Health Policy Flashcards
Why do we study health policy?
- Societal activities, including health initiatives, are influenced by politics.
- Funding allocation: politics plays a critical role in the distribution of funds.
- Real-world practice change: w/o understanding health policy, even the most scientifically sound solutions may fail to be adopted into practice.
It is important to study health policy in order to understand processes essential for implementing technical solutions and for actual change in health practices to occur.
What is a policy?
Policy: principle or plan to guide decisions, actions and outcomes. Examples: laws, documents, procedures, could be unwritten practices or informal. It is a way of working, vision, program of action, responsibilities or an unwritten cultural or ethical code.
Policy as intent vs policy as practice.
Public Policy: anything a government choose to do or not to do, refers to the policies/priorities of governmental agencies. It can also be the decision to not act on an issue.
Who are policy makers? Who are the policy elite?
Policy makers are those who impact or shape policies in entities like national or regional governments, global corporates or local enterprises, and medical centers or hospitals.
The policy elite are a specific group of high-ranking policy decision makers within a policy system, frequently possessing exclusive access to other senior figures within the same and different organizations. In CH, policy elite would be FOPH, Governmental powers, Minister of Health in each canton, anyone in parliament in Bern or Health Policy commissions.
Influencers don’t make decisions, but have influence. Focus beyond government, but also other actors.
What is a health policy? What are some examples?
Health policy is the array of decisions (or non decisions) that shape the structure, personnel, services, funding and recipients involved in the health and healthcare system.
An analysis of health policy would also consider the influence of sectors outside traditional healthcare that impact health, such as transportation, environment or food industries.
Government health policies would include mandatory health screenings and vaccination policies.
What is policy analysis? What would some examples of different focuses be?
2 definitions:
- Analysis of policy (retrospective): applied to understand how and why policies were created and assessing their success and impact
- Analysis for policy (prospective): apply to plan a particular policy; looks forward and tries to anticipate what will happen if a policy is introduced.
Different backgrounds have different focus in analysis, for example:
- economist: health policy as a method for the most effective and efficient distribution of limited health resources
- public health expert: policy as a tool to affect health determinants and boost health equity across populations
- physician: health policy’s role in enhancing individual healthcare services
Health policy is linked with politics - therefore, policy analysis also deals with the policy influencers and how they exercise influence under different conditions.
What are some examples of things that are looked at in policy analysis?
Policy analysis looks beyond the content of health policies - it also focuses on “who” “how” and “why” questions.
Decision - Making (who are the main decision makers, what are the roles of different stakeholders in shaping policy?)
Implementation (who is responsible for implementation, how are these policies put into action?)
Conditions and Execution ( under what conditions are health policies introduced and executed? What factors contribute to neglect of certain policies)
Motivations and Incentives (how can inter-ministerial collaboration be motivated to address social determinants of health? what incentive structures can be developed to promote comprehensive health policy implementation?)
Politics and Process (how do politics influence the policy making process? What processes ensure the integrations of health policies into broader political agenda?)
What is the health policy triangle?
The Health Policy Triangle is a way to analyse policies, including:
- Content: analysing the substance of a policy that describes its essential parts (the objectives)
- Actors: analysing the role of stakeholders (can’t detach experts from the orgs they are working for).
- Context: analysing systemic factors (political, social, cultural, local, regional, national, international) in which actors and processes interact
Process
What are some examples of contextual factors in policy analysis?
Examples of contextual factors include:
- Situational Factors: temporary conditions that can as a “focusing event.” Example: new regulations on buildings following an earthquake.
- Structural Factors: Unchanging elements of society. Example: political and social structure. Economics and employment, i.e. low wages and high workloads for nurses, lead to migration. National resources: a country’s ability to fund health services and influence health policy priorities.
- Cultural Factors: Impact of social hierarchy, gender and stigma, religious and political factors. (Does a disease carry a stigma? Is hierarchy too strict to challenge a senior official? What are the religious and political views on health policies in relation to reproductive health services?)
International Factors: things that lead to interdependence and international cooperation, like cross border health issues.
How does policy making unfold? What are the Stages of Policy making?
What is the policy cycle?
The policy cycle shows the stages of policy making, and how the process of policy making unfolds.
What is missing from the policy triangle and the stages of policy making/policy cycle?
These frameworks are helpful to simplify the complex, dynamic and interactive nature of policy making; however little attention is spent on other factors like:
- Ideas (values, evidence, anecdotes and arguments that shape policy
- Institutions (“rules of the game”, how organizations function, both the official rules and procedures, as well as the unwritten, informal, behavior norms.
