Health policy in action by Top

Health Policy in Action From national to Global Empowerment

Tatchalerm Sudhipongpracha, Ph.D. Faculty of Public Health Thammasat University

Forward Nowadays, the view that health is determined only by biological factors is neither acceptable nor plausible, given what we know about the wider determinants of health. Our health is influenced equally, if not more, by the environmental, social, cultural, and political factors. The Rio Political Declaration on Social Determinants of Health is a global commitment that provides a broadly global context for this book. The declaration calls for intersectoral actions, public policies, and health services in order to reduce health inequity. The conception and creation of this book is a reflection of the policies and practices that address the social determinants of health from local to international levels. The aim of this book is to familiarize midlevel health professionals with the complexity and challenges of policy making. With the stream of knowledge in health policy and policy making, these health professionals are expected to play an instrumental role in ensuring that health considerations are high on the public policies and political agenda. A variety of teaching and learning methods are suggested throughout this book to allow students to learn from one another by sharing their work experiences and different perspectives on health. Each chapter is structured in such a way that concludes with its own set of group activity and wrap-up questions. These exercises can be transferred and applied across cultures, countries, and institutional contexts. This book was originally written for students enrolled in two graduate courses at the Faculty of Public Health, Thammasat University. The first course in which this book was first used in 2016 as a teaching note was GH604 Policy Development and Analysis in the Master of Public Health program in Global Health. Afterwards, more chapters and exercises were added to improve the structure and content of the book. The second version of the book is now used for both the GH604 course and PB641 Public Health Policy and Management in the Master of Public Health program in Health Service Management.

Tatchalerm Sudhipongpracha, M.P.A., Ph.D. Faculty of Public Health Thammasat University

Table of Contents CHAPTER 1 Problem Framing 1.1 1.2 1.3 1.4 1.5

INTRODUCTION LEVEL OF PROBLEM FRAMING PROBLEM IDENTIFICATION CONTEXTUALIZATION STRATEGIC FRAME ANALYSIS (SFA) 1.5.1 Use of Numbers 1.5.2 Messengers 1.5.3 Visuals 1.5.4 Metaphors and Simplifying Models GROUP ACTIVITY WRAP-UP QUESTIONS

2 2 4 6 7 8 9 10 11 13 14

CHAPTER 2 Essential Concepts in Health Policy Studies

2.1 2.2

16 16 18 18 18 19 19 21 22 23 23 23 24 25 26 28 28

1.6 1.7

2.3 2.4 2.5

2.6

2.7 2.8 2.9

INTRODUCTION CONCEPTS OF HEALTH 2.2.1 Biomedical model 2.2.2 Psychosocial model 2.2.3 Holistic model 2.2.4 Life-course approach to health POPULATION HEALTH INTERNATIONAL HEALTH AND GLOBAL HEALTH HEALTH POLICY AND HEALTHY PUBLIC POLICY 2.5.1 Health policy 2.5.2 Healthy public policy HEALTH IN ALL POLICIES (HiAPs) 2.6.1 Definition of HiAP 2.6.2 Approaches to population health management GLOBALIZATION AND ITS IMPACT ON POPULATION HEALTH GROUP ACTIVITY WRAP-UP QUESTIONS

Page ii

Table of Contents

CHAPTER 3 Health Policy Making

3.1 3.2 3.3

31 31 33 33 35 35 36 37 37 37 37 38 40

3.4

3.5 3.6

INTRODUCTION DEFINITION OF POLICY POLICY CATEGORIZATION 3.3.1 Policy classification by levels of implementation 3.3.2 Population-oriented classificatory framework POLICY MAKING CYCLE 3.4.1 Agenda setting 3.4.2 Policy formulation 3.4.3 Public policy decision making 3.4.4 Policy implementation 3.4.5 Policy evaluation GROUP ACTIVITY WRAP-UP QUESTIONS

CHAPTER 4 Agenda Setting in the Health Sector

4.1 4.2 4.3

43 43 44 44 45 46 47 49 50

4.4 4.5 4.6 4.7

INTRODUCTION DEFINITION OF POLICY AGENDA AGENDA SETTING MODELS 4.3.1 The Hall model 4.3.2 The Kingdon model POLICY WINDOW CHANGE AGENTS AND POLICY ENTREPRENEURS GROUP ACTIVITY WRAP-UP QUESTIONS

CHAPTER 5 Stakeholders and Policy Actors in Health

5.1 5.2 5.3

52 52 54 54 54 55

INTRODUCTION AN OVERVIEW OF STAKEHOLDER ANALYSIS (SA) HOW TO PERFORM STAKEHOLDER ANALYSIS (SA) 5.3.1 The first step: evaluating effective powers 5.3.2 The second step: categorizing stakeholders 5.3.3 The third step: scenario building

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Table of Contents

5.4

Page iii

GOVERNMENT ACTORS 5.4.1 Contribution of the bureaucracy 5.4.2 Expanding the boundary of the health sector 5.4.3 Future roles of government BUSINESS ACTORS NON-PROFIT ACTORS GLOBAL ACTORS GROUP ACTIVITY WRAP-UP QUESTIONS

56 57 58 59 59 60 62 63 64

CHAPTER 6 Public Health Leadership and Policy Execution

6.1 6.2

66 66 66 67 68 69 69 69 70 70 71

5.5 5.6 5.7 5.8 5.9

6.3 6.4 6.5

6.6 6.7

INTRODUCTION MODELS OF POLICY IMPLEMENTATION 6.2.1 Top-down model 6.2.2 Bottom-up model PRINCIPAL-AGENT THEORY “HiAP” LEADERSHIP CURRENT LEADERSHIP CHALLENGES IN THE HEALTH SECTOR 6.5.1 Limited political influence 6.5.2 Constrained resources and staff turnover 6.5.3 Working in vertical, fragmented units 6.5.4 Difficulty gathering and disseminating evidence 6.5.5 Politicization of the bureaucracy, corruption, and regulatory capture 6.5.6 Political commitment and discontinuity GROUP ACTIVITY WRAP-UP QUESTIONS

71 72 72 73

CHAPTER 7 Intersectoral Collaboration in Health

7.1 7.2

75 75 76 77 77 77

INTRODUCTION INTERSECTORAL COLLABORATION 7.2.1 Cabinet secretaries 7.2.2 Parliamentary committees 7.2.3 Inter-ministerial/inter-departmental committees 7.2.4 Joint Budgeting

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page iv

7.3

7.4 7.5

Table of Contents

7.2.5 Intersectoral policy making 7.2.6 Non-government stakeholder engagement WHOLE-OF-GOVERNMENT AND WHOLE-OF-SOCIETY APPROACHES 7.3.1 Civil society and HiAP 7.3.2 Principles of stakeholder engagement 7.3.3 Challenges of stakeholder engagement GROUP ACTIVITY WRAP-UP QUESTIONS

78 78 79 80 81 82 82 83

CHAPTER 8 Negotiation and Advocacy for Health

8.1 8.2 8.3 8.4

85 85 86 88 88 88 88 89 89 90 90 90 90 91 92 92 93 94 94 95 95

8.5

8.6

INTRODUCTION BASIS OF POLICY NEGOTIATION APPROACHES TO POLICY NEGOTIATION STAGES OF THE NEGOTIATION PROCESS 8.4.1 Understanding a problem raised in agenda setting 8.4.2 Identify stakeholders and their interests 8.4.3 Consult with stakeholders 8.4.4 Establish negotiation agenda 8.4.5 Develop positions and strategies 8.4.6 Negotiate with stakeholders 8.4.7 Assess proposed agreement GROUP ACTIVITY 8.5.1 Assignment detail 8.5.2 Debate procedures 8.5.3 Moderated Vs. unmoderated caucus 8.5.4 Working paper 8.5.5 Draft resolution 8.5.6 Final resolution 8.5.7 Closing the debate 8.5.8 Voting procedure WRAP-UP QUESTIONS

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Table of Contents

Page v

CHAPTER 9 Monitoring and evaluation (M&E) 9.1 9.2 9.3

9.4

9.5 9.6

INTRODUCTION DEFINITION OF M&E AND CYCLE OF HEALTH MONITORING HEALTH IMPACT ASSESSMENT (HIA) 9.3.1 Definition and purpose of HIA 9.3.2 HIA Procedure HEALTH LENS ANALYSIS (HLA) 9.4.1 Definition and purpose of HLA 9.4.2 HLA Procedure GROUP ACTIVITY WRAP-UP QUESTIONS

97 98 99 100 101 101 101 102 102 104

References

106

APPENDIX A APPENDIX B APPENDIX C APPENDIX D

116 129 141 158

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Figures Figure 1. Level of Problem Framing ............................................................................. 3 Figure 2. “The Yes Man” by Jacques Servin and Igor Vamos. ........................... 13 Figure 3. Organizational Classification of Policies ............................................... 34 Figure 4. Kingdon Agenda Setting Model ................................................................. 46 Figure 5. Category of Stakeholders Based on Their Effective Powers ......... 55 Figure 6. Degree of Collaboration................................................................................ 76 Figure 7. The Scope of Negotiation for Health ....................................................... 86 Figure 8. Four Main Approaches to Policy Negotiation ..................................... 87 Figure 9. Results Chain Analysis .................................................................................. 97 Figure 10. Stages of the Cycle of Health Monitoring ........................................... 98 Figure 11. “Sustainable Development in Brazil” ................................................ 103

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Tables Table 1. Selected Classificatory Frameworks of Policy Cycle Stages............. 36 Table 2. Modifiable Risk Factors for CVD, Cancer, Type II Diabetes, and Chronic Lung Disease .............................................................................. 39 Table 3. Organization-based Policies and Programs ............................................ 40 Table 4. Population-oriented Policies and Programs .......................................... 40 Table 5. Mechanisms of Intersectoral Collaboration............................................ 79

CHAPTER 1 Problem Framing Topics and Concepts Problem framing Problem identification Contextualization Strategic Frame Analysis (SFA) framework

Learning Objectives Understand the importance of problem framing Explain different levels of problem framing and why some social issues attract the public attention, while others do not Describe the basic elements of the Strategic Frame Analysis (SFA) Use the Strategic Frame Analysis (SFA) framework to critically appraise complex social issues

Teaching and Learning Techniques Problem-based learning Summarizing lecture Group discussion

Materials and Equipment PowerPoint file for presentation Video clip “The Yes Men” (Available on YouTube.com) Flipcharts and markers

Additional Learning Resource Bacchi, C. (2009). Analyzing Policy: What’s the Problem Represented to Be? Australia: Pearson. (Chapter 1). National Academies of Sciences, Engineering, and Medicine. (2016). Why Frames Matter? Framing the Dialogue on Race and Ethnicity to Advance Health Equity: Proceedings of a Workshop (pp. 37-44). Washington, DC.: The National Academies Press.

