  Several IHSP faculty are continually engaged in research on the political processes of health policy reform across a wide number of countries and settings.

Methodology
While research methodologies are tailored to the specific analysis at hand, a systematic stakeholder analysis usually is a key component to the research.  In particular, many of our analyses have made use of the PolicyMaker approach, a methodology and software program developed by IHSP researcher Michael Reich (see (Reich 1996; Glassman, Reich et al. 1999)).  The PolicyMaker approach systematically analyzes stakeholder positions and likely outcomes resulting from policy reform initiatives.  Its five components of analysis include: 1) defining the policy content in question; 2) identifying political players, their interests and positions; 3) identifying opportunities and obstacles to change which exist in the political environment; 4) designing political strategies that will heighten a policy
’s feasibility; and 5) assessing potential gains/impacts of those strategies.

Findings
In the 1990’s a comparative study was conducted on the policy process of health reform in Chile, Colombia and Mexico (where Chile and Colombia had successfully undertaken health while Mexico had not), evaluating the success and failure of political strategies for adoption of a significant reform (see (González-Rossetti and Bossert 2000)).  Conventional wisdom suggests that it is often easier to implementing broad reforms in authoritarian regimes is easier than in democratic systems because the former regimes can make decisions without having to respond to different interest groups that can often block reforms.  Contrary to this expectation, however, our stakeholder and institutional analyses indicated that the formation of relatively stable and coherent “change teams” in Chile and Colombia were major factor in the success of reforms there.  Made up of technical experts with a shared ideological commitment and who did not see themselves as politicians, the health sector change teams garnered critical support by the president and other major political actors.  As importantly, these teams had links to a macro-economic “change team” which had successfully developed policies of economic reform and that sent key members to work in the Ministry of Health.  By contrast, efforts to create a coherent health sector change team in Mexico were frustrated by intense internal competition among key macro-economic change team members over the anticipated selection of the next president.  Finally, the health sector change teams in Chile and Colombia were insulated from the broader political process until it had developed a significant technically defined package of reforms. The reform package was then presented as a complete reform and as the president's own proposal for legislative attention, with the change team able to overwhelm opposition with well-developed technical arguments.

In 2000, IHSP faculty conducted a study of the policy process surrounding national health insurance reform in Poland.  The analysis centered around the National Health Insurance Law, legislations designed to separate health service financing from provision, but also the culmination of a long and contentious reform process of competing proposals.  The research addressed reasons why it took much longer for health reform to be decided and implemented in Poland compared to neighboring (and also newly democratic) countries, why Poland eschewed greater involvement of market mechanisms that have been tried in other Central and Eastern European countries, and which political strategies could be used to continue the process toward a greater consensus on innovative health reform proposals.  In addition to a traditional stakeholder analysis, they analysis reviewed the respective roles that “coalition politics”, incumbency, lobbying, bureaucratic politics and technical information played in the policy process.  The research found that the lack of a sufficiently strong coalition of actors committed to any one health reform proposal accounted in part for the protracted reform process.  In terms of market mechanisms, it appeared that pro-market forces were less adept at building consensus than their post-Communist counterparts.  Finally, the analysis concluded that successful implementation of the reform would require a strengthened coalition of insurance law supporters to overcome institutional inertia, a stronger regulatory role by the Ministry of Health, and building of bargaining skills by political actors to maintain strong coalitions.

Conclusions
Studies on the policy process provide a number of lessons for major reform efforts in developing countries.  In contexts where change teams are crucial to the reform effort (as in Colombia and Chile), developing support for reform at executive level, as well as in the Planning and Finance Ministries, can be critical to success.  Additionally, strong vertical links to high-level officials and horizontal links to officials in other sectors, as well as command of technical arguments, lend a necessary degree of legitimacy and effectiveness.  Finally, isolation of the change team in the formulation of policy resulted in a single and coherent reform package that could be supported by the major political actors.  In other contexts where the more fluid and unstable coalition politics dominate (as in Poland), strengthening basic democratic policy process skills (e.g., bargaining and consensus-building) at all levels may be as important as garnering higher-level support or developing links to officials.

Citations
Reich, M. R. (1996). "Applied Political Analysis for Health Policy Reform." Current Issues in Public Health 2: 186-191.
Glassman, A., M. R. Reich, et al. (1999). "Political analysis of health reform in the Dominican Republic." Health Policy Plan 14(2): 115-26.
González-Rossetti, A. and T. Bossert (2000). Enhancing the Political Feasibility of Health Reform: A Comparative Analysis of Chile, Colombia, and Mexico. Boston, MA, Data for Decision Making project.

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