- Interests (potential benefits or drawbacks a policy change could bring into an actor or a group).
–> Look at the Kaleidoscope Model of Policy Change
What is the Kaleidoscope Model of Policy Change?
The Kaleidoscope Model of Policy Change is based on a review of existing approaches. It considers policy change processes in the development contexts in developing countries.
It asks what are the key drivers of change in several policy process contexts? What conditions allow policy change to happen?
For example, there is a section for “agenda setting” that includes if there was a focusing event, powerful advocacy coalitions or if the problem is recognized and relevant .
What is power? Where do the theories say it lies and what are the 3 dimensions/expressions of power?
Theories of power focus on:
- Structure (of relationships and institutions)
- Agency (an actor’s ability to achiever influence and further their goals)
- Both structure and Agency
The three dimensions of power are:
-decision making (laws, observable)
- non-decision making (keeping something off the agenda. lobbies / behind the scenes discussions)
- thought control (social norms/perceptions. controlling information. most subtle.)
What are the 3 theories of how power is distributed in government ?
- Pluralism - ideal for democracies. No elite group/ many members who express opinions, multiple sources of power. Impartial state chooses what fits best.
- Elitism - Privileged minority shapes policy. Policies reflect interests of elites, not general population. Those who govern are unlike those who do not, policies mirror elite’s values - population may be manipulated. Typically more conservative/ slow to make change.
- Public Choice - State seen as self-interested entity, that doesn’t serve all societal interests equally. Elected officials cater to specific groups.
There is variability in how power is distributed, that is related to the context. For example at different levels or based on the decision to be made. For example, technical decisions like funding are made by expert groups, while high-stakes political decisions are made by political elites.
How does the role of the government and the state impact health of individuals, thinking about the distribution of power in policy process ?
Government policies and regulations impact various aspects of individual lives.
For example, access to abortion, legality of sex workers, availability of gender reassignment, number of children ppl can have etc).
Policy makers (including politicians) are driven by both personal ideas and self-interest.
The government’s structure (institutions) such as norms, electoral system, legislative procedures, heavily shapes the policy process.
Path dependency: there are certain steps you have to adhere to (within the political process), that can restrict policy evolution
What are the two ways to characterize governmental systems?
In an ideal world, two features have a major effect on the ability of governments to make and implement policy:
- Autonomy
The government’s ability to avoid influence. Able to prioritize the nation’s collective wellbeing over desires of specific groups. - Capacity
The ability of the government to device and enforce policies.
What are 3 ways that we can characterize government systems?
- Federal vs unitary systems
(Federal = US, Canada, CH .. Unitary is central government = France) - Role of political parties
- Majority vs proportional electoral systems
What are some things to note about Switzerland’s government?
In Switzerland, there are 26 cantons (sometimes they work together) and 2,020 communities governing within.
Magic Formula: 2:2:2:1, political composition of Federal Council. Equal rights, rotating presidency.
What is the impact of federalism on policy?
Federalism, as a system of government, divides powers and responsibilities between a central government and regional or state governments.
Decision making is localized, and therefore varies across states/regions.
The influence of federalism on policy is multifaceted. It allows for diversity, experimentation, and responsiveness but may also lead to inconsistencies, coordination challenges, and potential inequalities. The impact largely depends on how well the federal and state governments work together and how effectively they address the needs of their respective populations.
What is the role of civil/public servants in the policy process?
Civil servants are key in managing policy processes; extending beyond serving politicians. Many responsibilities and implementation is delegated to them and they often serve for a long time. Their influence would vary by countries and task: for example for routine, technical matters like hospital reimbursements, civil servants have more control and input.
What does the Ministry of Health do? What is Health in All Policies?
Government bureaucracy is divided into departments/ministries with specific functions.
The Ministry of Health are vital to guiding health systems, stewardship and navigating through the system. Their role includes setting the health policy directions, vision, regulating the sector, promoting health advocacy and collecting and using information to inform decisions.
Health in All Policies states that health should be part of all policies (transportation, education, economics). It shouldn’t stand alone - every policy/ministry should consider the health impacts. This is hard, bc there are competing priorities in different ministries.
The WHO promotes this: looking at everything with a health lens.
What are some types of interest groups and their characteristics?
Interest groups are voluntary, located outside of formal government, but have a goal of shaping policies aligning to their goals, do not plan to take formal political power.