Page 2

Chapter 1

1.1 INTRODUCTION Frames are powerful not only because we have internalized them from media, but because they have become second nature to us – they allow us to process information efficiently and get about our lives. The limited number of frames we use allows us to understand new information in terms of stories we already know. Deborah Tannen (1999, p. 4) argues: “People approach the world not as naïve, blank-slate receptacles who take in stimuli …in some independent and objective way, but rather as experienced and sophisticated veterans of perception who have stored their prior experiences as an organized mass. This prior experience then takes the form of expectations about the world, and in the vast majority of cases, the world, being a systematic place, confirms these expectations, saving the individual the trouble of figuring things out anew all the time.” In this way, the challenge of communications becomes reframing— providing a different lens for the processing of new information. By identifying and empowering rival frames in our communications, we can signal to the public how to think about a given social issue. But, how do we choose between competing frames? How do we know which ones will set up the policy outcomes we wish to promote? Making that decision requires a base of research that probes beneath visible public opinion to determine why people think the way they do. This research must help us choose wisely between competing options on the basis of empirical evidence. Only in this way can health advocates feel secure that their individual communications tactics are enhancing the larger goal of advancing policy attitudes and solutions (Cockburn et al., 2005; Siyanbola et al., 2016; Von Thiele Schwarz, 2016).

1.2 LEVEL OF PROBLEM FRAMING Problem frames are only possible because ideas and issues come in hierarchies. The cognitive sciences teach us that these hierarchies, or levels of thought, track and direct our thinking. Higher-level frames act as primes for lower-level frames, and higher-level frames map their values and reasoning onto the lower-level frames.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 3

Figure 1. Level of Problem Framing

In the end, problem framing helps us answer the following questions: o How does the public think about a particular issue? o What frames are available to them from media, science and advocates’ own communications? o What are the consequences of these current frames on public reasoning and policy attitudes? o How can this issue be reframed to evoke a different way of thinking, one that reveals alternative policy choices? o What are the larger values within which this issue should be framed? By appealing to higher-level values to reframe, we can signal to people how to think about various social issues. And by testing the ability of certain Level 3 frames to lift policy preferences on those issues, we can be sure that we are moving people toward consideration of solutions. Strategic frame analysis adopts the position, now current in several academic disciplines, that people reason on the basis of deeply held moral values, more than on the basis of self-interest or “pocket-book” appeals (Mutz & Soss, 1997). When we approach people as citizens, parents and stewards of the earth, we tap into powerful models that guide their thinking about themselves and their political responsibilities. We do this not by playing “identity politics” or forcing people to identify themselves as “environmentalists” or “child advocates,” but rather by reminding them of

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 4

Chapter 1

the widely shared Level Three values they already incorporate into their thinking about how to make important choices for the world. At issue are words and concepts like “responsibility,” “choice,” “dependence,” “protection,” and “stewardship.” Adopting the perspective of strategic frame analysis means understanding that communications is storytelling, but that the stories we tell must have all the elements in place: frames, messengers, evidence, cause and effect. We must tell a story that is about politics, in the sense that it is about the values that drive us to communal action. We must tell a story that invites people into the solution, by demonstrating that solutions exist. Therefore, strategic frame analysis is a key building block in the policymaking process and every activity that you undertake in pursuit of policy making. Used effectively, strategic frame analysis can become the foundation upon which your organization builds its policy-advocacy strategy.

1.3 PROBLEM IDENTIFICATION At the problem identification/policy formation stage, more than at any other stages, that framing becomes critical. The first step involves getting a problem onto the radar screen of the legislative body that must deal with that issue (Clemons & McBeth, 2001). Problems gain legislative attention in many ways, but typically gaining agenda status happens once there has been a value-driven, subjective determination that an issue is now a “public problem.” The question then becomes: Why do some issues become public problems reaching agenda status and others do not? The answer has to do with frame construction in the sense that an issue must be constructed so that it is perceived as qualifying as a social problem (Best, 1995). This is a key objective in getting the attention of the legislative body in charge. This assertion is derived from the notion that issues get attention when they are labeled as social or public problems (Best, 1995). How an issue becomes labeled as a social problem is not based entirely on objective measures of the severity of the condition, but rather on a host of factors related to how society perceives or constructs the information presented regarding the issue (Best, 1995). Accordingly, Strategic Frame Analysis (SFA) is applied to help determine the organizing constructs or values that may be used to frame an issue in order to make it

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 5

known as a social problem that then captures the minds and concerns of the public and its elected officials. First, a few ideas on why a social condition is not automatically considered a social problem and why it must be considered as one before it can become a legislative priority. Best (1995) asserts that until something is labeled a “social problem” it does not rise to a level of importance sufficient to attract the attention of the public and policymakers. His view is called the subjective, constructionist perspective because it says a social condition is a product of something defined or constructed by society through social activities (Best, 1995). For example, when a news conference is held on crack houses or a demonstration on litter, or investigative reporters publish stories, or when advocacy groups publish a report, they are constructing or framing the issue using claims that help build the issue into a social problem. Spector and Kitsuse (1977) use the term “claims making” to define the activities of individuals or groups making assertions of grievances and claims with respect to some putative conditions that result in social problems. According to all of these definitions, it does not matter if the objective condition exists or even if it may be severe. It only matters that people make claims about it in a way that invokes a subjective mental construct that will frame the issue as a public problem of magnitude worthy of attention. In other words, social problems are the result of claims-making that frames the issue in a way that triggers organizing principles attached to an individual’s deeply held worldviews and values (Best, 1995). Claims-making draws attention to social conditions and shapes our sense of the nature of the problem (Best, 1995). Through rhetoric, every social condition can be constructed as many different social problems. A claims-makers' success [or framing] depends in part upon whether the claims persuade others that X is a social problem or that Y offers the solution (Best, 1995). In the area of public health, the construction of a problem explicates embedded values and ideals of those who “made” the health problem in the first place (Guttman, 2000). The results of that construction further determine whether the problem gets on the agenda, as well as the range of policy solutions that appear natural or appropriate. For instance, using claims that frame the problem at the organizational level assumes a major

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 6

Chapter 1

cause of the problem is based in organizational arrangements or practices (Guttman, 2000). The problem of an overweight America is defined as people’s lack of time or facilities at work to exercise, or an absence of food at work that is high in nutritional value (Guttman, 2002). Identifying the problem of overweight adults at this marketplace level may involve a frame that links the problem to industry’s quest for profits through the marketing of inexpensive food products high in calories instead of nutritious products that are more expensive and thus made less accessible (Guttman, 2002). In this instance, the description of the problem involves a frame including claims that value the public good over market autonomy. In order to evaluate the relative merits of different frames applied to the social problems we wish to take into the policy process, we need to ask the following kinds of questions: Would such a frame make this problem a public issue that gets the attention of a legislature? In the instance above, involving the problem of obesity, we would ask: If the issue is framed in this way, would the legislature then consider marketplace restrictions on advertising or regulations on food content?

1.4 CONTEXTUALIZATION Context is one of the most difficult elements of the frame to describe, and one of the most important to get right (Gilliam & Bales, 2001). Context provides more than details about individuals; it focuses on issues and trends that are common to groups. And to identify trends requires systemslevel thinking. This means that you must be strategic in identifying the problem you want to communicate as one that involves the entire community. The way you identify the problem makes all the difference in how people are able to view your solutions. When people understand issues as individual problems, they may feel critical or compassionate, but they will not see policies and programs as the solutions. For example, the dominant frame for children’s issues is a needy child and a parent, and this two-person frame sets up the idea that the parent, and the parent alone, is responsible for the child’s needs. However, if you provide context and broaden the frame to include other parents, the community, business leaders, and the mayor, you define the problem as public in nature and expand the possibilities for meeting children’s needs. In other words, putting policy issues into the contextual frame requires systems-level thinking, which gives us more options in defining the problem and in

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 7

creating appropriate solutions. Without systems thinking, we are forced into narrow solutions: “Fix the parents in order to fix the kids” (Gilliam & Bales, 2001). Context is one of the missing ingredients that distinguish episodic from thematic reporting—important distinctions for community development advocates. Iyengar (1991) explains that “the essential difference between episodic and thematic framing is that episodic framing depicts concrete events that illustrate issues, while thematic framing presents collective or general evidence.” Episodic reporting is heavily reliant on case studies, human interests, and event-oriented reporting, and depicts public issues as the plight of an individual. By contrast, thematic framing places the individual incident within long-term or national trends. It explores causes and effects, and explains, rather than dramatizes.

1.5 STRATEGIC FRAME ANALYSIS (SFA) Strategic Frame Analysis (SFA) incorporates key concepts from the cognitive and social sciences that govern how people process information, especially news, with special emphasis on social problems, from adolescent development and child care to low-wage work and violence prevention (Gilliam & Bales, 2002). Context defines an issue as “public” in nature, and therefore appropriately solved in the realm of policy (Gamson, 1992). To use context effectively, the following steps are necessary: o Link current data and messages to long-term trends. o Tell the public what is at stake and what it means to neglect this problem. o Define the problem so that community influences and opportunities are apparent – connect the dots, both verbally and in illustrations. o Focus on how well the community/state is doing in addressing this problem, not on how well individuals are addressing it. o Connect the episodes of your community’s issues to root causes, conditions, and trends with which people are familiar. o Present a solution.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 8

Chapter 1

1.5.1 Use of Numbers An important finding from the cognitive sciences is the ability of the frame to overpower the numbers that follow. In other words, if the facts do not fit the frame, it is the facts that are rejected, not the frame. Confronted with facts that one might presume would cause the group to reconsider its position, people opt instead to adhere to their original position and to ignore the conflicting data. As many have come to realize, both numbers and narratives evoke frames (Shannah et al., 2011). The trick is how to combine them so that they work together to evoke a frame of collective responsibility and public policy. Here are some simple suggestions for integrating narrative and numbers: o Do not provide numbers without telling what they mean. While scientists concerned with objectivity may feel it important to put the numbers out there and let the facts fall where they may, they are setting the stage for public misunderstanding by those who do not hold back from interpretation. o Provide the interpretation first, then the data. That way, your numbers connect to an idea. By raising the broader principle first, you allow people to hear your numbers as evidence, not as raw data. It is imperative that those who seek to engage and educate the public find ways to help people imagine the reality the numbers represent, so that they can appropriately assess what is at stake. Health-related Examples of How to Use Numbers Effectively 1. The correlation between violent media and aggression is larger than the effect that wearing a condom has on decreasing the risk of HIV, larger than the correlation between exposure to lead and decreased IQ levels in kids, larger than the effects of exposure to asbestos, larger than the effect of secondhand smoke on cancer. 2. Surgeon General David makes the link between medicine and dentistry and implies that dental care is just as important as medical care. There are 100 million people in this county without access to fluoridated water and over 100 million people in this country without dental health insurance. For every child who is uninsured for medical care, there are two to three children who are uninsured for dental care.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 9

