Applied Political Analysis for Health Policy Reform

Applied Political Analysis for Health Policy Reform By Michael R. Reich, PhD Professor of International Health Policy Harvard School of Public Health 677 Huntington Avenue Boston, MA 02115 Published in: Current Issues in Public Health 2:186-191, 1996

The demise of the Clinton health reform in 1994 vividly demonstrated, to observers around the world, that politics matters in health policy reform. The Clinton failure has been attributed primarily to political factors especially the mobilization of multiple interest groups against the plan, the secrecy and technocratic emphasis of the health reform team, and the lack of savvy strategic attention to political feasibility during the policy s design [1,2]. The Clinton reform provided a comprehensive analysis of problems in the nation s health system, but the solution was difficult to explain persuasively to the public or to politicians. The Clinton team failed to mobilize the reform s supporters into an effective coalition, but ironically succeeded in bringing together diverse groups into an extraordinarily powerful coalition of opponents. The experience with the Clinton plan shows that politics affects the definition of a policy problem [3] as well as the origins, formulation, acceptance, and implementation of public policy [4]. Political processes are particularly important in health policy reform, because the proposed changes seek to redistribute resources. Health policy reform often seeks to expand benefits for relatively powerless groups in society and promises to impose new costs on relatively powerful groups. The resulting political challenges are significant. In short, successful health reform requires astute political management, in developing countries as well [5]. Reformers must be able to assess the political feasibility of a policy, manage the processes of policy design and acceptance, and create strategies that improve the prospects of implementation. Applied political analysis provides rapid assessment procedures to probe the political dimensions of policymaking, in ways that enhance the quality of reform processes. But these methods are not well developed in public health. Health agencies tend to stress epidemiological and economic analysis, and they rarely use systematic political analysis in policy reform efforts. Schools of public health teach few courses on political management. The American Journal of Public Health includes special sections on law and ethics, history, and public health policy, but nothing specific to politics. Only one journal directly addresses health politics (the Journal of Health Policy, Politics and Law), and its articles tend to be more scholarly than applied. For developing countries, international agencies tend to disregard political analysis and focus on economic analysis, a pattern exemplified by the World Bank [6]. For example, the World Development Report 1993: Investing in Health, from the World Bank, contained seven chapters on how to improve the "efficiency" of health investments in developing countries, but provided only five paragraphs on the reform process and few specific ideas on how to manage the implementation of policy reform [7]. Similar problems have been noted with the Bank s analysis of the economic reforms adopted by former socialist countries [8]. This article introduces a method of applied political analysis, called PolicyMaker [9], and suggests how the method can assist in managing the politics of health policy reform. APPLIED POLITICAL ANALYSIS PolicyMaker is a Windows-based software program for Computer-Assisted Political Analysis (CAPA). The software can be applied to any policy problem that involves multiple Applied Political Analysis for Health Policy Reform 2

players with diverging interests; the software is not specific to health policy. PolicyMaker brings together three methods of applied political analysis. First, the software uses political mapping techniques to analyze the political actors in a policy environment. These techniques assess the power and position of key political actors, and then display the supporters, opponents, and non-mobilized players in a political map of the policy. This mapping provides the basis for designing strategies of political management. Political mapping techniques have been used by Lindenberg and Crosby for assessing development policy reforms, from the perspective of government policymakers [10], and by Austin for analyzing business-government relations in developing countries, from the perspective of private company managers [11]. PolicyMaker s computerized version of political mapping enhances the flexibility of this method for application to diverse policy environments. Second, the software incorporates techniques of political risk analysis, in order to provide a quantitative assessment of whether a policy is politically feasible. These methods have been used, for example, by multinational corporations to assess the stability of particular countries, as a factor in deciding on investment strategies [12,13]. In PolicyMaker, political risk analysis methods have been adapted to assess the feasibility of a particular policy, through an algorithm that is calculated in several basic forms and can be modified by the user. Third, PolicyMaker uses methods of organizational analysis and a rule-based decision system, in order to suggest strategies that can enhance a policy s feasibility. Organizational theorists stress the importance of selecting appropriate strategies to promote organizational change and overcome resistance [14]. These methods involve an assessment of the stakeholders and their relationships, and the opportunities and obstacles to change. The software includes 31 basic political strategies, which can be customized by users, to affect the power, position, and number of mobilized players and thereby change a policy s political feasibility. OBJECTIVES OF POLICYMAKER PolicyMaker has descriptive, explanatory, and prescriptive objectives. As a descriptive tool, PolicyMaker provides a method for collecting and organizing important political information about a policy. PolicyMaker serves as a database for assessments of: the policy s content, the major players, the power and policy positions of key players, the interests of different players, and the networks and coalitions that connect the players. The software also assists the user in identifying opportunities and obstacles to policy change. These kinds of political data are often well known to people involved in a policy debate, but the information is rarely collected and organized systematically. As an explanatory tool, PolicyMaker can help explain how a particular policy was decided in the past and which strategies were effective in a particular political environment. PolicyMaker incorporates political mapping and political risk analysis models to explain policy-making processes (based on an assessment of influence of supporters versus opponents, and the impacts of political strategies adopted by both sides). When used in this retrospective mode, PolicyMaker Applied Political Analysis for Health Policy Reform 3

