The challenge was daunting: How best to improve the worker-training capacity of a large, impoverished African nation's fragile, failing public health system? Last summer, Harvard School of Public Health Lecturer Tom Bossert and three doctoral students traveled to the AIDS-stricken sub-Saharan country* at the behest of an international aid agency that funds health programs. The HSPH team's assignment was to come up with a set of reform strategies -- ones that would work in the real world, where political forces rule.

The country in question, the team learned, had an alarming shortage of health care workers. Many doctors were leaving for Botswana, South Africa, England, the U.S., and other developed nations; others were dying of AIDS. The largely rural population had little access to even basic public health measures. These problems were big, yet in two weeks Bossert and his students would need to address the health system's human-resource, education, and financing problems. Mindful of others' past failures, the aid agency also directed HSPH team members to analyze the political feasibility of their proposed policies. In essence, they were asked to answer the question: Would their plan fly?

Would stakeholders go for it? Would the government buy in? What about organizations that would help foot the bill, including the World Bank, United States Agency for International Development, and similar agencies in Canada and Britain? It was one thing to show people what to do, Bossert knew, another to get backing from the people in power.

Fortunately, Bossert had a software package to help sort out these issues: PolicyMaker 2.3. Developed by his colleague, Department of Population and International Health Professor Michael Reich, and sold on the Internet for $89, the software had a proven track record. It had already been used to set local health priorities in Tanzania, analyze government tobacco policy in Vietnam, shape national pharmaceutical policies in nine African nations, and spur health reforms in Zambia, Mexico, and the Dominican Republic.

WHETHER YOU ARE a health minister looking to overhaul your health system, a state official looking to boost mass-transit funding, or just an Average Joe trying to get your kids to agree on where to take vacation this summer, PolicyMaker 2.3 can help you get results.

According to Bossert, a political scientist and director of the International Health Systems Program at HSPH, PolicyMaker 2.3 leads users step-by-step through an analysis of their particular issue or policy option. Users must state their proposed policy, then rank players according to how strongly or weakly they align with it (or oppose it), also weighing how powerful each is politically.

Political considerations are pivotal, explains Reich, the School's Taro Takemi Professor of International Health Policy. "While public health professionals -- indeed, policy experts in many fields -- tend to be well trained in finding the right technical answer to a problem, they are less likely to be well schooled in politics. As a result, bad decisions are sometimes made despite good analysis, because of the political context.

"In health care, reforms often impose costs on well-organized, powerful groups, such as physicians or the pharmaceutical industry, while the benefits accrue primarily to poor, marginalized, or rural residents who aren't well-organized and politically connected. This can create significant political obstacles to reform -- even when leaders hold all the cards, as in a dictatorship."

PolicyMaker helps users clarify public perceptions of their proposed policy. It also forces them to think in a structured way about opportunities for and obstacles against a particular course of action, then plot strategies for achieving consensus.

A Political Primer

While no computer program can turn the art of policy making into a totally programmable science, PolicyMaker makes it possible for someone who isn't a natural politician to start thinking like one. Included is a toolbox of nearly three dozen political strategies users can try to push their agenda forward.

According to Bossert, PolicyMaker points out how to capitalize on alliances among groups that might favor the policy. And it identifies tactics for shifting an interest group from an unfavorable stance to a favorable or neutral one. In some cases, Bossert notes, "the software shows that the best route to success requires positioning the policy so that it enhances -- or diminishes -- the power of certain key individuals and groups."

PolicyMaker can help the many public health professionals who view politics as an impediment to doing the "right" thing, Bossert says. Since its release nearly a decade ago, HSPH faculty have used PolicyMaker to teach a World Bank flagship health care course for policy analysts, and to train managers in health ministries as well as donor agencies, such as the Inter-American Development Bank. In the field, the software has been used to promote health reforms, revise tax codes, and even deal with communist insurgents.

IN AFRICA, HSPH TEAM
members visited their host country's capital city and two provinces. From interviews with officials from the health, education, and finance ministries, they gleaned data and a sense of stakeholders' positions. Bossert and students input all of this information into PolicyMaker, along with their recommendations, to see which proposals would pass muster with the "powers that be."

For example, to get the country the most bang for its buck, the team advised creating programs to train more public health physicians who could serve in rural clinics. Sorely needed, too, were more health extension workers, who require only one year of training. Both these goals would be possible by boosting spending for salaries and education by 8 percent, a figure Bossert calls "reasonable and do-able. " But we weren't sure the international funders would go for it," he remembers.

Using PolicyMaker, however, the HSPH team uncovered a remarkable degree of consensus on the importance of training among donor agencies, non-governmental organizations, and professional associations. Even the country's own Ministry of Finance seemed willing to consider a health-budget increase. In fact, many of the HSPH team's recommendations were already on key stakeholders' agendas. "We were encouraged by the timing of our proposals," Bossert recalls, "and the idea that, ultimately, we might be taken seriously."

An In-Depth Experience

As for the time it takes to use Policy-Maker, that can vary greatly. It all depends on how much knowledge
users have, and how conscientious they are in ensuring that all the players are identified, all positions considered, and all opportunities for increasing the likelihood of success are taken into account.

"We do a two-day training on this program," Bossert says, "and discourage people from using it on their own. By using it in a group, people are obliged to explore and justify all the information they're loading into their computers."

Such was the case when Bossert and Reich met with Latin American health ministers in the early 1990's. Recalls Bossert: "They played with PolicyMaker all night and came back the next morning, saying, 'This is terrific. It forces us to identify groups and individuals who are neutral, then plan how best to mobilize them. It makes us think about all the stakeholders, not just the obvious ones.'"

Reich recounts another Policy-Maker story, this one involving health reformers in the Dominican Republic in the mid-1990s. Initially, reform efforts there were painted in the press as a scheme for privatizing health services. To counter that negative view, the reformers reframed their plan in simpler, more positive terms.

Unfortunately, key politicians following an election presented insurmountable challenges to the plan, and only a fraction of the total package was adopted. Two years later, however, the reformers repeated their PolicyMaker analysis, updated players' position maps, modified their strategies -- and had greater success the second time around.

Bossert and Reich believe PolicyMaker is a boon to public health professionals, especially to those who see politics as a barrier to progress. Of course, the better the information that goes into the program, the more successful the end result will be. The opposite is also true: Garbage in, garbage out.

"PolicyMaker isn't a magic wand," Reich warns. "We place a 'caveat computator' on the program: 'Do not confuse your analysis with reality.'"

Karin Kiewra is the editor of the Review and associate director of Development Communications for the Harvard School of Public Health.



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