1.5.2 Messengers Choice of messenger is one of the most important tactical choices to be made before taking an issue public. Messengers are the people who become the physical symbol of the issue —they sign op-eds, appear at news conferences and before civic groups, speak on TV and radio talk shows, and testify at hearings. They answer the question, “who says this is a problem I should pay attention to?” Messages can be reinforced or undermined by their attachment to a spokesperson. Skill is required in matching the message to the messenger, and in anticipating the impact of particular messengers on public thinking (Shannah et al., 2011). The problem inherent in the choice of messenger is that, without a careful appraisal of the match of messenger and message, you are likely to reinforce one of these negative roles for the public, inadvertently allowing the public or critics to dismiss their testimony. In our research on global warming, for example, environmentalists were less credible than those who were not perceived as having a vested interest, or suspected of being “extreme” on environmental issues. On children’s oral health, dentists were deemed less objective than pediatricians or school nurses. Does this mean that environmentalists and dentists should quit advocacy? No, but the choice of the spokesperson for the issue, should be made tactically, taking into account the way the public is likely to read the combination of the message and the messenger. Then, how should they weigh in on the issue? They can wield their professional authority in support of the out-front spokesperson. Health-related Examples of How to Use Messengers Effectively 1. In Texas, the local public-health officers sought to influence the allocation of resources in the legislature to obtain additional dollars for public health. That year all of the speakers at legislative hearings were directors of local and county public-health departments. Later, many legislators said that the testimony did not help persuade them because these individuals were seen as having a vested interest in obtaining more money for their departments instead of as representing the public-health needs of their jurisdictions. While listening to the testimony and thinking about it later, the legislators could not hear the truth of the words because the messengers were discounted.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 10

Chapter 1

2. Because dentists are perceived as too vested in dentistry to be objective about the issue of children’s oral health, other messengers needed to be identified. In the “Watch Your Mouth” campaign, pediatricians and school nurses were used effectively as the advocates for better oral-health policies. In both cases, these messengers brought important framing connections associated with their professions. Pediatricians helped emphasize that oral health is part of overall health, a problem identified in the communications research. And school nurses took the issue into the schools, connecting health to achievement and, further, to the locus of public responsibility for children. Both messengers were unexpected, knowledgeable, trustworthy, and furthered additional framing goals.

1.5.3 Visuals We have been concentrating on words and how they trigger models and frames. But, do not underestimate the power of visuals (Gamson, 1992). After all, it has been said, “a picture is worth a thousand words.” Pictures trigger the same mental models and frames as words. It is important to be aware of this, so that the frames introduced by the pictures do not work against the frames introduced by the words. Advocates often say that they cannot control the pictures at news conferences, but to some extent they can—in the way they stage the news conference and in what they suggest to the media as the visuals to accompany the story. Furthermore, advocates produce many other vehicles – such as Websites, advertising, brochures, fact sheets, action alerts and reports – in which they can control all the visual elements—and therefore the messages they send. What are the factors to consider when planning a visual, whether it is a film clip, photograph, illustration, or graphic (including maps and charts)? First, it is important to anticipate the visuals or symbols that will be applied to your issue if you do nothing to control them. More than likely, these will be generic images and will trigger frames that are traditionally associated with that issue. These stock images can reinforce stereotypes, emphasize dramatic episodes and details to the detriment of context and trends, exclude solutions and disperse accountability. Second, recognize that choosing the “right” visual is only the first step. Even image placement can reinforce or undermine your message. When you orchestrate a series of dire-problem pictures and leave the

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 11

solutions photos to the end, you promote a frame of despair or intractability, regardless of what your word frames attempt to convey. Location, size, and color can all affect the impact of your visuals. Images seem more important when they are centered, in the foreground, brightly colored, sharply defined, or overlapping with other elements. Human figures, cultural symbols or icons also signify importance. Consider the layout of your document as a whole, or the sequencing of your photos on Websites and in film and video. Health-related Examples of How to Use Visuals Effectively When the illustration for children’s oral health is a parent and child, or a dentist and a child, community-wide and policy efforts to improve oral health are hard to visualize. Perhaps the cleverest use of visuals to advance children’s oral health comes from the Sierra Health Foundation’s news conference to call attention to the Surgeon General’s Report on Oral Health. The foundation supplied new B-roll (background footage) to local news stations that featured drinking water coming out of the tap and showed pie charts of trends in fluoridation across California counties. Another strategic decision made by the foundation was its choice of location for the news conference: the State Capitol. Even though no legislation was pending, the reporter delivered the news with the Capitol as backdrop, reinforcing the notion that the issue under discussion was authentically a public responsibility.

1.5.4 Metaphors and Simplifying Models According to researchers associated with Cultural Logic, numerous studies in the cognitive sciences have established that both the development and the learning of complex, abstract or technical concepts typically rely on analogies. Aubrun and Grady (2000, p.23) points out that: “An explanation that reduces a complex problem to a simple, concrete analogy or metaphor contributes to understanding by helping people organize information into a clear picture in their heads, including facts and ideas previously learned but not organized in a coherent way.”

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 12

Chapter 1

Once this analogical picture has been formed, it becomes the basis for new reasoning about the topic. Better understanding also leads to an increase in engagement and motivation. Lakoff (1987, p. 33) introduces the notion that frames derive from a vast conceptual system whose unit is metaphor: “Metaphors as linguistic expressions are possible precisely because there are metaphors in a person’s conceptual system.” The systematism of this vast conceptual framework allows individuals to understand new information in the context of what they already know to be familiar, and to reject information that does not fit. “Metaphors may create social realities for us,” according to Lakoff and Johnson (1979, p. 10). “A metaphor may thus be a guide for future action. Indeed, their very purpose is to connect random information to myths, ideologies and stereotypes that allow the individual to process and store the new with the old. In this sense, frames reinforce worldview (Lakoff, 1996, p. 374). The metaphors chosen to describe the issue drive public reaction and reasoning. For example, the “horse race” metaphor applied to political elections has been shown to reduce attention to specific issues in favor of character, strategy and poll results. Because every word that we speak, and every image that we produce, is linked in different ways to many frames and models (words and images in fact trigger the models), language and imagery will always manipulate. That is unavoidable. However, by bringing a level of analysis to these metaphors and models, advocates will be less likely to be caught by correspondences or conclusions that are evoked by the language and imagery we or someone else use, but that in fact work against the policies or positions we are advocating (Aubrun & Grady, 2000) Simplifying models are a kind of metaphorical frame that both capture the essence of a scientific concept, and have a high capacity for spreading through a population. Teaching with analogies is a familiar strategy in educational contexts. Common examples of analogies that serve to teach basic science concepts include “the heart is a pump,” “the eye is a camera,” “the cell is a factory,” “the kidney is a waste filter,” “photosynthesis is like baking bread,” “an electric circuit is like water circuit,” and “the brain is a computer.” Both metaphors and simplifying models help us understand a problem and its associate solutions by giving us a simple way of understanding how something works (Ansolabehere & Iyengar, 1995; Bales, 1998).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Problem Framing and Policy Context

Page 13

1.6 GROUP ACTIVITY The purpose of this video clip is to expose students to the complexity of social issues confronting our globalizing world. Different people may have different perspectives of what these issues are all about, how to analyze them, and their solutions. Figure 2. â&#x20AC;&#x153;The Yes Manâ&#x20AC;? by Jacques Servin and Igor Vamos. (URL: https://youtu.be/hmuF3SJhWI4)

Suggested activities: o Prior to a lecture on the strategic frame analysis, students should be asked to develop a list of health and non-health issues based on the video clip. Instructor can begin this exercise by dividing students into two groups. The first group should be assigned to list all the non-health issues from the video clip. The second group is responsible for identifying the health-related issues. Each group will be given 10-15 minutes to finalize their lists. After students present their issue lists, instructor should ask how the health and non-health issues are related.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 14

Chapter 1

o After the lecture, instructor can ask students to choose one global health issue from the video clip and frame their chosen issue using the strategic frame analysis framework. Students should first formulate their argument about their chosen issue, specify the context in which their chosen topic arises, and prepare their problem statement to demonstrate how important the chosen global health issue is by using numbers, identifying potential messengers, suggesting visual aids, and developing metaphors or a simplifying model to emphasize the issue.

1.7 WRAP-UP QUESTIONS o What does problem framing mean? Why are problem frames necessary for an understanding of social issues, particularly health-related issues at the local, national, and global levels? o What are the three levels of problem framing? What is the relationship among these levels of problem framing? o Why do we need to identify and explain the contextual background of a policy issue before proceeding to the next step of problem framing? o Describe the basic elements of the Strategic Framing Analysis (SFA) framework. Provide a short example of how SFA can be used in the health sector context.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

CHAPTER 2 Essential Concepts in Health Policy Studies Topics and Concepts Health, population health, international health, global health Health policy and healthy public policy The “Health in All Policies” (HiAPs) approach to health

Learning Objectives Explain the essential concepts in health policy studies Distinguish between health policy and healthy public policy Understand the “Health in All Policies” (HiAPs) approach to health and development Understand how globalization affects health, well-being, and health equities at the local, national, and global levels

Teaching and Learning Techniques Lecture Class dialogue Group discussion

Materials and Equipment PowerPoint file for presentation Flipcharts and markers

Additional Learning Resource Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. (Chapter 1). National Association of County & City Health Officials (NACCHO). (2014). Exploring the Roots of Health Inequity: Essays for Reflection. NACCHO. (Essay 2).

