Chapter V
Health Policy:
Making and Implementation
Health Policy-Making
Health Policy is a process in which policies are initiated, developed or
formulated, negotiated, communicated, implemented and evaluated.
The most common approach to understanding policy processes is to use what is
called the ‘stages heuristic’ (Sabatier and Jenkins-Smith 1993).
Policy process: the stages heuristic model
problem
identification/
AGENDA
issue
SETTING recognition/
prioritisation
POLICY
POLICY
EVALUATION
FORMULATION
POLICY
IMPLEMENTATION
The process of policy making
Agenda setting
The first stage in policy making refers to the identification of a public problem, which
requires the government to intervene. In fact, there a many problems, but only a small
number will be given official attention by legislators and executives.
Why do issues get onto the policy agenda?
Why do some issues are taken seriously and other not?
Why do policy makers take action when they do?
Models to explain:
The Hall model: legitimacy, feasibility, support
The Kingdon model: agenda setting through three streams
(problem, politics and policies)
The Hall Model (Hall et al. 1975).
The model suggests that when an issue falls high in relation to 3 concepts of legitimacy,
feasibility, support it becomes on the government agenda.
Legitimacy:Is a characteristic of the issues that governments believe
they should be concerned about.
Feasibility: The potential for implementing policy
Can the government do anything about it?
Defined by prevailing technical and theoretical knowledge,
financial resources, infrastructure, skilled workers; administrative
capability and existence of the necessary infrastructure of
government
Support: Relates to public support for government to intervene
particular health policy issues
Kingdon’s Model (John Kingdon’s, 1984)
Kingdon’s Model
The problem stream
The perceptions of problems as public matters requiring
government actions
The issue is noticed by government
The policy stream
The ongoing analyses of problems and the proposed solutions
and its associated debates
The politics stream
Events that impel the government to take action
Policy formulation
The second stage in the policy cycle – policy formulation – involves the
definition, discussion, acceptation or rejection of feasible courses of action for
coping with policy problems.
Policy implementation
Policy implementation involves translating the goals and objectives of a policy
into an action.
Implementation represents the conversion of new laws and programs into
practice. Without proper implementation, policy has neither substance nor
significance. Thus, policy success depends on how well bureaucratic structures
implement government decisions.
Theoretical models of policy implementation
TOP DOWN BOTTOM UP
POLICY SUB-SYSTEM /
PRINCIPLE AGENT
ADVOCACY COALITION
‘Top-down’ approaches
Policies set at a national or international level have to be communicated to
subordinate levels (e.g. health authorities, hospitals, clinics) which are then
charged with putting them into practice.
‘Top-down’ approaches
Six necessary and sufficient conditions for effective policy
implementation (Sabatier and Mazmanian 1979)
1. Clear and logically consistent objectives
2. Adequate causal theory (i.e. a valid theory as to how particular actions
would lead to the desired outcomes)
3. An implementation process structured to enhance compliance by
implementers (e.g. appropriate incentives and sanctions to influence
subordinates in the required way)
4. Committed, skillful, implementing officials
5. Support from interest groups and legislature
6. No changes in socio-economic conditions that undermine political
support or the causal theory underlying the policy
‘‘Bottom-up’ approaches
The ‘bottom-up’ view of the implementation process is that
implementers often play an important function in
implementation, not just as managers of policy handed down
from above, but as active participants in a complex process that
informs those higher up in the system, and that policy should be
made with this insight in mind.
‘‘Bottom-up’ approaches
Bottom-up designers begin their implementation strategy
formation with the target groups and service deliverers, because
they find that the target groups are the actual implementers of
policy (Matland, 1995, 146)
Principal–agent theory
From the principal–agent perspective, sub-optimal policy implementation is an
inevitable result of the structure of the institutions of modern government in which
decision makers (‘principals’) have to delegate responsibility for the
implementation of their policies to their officials (e.g. civil servants in the Ministry
of Health) and other ‘agents’ (e.g. managers, doctors and nurses in the health sector
or private contractors).
These ‘agents’ have discretion in how they operate on behalf of political
‘principals’ and may not even see themselves as primarily engaged in making a
reality of the wishes of these ‘principals’.
The policy sub-system or advocacy coalition framework
Sabatier’s framework is a general approach to understanding the
policy process
The large number of actors and networks within each sub-system
are organized into a smaller number of ‘advocacy coalitions’,
Factors as playing a critical role in shaping the policy
implementation:
Features of policy instruments – some instruments are intrinsically more demanding
technically and politically to use. They vary on at least four dimensions: resource
intensiveness; targeting; political risk; and degree of coerciveness.
Policy style and political culture – in different countries and different policy fields,
participants
Organizational culture – the past operating experience and ways of doing things of
the implementing organizations, linked to point
Context of the problem – the timing (e.g. in relation to how well the economy was
performing), the range of actors involved, the likely public reaction, etc.
Administrative decision makers’ subjective preferences – based on their
background, professional affiliations, training, cognitive style and so on.
Policy evaluation
Identifies what happens once a policy is put into effect – how it is
monitored, whether it achieves its objectives and whether it has
un- intended consequences. This may be the stage at which
policies are changed or terminated and new policies introduced.
Select a health problem and
apply it on one of the agenda
setting theories?