2 types:
Private sector (for profit):
business, professional and employer associations. They hold significant sway in public policy due to their role in the economy. Globalization enhances business power, as they can move operations if local policies are unfavorable.
Civil society (not for profit): campaigning groups (also for controversial goals) . Includes NGOs, social movements.
Public-Private Partnerships (PPP): designed to align interested of public, private and philanthropic expertise. Example: GAVI - Vaccine Alliance, combines efforts of WHO, UNICEF, World Bank and Gates Foundation. Challenging to oversee as each partner has varying goals and motives, public welfare vs private profit goals. Critics say it inherently harbors conflict of interest.
Professional Interest Groups: medical and nursing associations often have strong government influence.
What are “insider” and “outsider” interest groups?
Insider groups:
- recognized by the government and involved in policy development
- expect and receive early consultation or direct involvement in policy creation
- abide by the “rules of the game” like maintaining confidentiality in government committees.
Ex: medical associations
Outsider groups:
- either ideologically opposed to government involvement or not recognized as legitimate
Ex: anti-abortion groups, known for direct action against clinics
What is the Advocacy Coalition Framework? (ACF)
The Advocacy Coalition Framework is a model for understanding policy processes and changes. Policy is viewed as a continuous process with defined policy sub-systems. It is influenced by stable factors like societal values, structures and major external events.
The model does not include general public, as they do not directly participate as individuals.
Increase of significance in policy networks:
Governments now share decision making with external organizations.
Officials must negotiate and collaborate with interest groups.
Governance requires less hierarchy and more partnership; government’s role evolves to coordinating and overseeing diverse actors.
What theories explain how and why issues get onto the policy agenda?
Hall et al (1975): Legitimacy, feasibility and support.
When an issue scores highly in these areas, it will be on the government’s agenda.
Kingdon (2013): Policy windows and three streams
People take advantage of windows, to move items onto agenda: policies gain consideration when these 3 streams converge:
1 - problem steam
2 - policy steam
3 - politics stream
What is the principal- agent theory?
The principal- agent theory looks at policy implementation.
It is a framework that looks at networks and relationships.
It states that sub-optimal implementation would be a result of governmental structure.
Higher-level decision makers (principals) delegate policy execution to lower levels (agents). Delegation continues down the chain (from ministers to civil servants to healthcare professionals). Agents operate under indirect control, challenging to monitor.
There are factors that influence the principal - agent relationship.
Agents have discretion in their roles, and may prioritze their professional identity over being a public servant.
“Wicked problems”: difficult issues with no easy solutions, often debated in public policy.
What are some differences in health systems?
Looking at the organization of coverage in case of sickness, different health systems:
- public vs private health insurance provider
- finance insurance through taxes or contributions
What are characteristics of the health care system in Switzerland?
The Swiss Healthcare system is highly decentralized and federalist. Cantons are the most important decision making level in the area of healthcare. There is relatively little decision making at federal level. Main aspect of the CH system is that the cantons have more rights.
There is vertical policy implementation. Confederation, cantons and communes have joint powers in healthcare financing.
Direct democracy: there are extensive opportunities to participate for voters.
(Chart shows the organizations)
What is included in Switzerland’s federal division of tasks?
(The polity: formal structures, agencies, institutions)
What does the policy cycle look like in Switzerland?
Referendum - if someone disagrees, they vote.
Mandatory voting for anything to the constitution.
Anyone from parliament can hand in a proposal for the federal council to review.
What does evidence based mean?
Evidence based means formed on research, like RCT, experimental studies, etc.
Research based.
What is evidence based / informed policy?
Evidence based policy is the use of research methods. (a systematic, transparent access to and appraisal of evidence as an input into the policy making process.)
Evidenced informed policy: Recognizes the limits of evidence and the importance of other factors to guide policy. It allows for a broader choice of policy options, as there is a wider range of validated concepts and experiences.
What is knowledge translation? What are some examples?
Who is translating knowledge?
Knowledge translation is the exchange of information between produces/users (researches and policy makers).
For example, researchers could sit with decision makers and see what topics will come up, what studies/ research is needed?
Some examples are: policy briefs, evidence briefs for policy, issue briefs, evidence summaries, etc.
Knowledge brokers are translating knowledge. Some include: WHO, European Observatory on Health Systems & Policies, Swiss Learning Health System
What are some key features of a learning health system?
Learning health systems bridge evidence to action. The idea is to promote continuous dialogue between stakeholders and knowledge transfer.
Goal to provide evidence informed foundations for decision making and action recommendations.
Example: Swiss Learning Health Systems