serves as a practical method to help decision-makers learn from past experiences with real world policies. Finally, PolicyMaker can be used as a prescriptive tool to help design a set of political strategies, and assess the likely impacts of those strategies on policy formulation and implementation. The program can help improve the political feasibility of a particular policy, by identifying supporters and opponents, identifying potential supporters, and analyzing the effects of potential strategies. PolicyMaker suggests strategies for producing change, and helps analysts think systematically about future scenarios produced by specific strategies. In sum, the program is intended to help policymakers manage the processes of reform to improve the political skills of the reform team and enhance the political feasibility of policy reform. When used creatively, PolicyMaker can help promote strategic programming as well as strategic thinking [15]. FIVE STEPS OF ANALYSIS PolicyMaker guides the user through five analytical steps for assessing the political dimensions of policymaking (Figure 1). Step One Policy: The first step is to define the desired policy or decision, including major goals and mechanisms, and to propose an indicator to measure progress towards achieving each goal. Step Two Players: The second step is to identify the major players involved in the policy, including an evaluation of each player s position and power. This assessment resembles a stakeholder analysis. The data are then displayed in a Position Map, using political mapping techniques, to show the positions of players on a continuum from high support through to high opposition. The program presents the data in a Political Feasibility Graph, using an algorithm that calculates a feasibility index for the policy (based on the three variables of power, intensity of position, and number of mobilized groups). The user then assesses the policy s consequences for major players, identifies the main interests of each player, and evaluates linkages among players. Step Three Opportunities & Obstacles: The third step is to identify opportunities and obstacles to change, including transitions underway in the organization responsible for implementing the policy, in the general organizational environment, and in the broader political environment. Step Four Strategies: The program s fourth step provides a rule-based problem-solving system, using principles of artificial intelligence [16], to suggest strategies that can improve the policy s feasibility. This step employs data entered by the user and selects political strategies built into PolicyMaker. Strategies are then combined into alternative packages of strategies for action. Applied Political Analysis for Health Policy Reform 4

Step Five Impacts: The final step is to assess each strategy s likely impacts on the power and position of major players. This information is used to show the aggregate impacts of a strategy package on the policy s feasibility, and to compare alternative future scenarios. The program can also be used to track the implementation of strategies, and compare observed and anticipated impacts. APPLICATIONS OF POLICYMAKER This method of applied political analysis has been used in various health policy settings (Figure 2). Here, three instances of application to national health reform in developing countries are briefly described. In Zambia, the PolicyMaker method was used to assist in a consensus-building initiative on health sector reform. The method was applied by an analyst from the Harvard School of Public Health in collaboration with the Ministry of Health s Health Reform Implementation Team, with support from the World Health Organization. The method was used to analyze the players and the environment of health sector reform in Zambia, and to propose alternative strategies for introducing major reforms in the national health system, under the personal supervision of the Minister of Health, Dr. Katele Kalumba. In the Dominican Republic, the PolicyMaker method was applied in a team-building effort for the Health Reform Group, with support from the Inter-American Development Bank. The analysis identified a series of political and organizational obstacles to health sector reform in that country, and assisted in the development of a strategic plan for action. A research report based on the PolicyMaker analysis [17] suggested that the obstacles confronted in the Dominican Republic may be shared by other Latin American countries seeking to adopt health reform packages based on principles from the 1993 World Development Report. In Mexico, the method was used in an assessment of the political feasibility of a major reform of the national health system [18]. The political analysis was carried out in conjunction with a comprehensive examination of the epidemiological, economic, organizational, and financial factors that affect health system reform in Mexico. The analysis showed how health reform in Mexico depends on a broader transformation of state-society relations, and especially on the political management of two critical social groups: well-organized groups (such as organized labor) that have traditionally participated in the benefits of the Mexican state in exchange for political support, and marginalized groups (such as rural peasants) that have been historically excluded from those benefits but now play an increasingly important political role [18:72]. LESSONS FROM APPLICATIONS The experiences in applying PolicyMaker suggest a number of lessons about the politics of health reform processes in developing countries. Applied Political Analysis for Health Policy Reform 5