Page 16

Chapter 2

2.1 INTRODUCTION Expressions—such as public policy, the social determinants of health, and health—are common in the contemporary public health discourse. We frequently use these expressions without thinking about what they mean, much less about how they have risen in importance and what the consequences of their use (s) might be for the way (s) in which public health services are discussed and implemented. For instance, when discussing the social determinants of health, some people might think about a specific set of determinants (e.g., gender, income, education), while others might think about the processes that determine the distribution of health outcomes in a population. This chapter will take the meanings of commonly used expressions in the “Health in All Policies (HiAPs)” literature and attempt to demonstrate how they are used within the public health discourse. As a prelude to the fundamental concepts in health studies, this chapter assumes no prior knowledge in public health and hence, has been designed to accommodate students from the non-health sectors. These students are expected to understand and explain the essential concepts in health policy studies (i.e., public health, population health, international health, and global health). For students with a public health background, this chapter will help them distinguish between “health policy” and “healthy public policy.” Furthermore, they are expected to understand and explain how the process of globalization influences population health outcomes and health inequities at the local, national, and global levels.

2.2 CONCEPTS OF HEALTH There is a wide range of ideas associated with health and well-being, such as illnesses and medical treatment, hospital and medical staff, underprivileged children and the elderly, food and exercise, and environmental degradation. Health has many dimensions and is important to individuals and society. In the section, different concepts in health policy studies are defined and explained. Health and well-being are defined in myriad ways as articulated in different international agreements. Consider the following examples:

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 17

o World Health Organization Constitution (1946) “…Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity….the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition…Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures…” o United Nations Universal Declaration of Human Rights (1948) “……Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care, and necessary social services; and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control…” o International Covenant on Economic, Social and Cultural Rights (1966) “…The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: The provision for the reduction of the stillbirth rate and of infant mortality, and for the healthy development of the child; The improvement of all aspects of environmental and industrial hygiene; The prevention, treatment, and control of epidemic, endemic, occupational and other diseases; The creation of conditions which would assure to all medical service and medical attention in the event of sickness…” o Ottawa Charter (1986) “The fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. Improvement in health requires a secure foundation in these basic

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 18

Chapter 2

prerequisites…Good health is a major resource for social, economic, and personal development, and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioral, and biological factors can all favor health or be harmful to it…” An understanding of health is the foundation of all the health policy studies. Health is not perceived the same way by every professional group, such as biomedical scientists, social scientists, public health administrators, and ecologists. The lack of consensus on what health is leads to a variety of definitions of health.

2.2.1 Biomedical model This model defines “health” as an absence of the diseases. If someone is free from diseases, that person would be considered healthy. Traditionally, this concept of health is based on the “germ theory of the disease.” This theory views the human body as a machine, and diseases are an outcome of the breakdown of the machine (Bjorklund et al., 2006). To make an unhealthy person health, health professionals’ task is to repair the machine (Frey et al., 2013). In this conceptual model, limited attention is placed on the environmental, social, and cultural determinants of health. However, development of medical and social sciences has led to the conclusion that the biomedical concept of health is inadequate (Bjorklund et al., 2006).

2.2.2 Psychosocial model Development in the social scientific field reveals that health is not confined to a biomedical phenomenon (Johasson et al., 2009). Rather, health is influenced by social, psychological, cultural, economic, and political factors. Based on these so-called “psychosocial” factors, health has both biological and social dimensions.

2.2.3 Holistic model Recognizing the importance of social, economic, political, and environmental factors, the holistic concept of health combines both biomedical and psychosocial concept (Engel, 2009). This model is also known as the multidimensional concept of health, focusing on a person’s quality of life as a whole. To achieve this, emphasis of the holistic model is

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 19

on health promotion and prevention. All social sectors beyond the health sector must be mobilized to promote health (Lee, 2012).

2.2.4 Life-course approach to health A life course perspective on health reflects an underlying developmental trajectory determined by age (Hertzman & Power, 2006). Based on this perspective, health is multidimensional, encompassing biological, psychological, behavioral, and social dimensions. Thus, the lifecourse approach examines health by linking development trajectories to the multidimensional context in which health is embedded (Kuh & Hardy, 2002).

2.3 POPULATION HEALTH Population health refers to “the distribution of health outcomes within a population, the health determinants that influence the distribution, as well as the policies and interventions that impact those determinants” (Kindig, 2007, p. 139). Along this line of thinking, population health management programs are “designed to preserve wellness and minimize the physical and financial impact of illness” over the life course of population (Nash, 2012, p.1). By this definition, this population-based approach is different from clinical management since it requires considerably more knowledge and citizen engagement. Population health consists of three key components: determinants, outcomes, and policies (Nash et al., 2011). Health determinants are factors affecting individual and population-level health, ranging from the social and economic context to the physical environment and individual behaviors. Interaction and disparity in these determinants lead to health outcomes that can be improved with policies designed for health maintenance, disease prevention, and health risk management (Lavis et al., 2002). As such, the goal of population health management is to intervene in people’s life as early as possible to prevent illness, disability, and premature death (Berkman & Kawach, 2000). In a time of tightening resources and complex health challenges, population health management— though not a new concept—is quickly gaining popularity worldwide. There are two approaches of population health management: (1) defined population health management and (2) geographic population health management (Joshi et al., 2016). The first approach focuses the

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 20

Chapter 2

provision of medical services to a specific or defined population (Berwick et al., 2008). Major actors in this approach are healthcare providers who must be proficient in clinical skills and healthcare management. Alternatively, the second approach addresses population health needs beyond the traditional healthcare system. Based on this approach, diverse stakeholdersâ&#x20AC;&#x201D;including ordinary citizens, community leaders, government officials, and business ownersâ&#x20AC;&#x201D;are involved in influencing the social, political, and economic determinants of health. These two approaches require different sets of strategic actions. To enhance the health of a defined population, health professionals must possess skills in epidemiological analysis, biostatistics, and service coordination. Epidemiology and biostatistics allow health professionals and authorities to effectively identify and assist vulnerable populations with the most significant health disparities (Mulvaney-Day et al., 2007). Further, care coordination across multiple settings (i.e., acute, long term, and emergency) is essential for effective treatment of high-need, high-cost patients (Powers & Chaguturu, 2015). On the other hand, policy changes beyond clinical care delivery are necessary for overall improvements in geographic population health (Elbel et al., 2013). As such, health professionals need sufficient knowledge in social policy and development, as well as non-technical skills, such as network building and management, communication, leadership, and advocacy (Butterfoss & Kegler, 2012). Policy interventions related to geographic population health can be categorized into three levels of preventive behavior (Turnock, 2001);

o Primary preventive intervention seeks to limit new cases of a disease or an injury by reducing exposure of causative risk factors. This level of health intervention is holistic and typically not disease specific (Katz & Hofer, 1994). Examples include the addition of bicycle paths to promote physical activity among local residents and tobacco cessation program;

o Secondary preventive intervention seeks to identify and treat asymptomatic persons in the early stages before clinical signs and symptoms develop. Screenings, such as mammography, colorectal, blood sugar, blood pressure, and vision, are the quintessential activities of secondary prevention (Turnock, 2001); and

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 21

o Tertiary preventive intervention includes approaches that minimize negative effects of a disease or an injury. In doing so, disability can be prevented by restoring a person’s health to an optimal level of functioning (Katz & Hofer, 1994). Emergency and rehabilitative services are the main activities of tertiary intervention. Each level of intervention targets different risk factors and involves a diverse set of actors, ranging from specialist care providers, public health officials, to community organizations (Turnock, 2001). While some interventions distinctly fall under the purview of one entity, there are areas of overlap. Thus, effective population health management necessitates active collaboration among actors and agencies throughout the health system and society.

2.4 INTERNATIONAL HEALTH AND GLOBAL HEALTH Interests in the impacts of globalization on public health lead to the creation of the term “global health,” which is distinct from “international health”, although the distinction is not always made sufficiently clear.

o International Health. Health matters that concern two or more countries, often referred to within the development community as health matters relevant to the developing world. Although all sorts of public and private sectors may be involved, it is the primacy of the state-defined actors that distinguishes international health (Lee et al., 2002). Examples of international health policy is protection of state territories against external threats, quarantine systems (threat of disease outbreaks), and food safety regulations (threat of food-borne diseases).

o Global Health. International health becomes global health, when causes or consequences of a health issue go beyond territorial boundaries of states, and thus beyond the capacity of states to address the issues effectively alone. Global health is also concerned with factors that contribute to changes in the states’ capacity to deal with determinants of health, such as a global economic crisis (Lee et al., 2002; Connolly, 2007).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 22

Chapter 2

For example, illegal drug trade is conducted in a highly clandestine way, using global transportation, communications, and financial banking to directly challenge law enforcement authorities worldwide. Global climate change is another example of a health issue that transcends state boundaries and directly challenges the capacity of individual states to address its causes and consequences. Transnational activities (i.e. foreign exchange or Internet) have become de-territorialized in the sense that geographical location matters little. In public health, this de-territorialized nature of human activities is impacting both health determinants and effects (i.e., population health status). Globalization of economic, political, social, cultural, ecological, and technological systems needs to be considered as the broader determinants of public health. The impact of these processes of change leads to new patterns of population health and diseases that do not necessarily conform to, or are revealed by, national boundaries alone. These shifts in the geography of health determinants and health status, along with other geographies have called into question traditional ways in which we categorize health needs. Global health issues are those that are not confined to a specific country or groups of countries. This suggests that the ways in which we conceptualize the geographical boundaries of the world, as well as health-related issues, need to adapt to transjurisdictional processes. This does not mean that we should ignore the inequities in impact experienced within and across population groups. While global health, by definition, makes all individuals and groups potentially vulnerable given their transjurisdictional nature, those who have all the necessary resources, skills, and mobility to reduce or avoid the costs of globalization are at a clear advantage over those who do not.

2.5 HEALTH POLICY AND HEALTHY PUBLIC POLICY There is a difference between health policy and healthy public policy. To put it a nutshell, “health policy” is mainly concerned with health, while “healthy public policy” refers to all public policies and programs related to health.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 23

2.5.1 Health policy Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health system with the aim to: improve health, reduce inequalities in health, and provide equities of access to health care. There are two strands of health policy:

o Public health policy focuses on prevention of illnesses and diseases; and

o Healthcare policy involves improving people’s access to healthcare services and healthcare professionals.

2.5.2 Healthy public policy The concept of "healthy public policy" has deep historical roots. The 1847 English public health law was the first legal document that embraced the “Healthy Public Policy” philosophy. In addition to disease control and prevention, the 1847 legislation emphasized housing, social welfare, and environmental policies as important strategies to improve the urban poor’s livelihood (Milio, 2001). Healthy public policy is characterized by a concern for health and equity in all public policies. The aim of healthy public policy is to create a supportive environment in which people can live a healthy lifestyle. To implement this “Healthy Public Policy concept,” all government agencies need to take into consideration the health implications of their policies and programs when formulating and implementing policies. The government sector and the business sector should be accountable for the health consequences of their policy decisions (Evans et al., 1994; Walt, 2001).

