Elsevier

Health Policy

Volume 47, Issue 1, April 1999, Pages 69-83
Health Policy

Health sector reform and the interpretation of policy context

https://doi.org/10.1016/S0168-8510(99)00003-2Get rights and content

Abstract

Health sector reform is on the policy agenda of national governments and international agencies. This paper focuses on the policy process of health sector reform and, more specifically, the policy context. The importance of understanding policy context is emphasised and the elements of policy context are discussed. These are: demographic and epidemiological change; processes of social and economic change; economic and financial policy; politics and the political regime; ideology, public policy and the public sector. The paper then discusses the means for, and methods of, interpretation of the policy context. Particular emphasis is placed on linking policy context with an overall understanding of the policy process, the ‘messiness’ of policy-making, the interrelationship between the contextual factors, the contextual factors interpreted by policy actors, the use of analytical categories in the policy analysis. The paper concludes on the importance of strengthening policy analysis for effective health sector reform.

Introduction

Health sector reform (HSR) is an important issue on the policy agenda of governments. International agencies, both bilateral and multilateral, are also advocating the need to introduce major reforms to the health sector. While no strictly uniform and detailed recipe for change exists, key themes and approaches have emerged as dominant or preferred HSR policies. For example, changes are being introduced in the financing of health care as governments seek to widen their options and reduce levels of public spending with a shift away from collective tax-based systems to more individually based forms of financing health care, such as user charges, private insurance and compulsory health insurance. The introduction of a separation between purchaser and provider roles in health care, the development of contractual relations and managed markets within the public sector, the promotion of a more active role for the private (both for and not-for-profit) sector, decentralisation, and the introduction of user choice are commonly found as policies under consideration or implementation. They fall under the heading of the ‘new public management’ [1]. While these elements of change suggest a market orientation to contemporary HSR [2], perceptible shifts in policy orientation away from marketisation are also evident. In the UK, for example, the managed markets constructed and the competitive principles introduced during the Thatcher/Major era are now giving way to collaboration, partnerships, health alliances and ‘whole systems approach’. Networks are replacing markets although achieving these after some 10 years of market-style practices will not be easy [3].

While a body of research on the content and evaluation of these policies in a wide range of countries has been developed, comparatively little has been done on the policy process leading to health sector reform1. There is a need to develop research in this area to improve the record of implementation and to understand the complex country determinants of effective policy formulation and implementation. Indeed, there are major problems facing governments in policy-making for health sector reform, not least of which is the lack of internal policy-making capacity. This is reflected in various forms. These include a lack of research-based policy analysis, external imposition of reforms, top-down implementation and the lack of ownership among key stakeholders and a tendency to import reforms from other countries without critical appraisal or adaptation. Furthermore, frequent policy shifts experienced by some countries leave their health sector in a state of constant re-form and instability. No sooner had countries adopted competition and market systems than policies based on collaboration and alliances appear as the latest innovation or fad on the reform front.

This paper aims to contribute towards a strengthening of the HSR policy process by developing our understanding of this. Particular attention will be paid to the context of the policy process. Policy formulation and implementation take place in a context which gives explanatory and historical meaning to that policy. HSR policies respond in a complex fashion to issues in the social, political and economic environment. Failure to understand it can lead to misconceptions over the role, appropriateness, policy process and political feasibility of HSR.

This paper firstly presents a format for understanding the policy context of HSR. While the specific context will vary between countries, the format provides a set of key generic issues for consideration in and adaptation to particular cases. Policy makers may use the format for analysis in their own environment. Secondly, the paper discusses the means for, and methods of, interpretation of the policy context.

The analysis is based on, and brings together, two major sources of work. Firstly, it builds on exploratory research carried out by a research team2. The research was conducted in seven countries: Brazil, Kenya, Mexico, Pakistan, Romania, Thailand and the UK. The main aim of the exploratory research was to develop an understanding of the process of HSR policy formulation and implementation. The research was exploratory, interpretative and preliminary, the focus of which was the generation of interpretations. A loose data set was developed which was condensed and analysed by drawing out emerging themes. The field work was conducted through documentary analysis and in-country interviews with key stakeholders. Aspects of the research findings are in the process of further verification and in-depth analysis. The comparative work focused on four categories of the policy process: the structural context, the policy content, the policy actors and the processes of decision-making and is similar to that developed by de la Jara and Bossert [6], Walt [8] and Walt and Gilson [9]. The countries in the work were chosen to allow analysis of contextual features in highly contrasting environments. These ranged from the UK—a high income market economy with a well-developed welfare state infrastructure—to Romania, undergoing the process of transition from a command economy, to Thailand experiencing rapid economic change. Mexico and Brazil, as middle income countries, and Kenya and Pakistan, low income countries, allowed the research to analyse the process in these environments too. Experiences in the formulation and implementation of HSR also varied greatly among the countries analysed, and are indicated in Table 1.

The second source for this paper is work conducted over recent years by a group of policy analysts at the Nuffield Institute for Health, University of Leeds, UK. This work has focused on extensive observation of health policy in the UK and of international developments in health sector reform, and the provision of technical assistance in a wide range of countries. The paper draws on a number of insights from this work and integrates them with the research work mentioned above.

Section snippets

The Policy Context of Health Sector Reform

Policy is not developed in a vacuum, but in a complex context. Policies on HSR respond to a series of stimuli. These are a set of social, political and economic processes and structures which condition, to differing degrees, the policy system. Understanding these helps to explain why specific issues are on the agenda. It is this context that helps mould the manner in which policy formulation and implementation is conducted.

Concern for policy context is not new and is to be found in different

Means and methods of analysis

The preceding has identified contextual features that go some way to explaining the manner in which HSR is or is not on the policy agenda of many countries. It is important for the policy maker to understand these features as part of an integral analysis of the policy-making process. What interpretative guidelines can be offered to the policy-maker to understand these contextual features and how they relate to HSR? What means and methods of analysis can be used by the policy-maker to comprehend

Conclusions

This paper has focused on three key messages.

(1) The policy analyst needs to develop an understanding of the policy context of HSR. This importance goes beyond the intellectual satisfaction of interpreting historical processes and events, but is a key item in the practical concerns of policy formulation and implementation.

(2) Basic categories of the policy context of HSR may be developed as set out earlier.

(3) In analysing this context, particular attention has to be paid to the complexity of

Acknowledgements

We particularly wish to thank all those who helped us in the exploratory research, including interviewees, in the respective countries. We wish to acknowledge the financial support of DFID for the project ‘Health Sector Reform: Policy Formulation and Implementation. Comparing Experiences in the United Kingdom National Health Service and Developing Health Systems’. We also acknowledge the field work of Colin Thunhurst (in Pakistan), Cristian Vladescu (in Romania) and Frank Honigsbaum (literature

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