First, these applications confirm that health reform is a thoroughly political process. Reform proposals create an expectation that a significant redistribution of resources will occur in the health system, with new benefits for some groups and new costs for others. These groups typically seek to influence the reform process in ways that protect their interests. Second, because the reform process becomes a political process, the advocates of health reform can benefit from political analysis, in addition to technical analysis and ethical analysis. Reformers need political strategies to manage the interest groups, the bureaucracy, and the technocrats, and often in developing countries, to manage the international agencies. Third, health reform s success is often affected by ownership and leadership. Strong support by a current government can raise the chances of success, but can also create a dilemma, because subsequent governments are often reluctant to implement an inherited policy (especially if the ruling party changes). A core political challenge for reformers is to create constituencies and institutions that will promote continuing implementation by subsequent political leaders. Fourth, these examples illustrate the importance of political timing for the success of health reform. A policy reform initiated just after a strong electoral win often has good chances at success, because of ample political capital still unspent in the honeymoon period, while a reform conducted at the end of a government s time in office can confront significant obstacles, because of accumulated political debts and dwindling political capital. These experiences also show the strengths and limitations of PolicyMaker as a tool for applied political analysis. The applications demonstrate that PolicyMaker can serve different purposes: to help policy analysts assess political feasibility in a systematic manner; to assist in the design of strategies to improve the political feasibility of a policy; to assist in consensus-building efforts among diverse groups by helping policymakers understand the perspectives of other players; to provide a mechanism for team-building as the basis for introducing major policy changes; and to evaluate the relative feasibility of different policy options in a complex political environment. On the other hand, the applications show that political analysis involves risks and limitations, as with other forms of policy analysis (such as cost-benefit analysis and costeffectiveness analysis). First is the quality of the data. As with any analytical method, PolicyMaker is vulnerable to garbage-in, garbage-out. The quality of the analyst can affect the reliability of the data, analysis, and interpretation. This constraint is particularly important for applied political analysis, because this method involves subjective (but systematic) assessments of players, positions, and power, and speculation about the impacts of strategies. Political data often require judgment and interpretation, resulting in risks of bias from the values, interests and power of the analyst and the policymaker. Applied Political Analysis for Health Policy Reform 6

A second limitation is the analytical model contained in PolicyMaker. The software uses an algorithm to calculate an index of political feasibility, based on a formula that combines quantitative assessments of three factors (the power of players, the positions of players, and the number of mobilized players), as noted earlier. The feasibility algorithm can be modified in various ways to alter the model for assessing political feasibility. But this model (as with all models) is still limited by its assumptions and simplifications about how the world works. A third limitation is the fluid nature of policymaking. Sometimes, carrying out a PolicyMaker analysis can change what is being assessed. Applied political analysis can generate controversy, for example, if some participants see their interests threatened. If the analysis makes explicit the interests and agendas of organizations and individuals, then pressure may be directed against the analyst. On the other hand, the process of carrying out an analysis can put an issue on the political agenda and improve the chances of political feasibility. The role of the analyst, therefore, critically shapes the interaction between political analysis and the policymaking process. CONCLUSIONS Experiences with the PolicyMaker method demonstrate that this is a useful tool for managing the complex politics of health policy reform. The tool combines several forms of applied political analysis with computer techniques of rule-based decision assistance. The resulting method helps sort out the messy reality of policymaking, and assists the design of practical strategies to enhance a policy s political feasibility. At the same time, PolicyMaker is not foolproof. Each step requires careful consideration of potential bias in the data and the analysis. Policy analysts can reduce the risks of bias through ongoing consultation with decisionmakers and other players. Another way to lower these risks is to carry out PolicyMaker with a team of insiders (who are involved in the policymaking process) and outsiders (who are new to the policy problem), to combine local interpretation of the context with new ideas and external perspectives. Finally, this method of applied political analysis does not assess whether a policy is ethically sound or technically correct. Just as Computer-Aided Design (CAD) assists architects in the design of buildings, but does not tell an architect what kind of house to build, Computer- Assisted Political Analysis (CAPA) assists policy analysts in the design of policies, but does not tell an analyst what kind of policy is right. PolicyMaker is designed to help policymakers get what they want, which is not necessarily good from an ethical or a technical perspective. Managing the political dimensions should not substitute for assuring the ethical and technical bases of a policy. Applied Political Analysis for Health Policy Reform 7