2.6 HEALTH IN ALL POLICIES (HiAPs) Population health management encompasses all efforts to prevent disease, promote health, and prolong life among the population as a whole. Population-based health programs are designed to serve the entire populations, not only individual patients or diseases. In other words, population health management is concerned with the total health and social system not only the eradication of a specific disease. Some notable population health management programs include:

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 24

Chapter 2

o o o o o o o o

Infectious disease control; Road traffic safety; Safe workplace; Clean and healthy food; Safe drinking water; Mother and child healthcare; Decline in deaths from non-communicable diseases; and Tobacco control.

The “Health in All Policies (HiAPs)” framework is identical to the “Healthy Public Policy” because it belongs to a tradition of public health approaches that consider the underlying social and political determinants of population health. The “Healthy Public Policy” term is older than the HiAP concept, but they can be used interchangeably.

2.6.1 Definition of HiAP The “Health in All Policies (HiAPs)” framework is identical to the “Healthy Public Policy” because it belongs to a tradition of public health approaches that consider the underlying social and political determinants of population health. The “Healthy Public Policy” term is older than the HiAP concept, but they can be used interchangeably (Davies, 2001). HiAP is a multi-sectoral approach to public policies that take into account the health implications of policy decisions. By doing so, the HiAP approach seeks to prevent harmful health impacts and improve population health and healthy equity. Policy makers are held accountable for health impacts at all levels of policy making. The three policy situations that favor an HiAP approach are (Steenkamer et al., 2012):

o Complex health challenges. Examples of this scenario include non-communicable diseases (NCDs), antimicrobial resistance (AMRs), and health risk associated with climate change. These situations require multi-sectoral policy solutions based on a thorough analysis of the problem, technical feasibility, costs, and benefits of potential solutions, and any unintended consequences from the potential solutions.

o External policies with high health impact. This concerns policy proposals from non-health sectors that have significant impact on health or health equity. A wide range of government

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 25

and non-government agencies can impact on population heath, but the health sector must prioritize when to involve other sectors. Also, an HiAP approach helps legitimize the health sector’s involvement in policy decisions with indirect impacts on health. Examples of this second scenario include international declarations or agreements, such as free trade and environmental protection.

o Government priority affecting many sectors. This third scenario refers to a situation which the government sector implements a high-priority program that has health implications and requires multi-sectoral collaboration. In this situation, the health sector can help the government achieve its objectives, while promoting population health. The health sector’s proactive involvement in this scenario can develop and strengthen ties with other sectors and establish a reputation for leadership and expertise. Examples of this third scenario include early childhood development, food security program, and environment-related measures.

2.6.2Approaches to population health management As medicine dramatically developed in the 1800s due to advances in chemistry and laboratory techniques, bacteriology and virology emerged. This gave rise the “biomedical approach” to public health, which focuses on the control and treatment of diseases, especially communicable diseases. Since the 1800s, this biomedical approach has been typified by mass vaccination programs and new drug development (Hofrichter, 2003). A competing public health paradigm—the “Sanitary-environmental Approach”—is sometimes referred to as the “Salutogenic Model” (Bovaird & Loeffler, 2013). This approach ensures that people live and work in healthy and safe conditions, such as adequate housing, proper sanitation, access to uncontaminated and nutritious food, and a safe work environment. Importantly, research works show that improvements in nutrition and livelihood were primarily responsible for the dramatic reductions in mortality among the European countries throughout the 19th century. This means that mortality rates plummeted and life expectancies increased before the biomedical approach. The sanitary-environmental approach has also been credited with improving people’s livelihood in Latin America countries in the 1930s when the Latin American

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 26

Chapter 2

governments adopted development programs outside the health sector, including improving access to safe food and water, housing, education, and public transportation. Other developing countries made similar transitions to the sanitary-environmental approach in the post-WWII era, such as Thailand, China, and India. Apart from multi-sectoral collaboration, efforts to address the social and economic determinants of health require the reduction (or slowing) of wealth inequities between the rich and the poor. These efforts triggered social and political movements in the 19th-century European countries when a number of social and welfare reforms were adopted to improve livelihoods of factory workers living in the rapidly growing urban areas. In the 20th century, governments of newly independent nations embraced social and economic development policies as part of their nation-building strategies. All these socially-oriented policies have led to the “socialbehavioral approach” that emphasizes changes in lifestyles and behavioral patterns (Cohen et al., 2000). Founded on the psychological theories, the social-behavioral approach aims to reduce disease risk factors. Programs that follow this approach include campaigns against health risks, such as substance abuse, reckless driving, lack of physical exercise, and unprotected sexual intercourse. These efforts demonstrate that improvements in population health necessitate structural changes to all the conditions that shape people’s health.

2.7 GLOBALIZATION AND ITS IMPACT ON POPULATION HEALTH Globalization is one of the most discussed and undoubtedly one of the most disputed terms of the recent years. Initially, the debate concentrated on economic globalization, but recognition of political, social, cultural, technological, and environmental aspects of globalization has rapidly grown during the past few decades. Debates are continuing whether or not the process is actually occurring, to what extent, for what reasons, in what forms, and with what consequences. Health is an important sector of most economies and a core area of social policy. Public expenditure on health as a proportion of total public expenditure varies widely among countries, with India and Indonesia spending 3.9% and 3.0% respectively. In sharp contrast, Andorra and

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 27

Argentina spend 38.5% and 21.6%, respectively (Adler & Newman, 2002). Indeed, the health sector has been the focus of global governance reform efforts in the past few years, which coincided with worldwide shifts in ideas about the welfare state and the role of public and private sectors in healthcare financing and provision. Global health became a policy agenda at major international political conferences in the 1990s and recently made it to be framed as a security issue at the United Nations Security Council (Frumence et al., 2013). This has resulted in international trade agreements, global financial and trade flows, and global environmental change, creating important implications for health governance. However, how does globalization actually affect policy making, whether “health policy” (within the health sector) or “healthy public policy” (within any sector affecting health and wellbeing) (Lee et al., 2002)? As demonstrated by O’Sullivan and Sheffrin (2003), impacts of globalization can be categorized as follows;

o Decisional impact denotes the extent to which the costs and benefits of policy choices confronting governments, firms, and households are influenced by the globalization forces and conditions; and

o Institutional impact denotes how enacted public policies reflect the range of policy options made available by the globalization process. Moreover, the adverse impacts of globalization on health reveal the weaknesses of global health governance system and institutions (Rootman et al., 2001). Lee and colleagues (2002) classify the “gaps” in international policy making related to global health governance as follows;

o Jurisdictional gap denotes the discrepancy between global/international and national health-related policies;

o Participation gap denotes the lack of cooperation and coordination among international agencies and sovereign states; and

o Incentive gap denotes developing countries’ reliance on international aid mechanisms at the expense of non-financial

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 28

Chapter 2

options that can offer sustainable strategies for health and development.

2.8 GROUP ACTIVITY o Students get in groups for a brainstorming exercise. Each group has to think about some of the ways that health in related to the following sectors: food, water, energy, education, economy, infrastructure and transport, governance, and environment? Conversely, how is each sector affected by population health conditions? For instance, insufficient food supply affects the people’s nutritional status. A healthy population is likely to promote economic development. o In your groups, identify government projects or programs from your countries/regions that follow the HiAP approach. How are your countries’ HiAP-oriented projects/programs linked to the biomedical and social-behavioral approaches to public health?

2.9 WRAP-UP QUESTIONS o Compare and contrast the different definitions of “health” from the World Health Organization Constitution, the United Nations Universal Declaration of Human Rights, and the Ottawa Charter. What disciplinary knowledge and technical skills are needed to address the different dimensions of “health” as demonstrated by these definitions? o Define “population health.” What are the two approaches to population health management? Discuss preventive healthcare in the context of population health management. o What is the key difference between international health and global health? What are the consequences of economic globalization for population health? Discuss other aspects of globalization (e.g., legal, environmental) and their impacts on health.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Essential Concepts in Health Policy Studies

Page 29

o Discuss the key characteristics of the HiAP approach to public health. How can the HiAP approach be adopted or applied in the global health context?

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

CHAPTER 3 Health Policy Making Topics and Concepts Definition of policy Policy categorization Policy making cycle

Learning Objectives Define policy and understand the complexity of public policy in the public health context Differentiate different types of policy Explain different stages of policy making Use the policy classificatory frameworks and policy-making process model to critically appraise health policy issues

Teaching and Learning Techniques Lecture Class dialogue Group discussion

Materials and Equipment PowerPoint file for presentation Flipcharts and markers

Additional Learning Resource Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. (Chapter 2). National Association of County & City Health Officials (NACCHO). (2014). Exploring the Roots of Health Inequity: Essays for Reflection. NACCHO. (Essay 4).

Health Policy Making

Page 31

3.1 INTRODUCTION Broadly speaking, a policy is a principle or a plan to guide decisions, actions and outcomes. In other words, policy is a system of thinking, planning, and doing for organizations, local government agencies, and national governments (Fischer et al., 2007). Policies can be laws, documents, procedures, guiding principles, statements of intent, or working frameworks. Policies may be written documents or unwritten practices. Policies can be implicit or explicit, formal or informal. Often, there can be a difference between policy as intent and policy in effect. Policies are also highly context specific and influenced by social, cultural, economic and political structures (Nagel, 2002). At the fundamental level, a policy consists of: o The area affected, public hospitals, community health, public health; o The objective or desired outcome, such as a reduction in hospital waiting lists, reduction in incidence of scabies; and

The actions that have been, or are to be, taken, including the legislative, financial and administrative mechanisms involved in the process of implementation.

Different environments (government departments, cities, countries) have different policies and this is influenced by their unique social, economic, political and cultural context (Turnock, 2001). Policy can be developed and implemented in different ways: through negotiation, repeated practice, decree/order or convention. There can often be a large (sometimes deliberate) discrepancy between policy as intent (i.e., what is planned, stated or written) and policy as practice (i.e., what actually happens). Policy analysis is a way of studying the way policies are created, so that existing policies can be changed or new ones created.

3.2 DEFINITION OF POLICY Policy means different things to different people. For economists, it means allocation of scarce resources. For public health professionals within a bureaucratic system, it means an attempt to influence the determinants of health in order to improve public health. For medical doctors, it signifies

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 32

Chapter 3

the government’s policy towards provision of health services (Ansoff, 1988; Heath, 1997). Policy refers to the actions that governments take in order to influence society (Barry, 2002). By this definition, health policy is about the best methods of financing health services and improving health service delivery. Since the central view about policy in this course is about the process of policy making, the definition provided by Bullock and colleagues (2001) is adopted: “The process by which societies translate their political vision into programs and actions to deliver ‘outcomes’, ‘desired changes’ in the real world.” Nonetheless, in the public policy literature, there are a variety of definitions of what policy is (Hill, 1997). One commonality among these different definitions is a core group of stakeholders involved in the policy making process. At the center, there are government actors, including elected and appointed officials. Outside of the policy making cycle, different groups of stakeholders have major stakes in each policy area, such as civic associations, the military, business and professional groups, religious groups, and foreign governments. How far these groups can influence the policy making process hinges on each country’s political and administrative system. In addition, the need for change is multifaceted. The world for which policy makers formulate policies is becoming increasingly complex, uncertain, and unpredictable. The electorate is better informed, has more expectations, and makes increasing demands for services tailored to their individual needs. Key policy issues—such as social welfare and health— overlap. In a globalizing world economy, there are few policy issues that are exclusively confined to a specific country’s national policy making process. Governments around the world need to respond quickly to changes in the international arena and provide support for their citizens businesses. Technological advances offer new tools and have the potential to fundamentally change the way in which policy is made. In addition to these external changes, government policy makers have now become attracted to policy solutions that work across conventional organizational and disciplinary boundaries. Government policy makers are required to adapt

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Health Policy Making

Page 33

to this new, fast-moving environment if they wish to remain relevant and their policies credible and effective.

3.3 POLICY CATEGORIZATION There are multiple ways to categorize policy. In this chapter, two classificatory frameworks for policies are presented as follows:

3.3.1 Policy classification by levels of implementation Diverse actors at different levels of implementation are involved in policy making (Figure 3). Programmatic policies serve target groups. Organizations act within communities. Governments serve their respective societies. International agencies and networks operate at the global level (Nagel, 2002; Fischer et al., 2007). o Programmatic policy. Program policy is set out in policies and/or strategies that address a specific program area (e.g., reproductive health, HIV health promotion, food safety). This type of policy provides direction and interpretation for resource management to achieve specific program goals. Program policies and strategies support the direction established in legislation, strategic policies, and other government programs. They often affect stakeholders directly and may be controversial (Walt, 2001). o Community policy. At the community level, policy is a course of actions selected by an organization to guide and determine present and future decisions and positions on community matters (Hill, 1997). o Public policy. Public policy can be generally defined as the course of action or inaction taken by governmental entities with regard to a particular issue or set of issues. Some scholars define it as a system of "courses of action, regulatory measures, laws, and funding priorities concerning a given topic promulgated by a governmental entity or its representatives." o Foreign policy. A countryâ&#x20AC;&#x2122;s foreign policy, also called the international relations policy, is a set of goals outlining how the country interacts with other countries economically, politically,

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 34

Chapter 3

socially, and militarily, and to a lesser extent, how the country will interact with non-state actors. This interaction is evaluated and monitored in an attempt to maximize benefits of multilateral international cooperation. Foreign policies are designed to help protect a country's national interests, national security, ideological goals, and economic prosperity. This can occur as a result of peaceful cooperation with other nations or through exploitation. o Global networks. These networks consist of international actors, states, multilateral institutions, corporate businesses, media agencies, professional bodies, non-governmental organizations, religious organizations, creating a global force that constitutes global governance. o Global governance. Defining global governance is challenging. The multiplicity of international actors complicates the United Nationsâ&#x20AC;&#x2122; search for a fitting role in an era of globalization. Global governance, humanityâ&#x20AC;&#x2122;s struggle to bring some sort of order to an increasingly interdependent, but still very chaotic, world, seems impossible without an active role by the worldâ&#x20AC;&#x2122;s premier international organizations: the United Nations and its specialized agencies (i.e. WHO, UNICEF, FAO, ILO, WTO, WB). Figure 3. Organizational Classification of Policies

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Health Policy Making

Page 35

3.3.2 Population-oriented classificatory framework Moreover, policies can be classified into four categories based on the population groups targeted by the policies (Buse et al., 2005). o Distributive policies. The provision of services or benefits to particular segments of the population. Distributive policies are characterized by the relative ease with which they can be adopted and implemented, since each policy can be implemented more or less in isolation from other policies. o Regulatory policies. The imposition of limitations or restrictions on the behavior of individuals or groups. Regulatory policies are reasonably specific and narrow in their impact. They determine who is restricted and who is given greater freedom o Self-Regulatory policies. Sought by an organization as a means of promoting its own interests. Self-regulation may benefit an organization directly or indirectly since being seen to be self-regulatory may enhance the official credibility of the organization. o Redistributive policies. Deliberate efforts by governments to change the distribution of income, wealth, property, or rights between groups in the population.

3.4 POLICY MAKING CYCLE It is important for us to understand the policy development/policy making cycle, so that as advocates for the public’s health we can plan the type of input needed to have an impact on the final policy. The description of a “policy cycle” initially proposed by Harold Laswell follows the seven stages of intelligence, promotion, prescription, invocation, application, termination, and appraisal (Jann & Wegrich 2007). However, the public policy theory now generally accepts that appraisal follows application and that the overall process is cyclical and therefore excludes a “termination” phase. This may be because new policies are being developed in an already crowded policy environment, leading to policy succession rather than a wholesale replacement of policies already in place (Hogwood & Peters,

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 36

Chapter 3

1983). Additionally, the policy cycle is deliberately iterative, in that evolving policy issues are addressed by a prescribed set of tools and activities over a period of time (Freeman, 2013). Indeed, the policy making process is cyclical and iterative, consisting of discrete stages with different actors and institutions (Howard, 2005). Generally, the policy cycle begins with agenda setting (also called problem or issue identification) and ends with evaluation before beginning anew (Howlett & Ramesh, 2003). The steps undertaken in between usually only vary in their nomenclature or level of separation (Howard, 2005). Table 1 gives a general overview these steps and how they vary slightly dependent on each individual’s choice of terms. Table 1. Selected Classificatory Frameworks of Policy Cycle Stages. Howlett and Ramesh (2003) • Agenda setting

• •

• Policy formulation • Public policy decision making

•

• Policy implementation • Policy evaluation

•

Howard (2005) Agenda setting or problem identification Analysis of the policy issue (s) Formulation of policy responses Decision to adopt a specific policy response Implementation of the chosen policy Evaluation of the policy

Jann and Wegrich (2007) • Agenda setting • Problem recognition and issue selection • Policy formulation • Decision making

• Implementation • Evaluation and termination

Each of the stages identified in Table 1 can be broken down into their constituent parts or sub-processes as follows.

3.4.1 Agenda setting Agenda setting or problem identification is the initial policy making step, and assumes the recognition of a policy problem. Although this stage of policy making is inherently political and not in the direct control of any single actor (Jann & Wegrich, 2007), it can occur in a bottom-up or topdown fashion, although it is unclear how successfully public opinion influences policy identification (Dye, 2008). As there is limited capacity within society and political institutions to address all possible policy responses to identified policy problems, actors actively promote policy issues important to them in order to have them promoted to the policy

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Health Policy Making

Page 37

agenda, and to remain prominent within the political debate (Birkland, 2007).

3.4.2 Policy formulation Policy formulation involves the identification of policy proposals in order to resolve identified issues. This process occurs within government ministries, interest groups, legislative committees, special commissions and policy think tanks (Dye, 2008). The policy formulation process precedes decision making, and is undertaken by policy experts who assess potential solutions and prepare them to be codified into legislation or regulation, along with initial analysis of feasibility, including but not limited to political acceptability and costs and benefits (Sidney, 2007). Policy experts are also responsible interacting with wider society, their policy networks and other social actors undertaking consultation in order to further shape policy proposals.

3.4.3 Public policy decision making Once a policy proposal (or proposals) has been formulated, it is presented to decision makers, usually cabinet, ministers and Parliament, for consideration prior to implementation (Jann & Wegrich, 2007).

3.4.4 Policy implementation Implementation is the phase at which all of the preceding planning activity is put into practice (Howlett & Ramesh, 2003). Resources are allocated, departmental responsibilities are assigned and often rules and regulations are developed by the bureaucracy in order to create new agencies with the role of translating laws into operational procedures (Dye, 2008). The implementation phase is a technical process, whereby the â&#x20AC;&#x153;street-levelâ&#x20AC;? bureaucrats need to interpret guidance from central authorities whilst providing everyday problem solving strategies in order to ensure a successful implementation structure (Pulzl & Trieb, 2007).

3.4.5 Policy evaluation Evaluation is the final stage of the iterative policy cycle, and policy outcomes are tested against intended objectives and impacts. In addition, an evaluation is made to determine any unintended consequences of policies, in order to establish whether a policy should be terminated or redesigned according to shifting policy goals or newly identified issues

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 38

Chapter 3

(Jann & Wegrich, 2007). The evaluation is undertaken by both governmental and societal actors in order to influence a reconceptualization of policy problems and solutions. This evaluation can be administrative (managerial and budgetary performance), judicial (judicial review and administrative discretion), or political (elections, think tanks, inquiries and legislative oversight), or a combination of the three in order to influence the direction and content of further iterations of the policy cycle (Howlette & Ramesh, 2003). However, many contemporary health issues are complex and influenced by factors outside the health sector as has been discussed in the two previous chapters. Chapter 2 introduces HIAP (Health-in-All-Actions Policy), which focuses on intersectoral collaboration. This also makes HiAP an inherently political process that involves the reallocation of resources, including power and responsibilities. It can stretch over long periods of time and usually involves many actors and interests, which may vary over the course of time. This means that the HiAP is not necessarily linear. The completion of one stage does not guarantee movement to the next. Nor is progress in one stage dependent on completion of all the tasks in the previous stage. We will see this with the concept of “Agenda Setting” in the next chapter.