ACKNOWLEDGMENT PolicyMaker has been developed with the financial assistance of the Edna McConnell Clark Foundation, the International Development Research Centre, the US Agency for International Development (the Data for Decision Making Project at the Harvard School of Public Health), and the Takemi Program in International Health at the Harvard School of Public Health. REFERENCES 1. Starr P: What happened to health care reform. American Prospect 1995, Winter:20-31. 2. Johnson H, Broder DS: The System: The American Way of Politics at the Breaking Point. Boston: Little, Brown and Company; 1996. 3. Rochefort DA, Cobb RW, eds: The Politics of Problem Definition: Shaping the Policy Agenda. Lawrence, KS: Kansas University Press; 1994. 4. Sabatier PA: Public policy: toward better theories of the policy process. In Political Science: Looking to the Future, Volume Two: Comparative Politics, Policy, and International Relations. Edited by Crotty E. Evanston, IL: Northwestern University Press; 1991:265-292. 5. Londoño JL: Managed competition in the tropics? Paper presented to the International Health Economics Association Inaugural Conference, Vancouver; May 1996. 6. Reich MR: The politics of health reform in developing countries: three cases of pharmaceutical policy. Health Pol 1995, 32:47-77. 7. World Bank: World Development Report 1993: Investing in Health. New York: Oxford University Press; 1993. 8. The Economist: Lessons of transition. June 29, 1996:81. 9. Reich MR, Cooper DM: PolicyMaker: Computer-Assisted Political Analysis. Software and Manual. Newton Centre, MA: PoliMap; 1996. 10. Lindenberg M, Crosby B: Managing Development: The Political Dimension. West Hartford, CT: Kumarian Press; 1981. 11. Austin JE: Managing in Developing Countries: Strategic Analysis and Operating Techniques. New York: Free Press; 1990:148-152. 12. Kobrin SJ: Managing Political Risk Assessment: Strategic Response to Environmental Change. Berkeley: University of California Press; 1982. Applied Political Analysis for Health Policy Reform 8

13. Coplin WD, O Leary MK: The 1983 Political Climate for International Business: A Forecast of Risk in 72 Countries. New York: Frost & Sullivan; 1982. 14. Kotter JP, Schlesinger LA: Choosing strategies for change. Harvard Business Review 1979, 57(2):106-114. 15. Mintzberg H: The Rise and Fall of Strategic Planning. New York: Free Press; 1994. 16. Winston PH: Artificial Intelligence. 3rd ed. Reading, MA: Addison-Wesley Publishing Co.; 1992. 17. Glassman AL: The Political Economy of Health Sector Reform in Latin America: WDR 1993 Generation Health Reform in the Dominican Republic. Masters Thesis submitted to the Department of Population and International Health. Boston: Harvard School of Public Health; 1996. 18. González Rossetti A, Soberón Acevedo G, Frenk Mora J, Reich MR, Martínez Valle A: La Dimensión Política en los Procesos de Reforma del Sistema de Salud. Mexico City: Fundación Mexicana para la Salud; 1995. SELECT BIBLIOGRAPHY Additional information about PolicyMaker can be obtained through the Internet (info@polimap.com) and on the World Wide Web (http://www.polimap.com). Applied Political Analysis for Health Policy Reform 9

Figure 1 Five Steps of PolicyMaker Analysis Policy: Step One Analyze the content of the policy, including goals and mechanisms. Players: Step Two Identify the key players and analyze positions, power, interests, and coalitions. Assess policy s current feasibility. Opportunities & Obstacles: Step Three Assess the opportunities & obstacles that affect the feasibility of the policy. Strategies: Step Four Design strategies to improve the policy s feasibility, by using expert advice provided in the program. Impacts: Step Five Estimate the impacts of strategies on positions, power, and number of players. Assess policy s future feasibility. Applied Political Analysis for Health Policy Reform 10

Figure 2 Examples of Applied Political Analysis Using the PolicyMaker Method Essential Health Interventions Project in Tanzania Reproductive Health Policy in Tanzania National Health Reform in Mexico, Dominican Republic, El Salvador, and Zambia Health of the City Program in Cambridge, Massachusetts School Children s Health Insurance in Egypt Sustainability of Expanded Program on Immunization in Ghana Partnership for Child Development in Ghana Tobacco Control Policy in Vietnam Comparative Study of National Drug Policies (Sri Lanka, India, Vietnam, Colombia, Thailand) Public Policy Lobbying Strategies by a Fortune 500 Company Applied Political Analysis for Health Policy Reform 11