3.5 GROUP ACTIVITY Noncommunicable diseases (NCDs) are responsible for about 40 million deaths each year, representing almost 75% of all deaths worldwide. This includes deaths caused by injuries from traffic accidents and chronic diseases, such as cardiovascular disease (CVD), cancer, diabetes (Type II), and chronic lung diseases. An emerging global health threat, NCD deaths now exceed all communicable, maternal, and perinatal nutrition-related deaths. The majority of these NCD deaths occur in low- and middle-income countries where health systems are often not equipped to respond effectively. For this exercise, students are divided into groups of 2-3 students each. In an international class, it is strongly recommended that students work with their colleagues from other countries or continents. In each group, student should help each other answer the following questions; o Identify the “modifiable” risk factors for CVD, cancer, Type II diabetes, and chronic lung disease:

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Health Policy Making

Page 39

Table 2. Modifiable Risk Factors for CVD, Cancer, Type II Diabetes, and Chronic Lung Disease CVD

Cancer

Type II DM

Chronic Lung Disease

• Tobacco Use • Alcohol Use • High cholesterol • High blood pressure • Unhealthy Diet • Physical inactivity • Obesity o Identify demographic and socio-economic factors that cause CVD, cancer, Type II diabetes, and chronic lung disease. Do these four NCDs affect the same population groups in your country? If not, specify how each population group in your country is affected by NCDs. o What are the implications of the challenge of NCD prevention and control in your country? Given the overlapping modifiable risk factors, what are the policies and programs that should be put in place to deal with the “invisible epidemic” of NCDs? To facilitate your group discussion, fill in the boxes in the two tables below with sample policies/programs.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 40

Chapter 3

Table 3. Organization-based Policies and Programs Policy Category Programmatic Policy

Sample Policy/Program/Project

Community Policy Public Policy Foreign Policy Global Policy

Table 4. Population-oriented Policies and Programs Policy Category Distributive Policy

Sample Policy/Program/Project

Regulatory Policy Self-regulatory Policy Redistributive Policy

3.6 WRAP-UP QUESTIONS o What is the definition of policy in this course? What is unique about this definition? And, despite the diverse definitions of policy in the public policy literature, what does this course identify as one of the commonalities among the different definitions? o Theoretically speaking, how many groups of stakeholders are involved in the policy-making process? What factor determines each stakeholder groupâ&#x20AC;&#x2122;s influence over policy making in each political setting?

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Health Policy Making

Page 41

o Policy making is inherently a political process, involving competition for resources, multi-faceted and transjurisdictional problems, and increased use of sophisticated (and costly) technology. Provide 1-2 examples of health policy and program that illustrate the political nature of policy making. Explain why. o How is foreign policy different from global policy? Provide examples to support your answer. o What are the differences among distributive, regulatory, selfregulatory, and redistributive policies?

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

CHAPTER 4 Agenda setting in the health sector Topics and Concepts Definition of agenda Agenda setting models Policy window Change agents and policy entrepreneurs

Learning Objectives Understand policy agenda Explain the process of agenda setting Describe different types of actors in agenda setting

Teaching and Learning Techniques Problem-based learning Introductory and summarizing lectures Group discussion

Materials and Equipment PowerPoint file for presentation Flipcharts and markers Case study: â&#x20AC;&#x153;Effects of the Global Pharmaceutical Drug Trade on Multi-drug Resistance Tuberculosis (MDR-TB) in Indiaâ&#x20AC;? (Appendix A)

Additional Learning Resource Bullock , H., Mountford, J., & Stanley, R. (2001). Better Policy Making. London: Center for Management and Policy Studies (Chapters 1 and 2). Ottersen, O., Dasgupta, J., Blouin, C., Buss, P., Chongsuvivatwong, V., Frenk, J., et al. (2014). The Political Origins of Health Inequality: Prospects for Change. Lancet, 333, 630-667. Sutton, R. (1999). The Policy Process: An Overview. London: Overseas Development Institute.

Agenda Setting in the Health Sector

Page 43

4.1 INTRODUCTION The central question in this chapter is how policy issues are identified. More specifically, why do some issues gain attention? How do issues get onto the policy agenda, and become enshrined in law, or regulations, or policy directives? And why are some issues ignored? Thus, the focus of this chapter is on public sector policy making, particularly why governments choose to act on some issues, but ignore the others. However, it is quite difficult to explain how and why some issues become prominent in the eyes of policy makers and others withdrawn from being viewed and discussed. From Chapters 1 and 3, it is often argued that changes in the policy context determine which issues get onto the agenda setting process. Depending on each policy context, a different set of policy actors capitalize on the “window of opportunity” and persuade other actors about what policy actions and initiatives should be adopted. This chapter addresses government policy making and why governments choose to act on some issues, but not the others. Different interest groups that influence the government agenda setting process are identified and discussed.

4.2 DEFINITION OF POLICY AGENDA Although policy agenda can be explained in several ways, in the context of government policy making we define the term agenda as: “A list of subjects or problems to which government officials and people outside the government closely associated with those officials, are paying attention at any given time” (Kingdon, 1984). For example, within the health policy domain, the Ministry of Public Health will consider, at any given time, a range of problems or issues, such as inefficiencies in health service provision, an increasing number of cigarette smokers, and access to new pharmaceutical products. Health policymakers may choose to focus on some of these myriad issues or problems. The agenda setting process narrows down a set of issues for the agenda setting process. Different government agencies have different issues/problems on their agenda. For instance, head of the executive branch (e.g., prime minister, president) consider issues of international and domestic importance, such as economic crisis, and terrorism. The Public Health

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 44

Chapter 4

Ministry has a more specialized agenda, ranging from “high politics” policies, such as health sector reform, to “low politics” issues, such as unit costs of hospital care and preventive health services.

4.3 AGENDA SETTING MODELS This question intrigues many policy analysts. Why do policymakers take action when they do? They sometimes react to a crisis, but policy making is dominated by “politics as usual.” In other words, more routine, day-to-day problems that need immediate solutions tend to get immediate attention from government policymakers. In the absence of any crisis, where do the driving forces behind a policy change come from? Several scholars have attempted to explain how and why some issues are taken seriously when there is no apparent crisis.

4.3.1 The Hall model The Hall model identifies three important reasons why some problems/issues find their ways to the government agenda setting process. o Legitimacy refers to those issues with which governments feel they should be concerned and in which they have the right to intervene. These are issues where governments feel most people will accept government intervention. o Feasibility refers to the potential of successfully implementing a policy. Feasibility is determined by technological know-how, financial resources, personnel, and organizational capacity. o Support refers to public support or public trust in government. This may be support from interest groups, citizen groups, and business associations. Based on these three conditions, governments will determine whether an issue or a problem should be given a high or low degree of attention. Often, governments put an issue on the policy agenda only because they wish to make a statement about it or to show that they are concerned. In this case, however, they do not expect to put such policy into action because the policy may not be feasible or may have a low degree of public support.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Agenda Setting in the Health Sector

Page 45

4.3.2 The Kingdon model This model considers agenda setting from three distinct perspectives (Kingdon, 1984): o Problem stream. Attention to a particular issue depends on conditions as expressed by statistics, focusing events, or policy feedback. Examples of these conditions are health statistics showing rising heart diseases (statistical indicator), an outbreak of avian influenza (focusing event), or successful decentralization of promotional health functions to local governments. However, many conditions are not necessarily perceived by everyone and every policy maker as problematic (e.g., malnutrition). Thus, policy makers will consider a certain existing condition to be a problem only when they feel that something needs to be changed. o Politics stream. This stream refers to both visible and hidden participants in the policy making process. Visible participants express their particular viewpoints, highlight specific problems, and use media to get public attention. These visible participants can be insiders (e.g., politicians, officials) or outsiders (e.g., interest groups). Hidden participants are specialists, such as academics, researchers, consultants, and experts, who are less concerned with getting an issue onto the agenda setting process than with proposing policy alternatives. However, hidden participants sometimes play an active role in getting public attention, especially in collaborating with the mass media. o Policy stream. A government policy emerges from the political process of problem identification and solution selection. To choose from a vast body of public problems and alternative policy solutions, policy makers apply different criteria, such as feasibility, relevance to the existing social values, consideration of unintended consequences, and public opinion. “Successful coupling” of these three streams provides an opportunity for fundamental changes in public policies (Kingdon, 1984). What causes these three streams to come together at one point in time may be due to many reasons: individual “policy entrepreneurs”, media attention, or

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 46

Chapter 4

â&#x20AC;&#x153;window of opportunityâ&#x20AC;? (government crisis). Keep in mind that participants in the policy making process do not always identify a problem before choosing a policy solution. A policy solution may exist long before an opportunity or a problem arises. Figure 4. Kingdon Agenda Setting Model

Partial couplings refer to situations in which issues do not get on government agenda. As illustrated in Figure 4, partial couplings can occur: o When there are solutions to problems, but without a receptive political climate, o When there is a receptive political climate to proposals, but without a sense that a compelling problem is being solved, or o When there are both a receptive political climate and problems calling for action, but without an available alternative to advocate.

4.4 POLICY WINDOW Based on the Kingdon agenda setting model, the three streams work along different, largely independent paths, until at particular times (i.e., policy windows), they flow together or intersect. This is when new issues are introduced into the policy making process and policies highly likely to

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Agenda Setting in the Health Sector

Page 47

change. As a result, policies do not get onto the agenda based on a series of logical/rational decisions. The three streams flow simultaneously, each with a life of its own, until they meet, at which point an issue is likely to be taken seriously by policy makers. The meeting of streams cannot be easily engineered or predicted. In this window of opportunity framework, the policy process is a complex interaction of the three spheres, where problems are identified and viable solutions articulated. The third sphere is the political environment where events take place independently, not necessarily related to problems or their solutions. When these three spheres come together, there is a window of opportunity for policy change. Three types of activities can help create this window of opportunity: (1) focusing attention on issues to get them onto the policy agenda (agenda-setting), (2) creating or strengthening coalitions that sustain attention around an issue (coalition building), and (3) increasing the knowledge that policymakers have about issues (policy learning). Researchers have identified four key factors that contribute to agenda setting: (1) presence of measurable indicators that describe the problem; (2) actions of “political entrepreneurs” or "policy advocates"; (3) events that focus the public attention on an issue; and (4) presence of policy options (Birkland, 1997; Buse et al., 2005). Confluence of these factors determines which issues attract policy makers’ attention. A coalitions of advocates—including researchers and think tank institutions, the media, the academic community, nongovernmental organizations (NGOs), and individual citizens with political party affiliation—can mobilize and sustain the public attention around a particular issue. Policy learning, also known as knowledge acquisition, occurs over a period of time. Translating technical or scientific facts into political or social facts is vitally important in generating a wider understanding of, and potential support for, policy reforms (Porter, 1995).

4.5 CHANGE AGENTS AND POLICY ENTREPRENEURS One way of classifying agenda setters is governments, interest groups, and the media.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 48

Chapter 4

o Government. Many actors may be agenda setters, but one of the most important agenda setters is the government, which has control over legislation and the policy process. o Interest groups. Other agenda setters include organized interests, whether they are international (e.g., UN, World Bank, IMF) or national (e.g., local business groups, NGOs, religious groups). o The media. How far do the media guide our attention to certain issues and influence how we think about them? How much leverage do they have over policy makers in their choice of issues of political concern? We must not underestimate the importance of the media as actors in agenda setting. To ensure effective collaboration, policymakers need to reach out to the research community, getting to know scholars and capitalizing on their advisory capacity. Policymakers should ask researchers for policy alternatives based on the researchersâ&#x20AC;&#x2122; scholarly orientation. It is important that government officials are committed to evidence-based policy making as a tool to solve the most pertinent questions/problems facing the government and its communities (Walt, 1994). In the context of discussing windows of opportunity and the complex, political nature of policy making, Kingdon (1984) emphasizes the importance of policy champions. A policy champion is a person or team willing and able to lead and manage the policy process. Policy champions proactively promote policy reforms, publicly support the policies and foster the support of others. They frame discussion of the issue, build consensus, attract resources, and seize and create opportunities to move the reform forward. Change agents and policy entrepreneurs are similar terms for this concept that highlights the creative dimension of breaking with existing ideas and initiating new policies. Researchers need to present their findings in clear and concise terms that non-experts can digest and use. It is equally important to determine what type of research tools and topics correspond to different policy areas or different stages of policy development. For example, government officials may not be receptive to logical modeling when they are at the early, stage of problem identification. Likewise, they will not be receptive to the introduction of new policy options at the implementation stage (Walt,

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Agenda Setting in the Health Sector

Page 49

2001). Also, government actors are essential players in disseminating evidence-based practices and policies. Importantly, strengthening channels of communications between researchers and policymakers is indispensable for health system improvement.

4.6 GROUP ACTIVITY The purpose of this group activity is for students to apply their understanding of the concepts of framing and windows of opportunity, which form part of the agenda-setting stage of the policy cycle.

o Students are divided into small groups. Before coming to class, each group will have to prepare for class by reading a case study on ““Effects of the Global Pharmaceutical Drug Trade on Multi-drug Resistance Tuberculosis (MDR-TB) in India” (Appendix A).

o In the context of problem framing and windows of opportunity, each group of students is required to answer the following questions: 1. How can the MDR-TB be “framed” as a problem that requires urgent action? 2. According to the Hall model, what must be present to support any proposed solution to the MDR-TB problem, so that it is adopted by government policy makers? 3. According to the Kingdon model, can you identify the politics stream, problem stream, and policy stream from the case study? Explain. 4. Based on the case study, what is the most appropriate solution to India’s MDR-TB solution? 5. How will you define the problem, so that other sectors are encouraged to take ownership of the issue and be part of the solution? 6. What existing or future opportunities can you see to put the issue on the agenda?

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 50

Chapter 4

o After 30 minutes, each group will be asked to briefly present how they would frame the issue and the opportunities they envisage to put MDR-TB on the policy agenda.

4.7 WRAP-UP QUESTIONS o What is the purpose of agenda setting? In the context of government policy making, how can the concept of agenda setting be used to explain how certain issues get the government’s attention, while the others do not?

o Explain the differences between the Hall model and Kingdon model of agenda setting.

o What does “partial coupling” mean? Provide an example of a policy situation when there are “solutions to problems, but without a receptive political climate.”

o What is “policy window”? How is it related to the politics stream, problem stream, and solution stream?

o Explain the differences between visible and invisible policy actors. What is the role of a policy champion/entrepreneur?

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

CHAPTER 5 Stakeholders and Policy actors in health Topics and Concepts Stakeholder analysis Government actors Business actors Non-profit actors Global actors

Learning Objectives Identify key policy actors in the public and global health sectors Describe each policy actor’s role in a policy cycle

Teaching and Learning Techniques Problem-based learning Introductory and summarizing lectures Group discussion

Materials and Equipment PowerPoint file for presentation Flipcharts and markers Case study: “Virtual Water Policy: A Case of Saudi Arabia” (Appendix B)

Additional Learning Resource Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. (Chapters 2 & 3).

Page 52

Chapter 5

5.1 INTRODUCTION This chapter introduces you to the roles of governmental agencies in formulating policy, as well as the roles of private sector organizations, international non-government organizations (NGOs), and international donor agencies in the fields of public and global health. The expected learning outcomes are a critical perspective toward the roles of key actors in public and global health and an appreciation of the political dynamics of these actorsâ&#x20AC;&#x2122; relationships.

5.2 AN OVERVIEW OF STAKEHOLDER ANALYSIS (SA) Stakeholder Analysis (SA) is a methodology used to facilitate institutional and policy reform processes by accounting for and often incorporating the needs of those who have a â&#x20AC;&#x2DC;stakeâ&#x20AC;&#x2122; or an interest in the reforms under consideration (Walzer & Sudhipongpracha, 2012). With information on stakeholders, their interests, and their capacity to oppose reform, reform advocates can choose how to best accommodate them, thus assuring policies adopted are politically realistic and sustainable (Bovaird, 2007). Although SA originated from the business sciences, it has evolved into a field that now incorporates economics, political science, game and decision theory, and environmental sciences. Current models of SA apply a variety of tools on both qualitative and quantitative data to understand stakeholders, their positions, influence with other groups, and their interest in a particular reform. In addition, it provides an idea of the impact of reform on political and social forces, illuminates the divergent viewpoints towards proposed reforms and the potential power struggles among groups and individuals, and helps identify potential strategies for negotiating with opposing stakeholders (Lyons, 2006). A stakeholder is any entity with a declared or conceivable interest or stake in a policy concern (Walzer & Sudhipongpracha, 2012). The range of stakeholders relevant to consider for analysis varies according to the complexity of the reform area targeted and the type of reform proposed and, where the stakeholders are not organized, the incentive to include them (Bifulco & Ladd, 2006). Stakeholders can be of any form, size and capacity. They can be individuals, organizations, or unorganized groups. In most cases, stakeholders fall into one or more of the following categories: international actors (e.g. donors), national or political actors (e.g.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 53

legislators, governors), public sector agencies (e.g., the Ministry of Public Healt), interest groups (e.g. unions, medical associations), commercial/ private for-profit, nonprofit organizations (NGOs, foundations), civil society members, and users/consumers. Four major attributes are important for Stakeholder Analysis: o The stakeholdersâ&#x20AC;&#x2122; position on the reform issue, o The level of influence (power) they hold, o The level of interest they have in the specific reform, and o The group/coalition to which they belong or can reasonably be associated with. These attributes are identified through various data collection methods, including interviews with country experts knowledgeable about stakeholders or with the actual stakeholders directly. The level of influence depends on the quantity and type of resources and power the stakeholder can marshal to promote its position on the reform. The level of interest or salience is the priority and importance the stakeholder attaches to the reform area (Laverack & Wallerstein, 2001). Broadly, these attributes signal the capability the stakeholder has to block or promote reform, join with others to form a coalition of support or opposition, and lead the direction/discussion of the reform. SA therefore provides a detailed understanding of the political, economic, and social impact of reform on interested groups, the hierarchy of authority and power among different groups and the actual perceptions of the reform among different groups, all of which are important for reform advocates to consider. Timing is an important factor in the implementation of Stakeholder Analysis to assure the usefulness of the results for policy formulation (Labonte et al., 2002). In most cases, SA should precede the finalizing of reform proposals. In early stages of policy formulation, SA can help gauge the likelihood of acceptance and sustainability of anticipated policy reforms. By initiating SA prior to the introduction of the reform and continuing to modify the policy proposal during the design process, potential obstacles to implementation and results can be avoided (Laverack & Wallerstein, 2001). When used at the right time and in conjunction with other tools such as qualitative political economy analyses and social impact assessments, SA can inform task team strategies to overcome opposition,

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 54

Chapter 5

build coalitions, and channel information and resources to promote and sustain proposed reform (Bifulco & Ladd, 2006).

5.3 HOW TO PERFORM STAKEHOLDER ANALYSIS (SA) SA must be based on an important measure called “effective power” (degree of power the stakeholder holds over other groups in relation to a reform area). Effective power is determined by weighting a combination of a stakeholder’s salience and influence. A clear assessment of each stakeholder’s power and likely impact on the policy making process is conducted through several steps. In this chapter, the SA procedure follows three steps:

5.3.1 The first step: evaluating effective powers Stakeholders are mapped on a continuum indicating support for the reform on a scale of 0 to 100 from low (far left) to high (far right). The varying degrees of support are marked on the line with a value indicating their reform preference. This implement also provides a quick visual of the ‘lay of the land’, illuminating clusters of groups that support, oppose or are indifferent to reform.

5.3.2 The second step: categorizing stakeholders The next step is to organize the stakeholder data according to relative power/influence and salience of each stakeholder to understand their potential support or opposition for the proposed reform. Often, a matrix is used to organize and classify the stakeholder data. One form is to map salience/interest and influence on the axes. This matrix provides a shorthand categorization and analysis of which stakeholders will gain or lose from a proposed reform and whether they can significantly impact the process. To guide strategic responses, stakeholders are categorized by their power and salience in a grid according to the following attributes: (1) degree of prioritization or attention to a policy area and (2) impact on policy implementation (Figure 5). Based on these two attributes, stakeholders can be divided into four distinct groups: o Promoters. Stakeholders who attach a high priority to the reform policy a priority and whose actions can have an impact on the implementation of the policy

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 55

o Defenders. Stakeholders who attach a high priority to the reform policy but whose actions cannot have an impact on the implementation of the policy o Latents. Stakeholders whose actions can affect the implementation of the reform policy but who attach a low priority to this policy o Apathetics. Stakeholders whose actions cannot affect the implementation of the reform policy and who attach a low priority to this policy Figure 5. Category of Stakeholders Based on Their Effective Powers

5.3.3 The third step: scenario building Figure 5 facilitates scenario-building and discussion and helps task teams determine appropriate responsive strategies (e.g. which stakeholders to target for negotiations and trade-offs, or which to buttress with resources and information, etc.). One of the main goals of SA is to reveal, and therefore potentially assist in reducing, the power imbalance among weaker groups which is often revealed during policy reform process. Depending on the attributes of the stakeholder (e.g. their level of influence vs. their salience on the issue), strategies may be tailored to address their concerns.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 56

Chapter 5

For example: o Maintain or increase power of reform supporters through building coalitions, and providing information and resources o Convert opposition into support through negotiations, information and/or coalition building, including offering tradeoffs. o Offset or counter powerful and not so powerful opponents Because stakeholders and their positions may change over the course of negotiations and analyses, SA should remain an ongoing process allowing for policy design to adjust as more is known about the political reality. Ultimately, SA is a critical tool in clarifying the micro political economy of a policy area and can help identify interested parties that should be incorporated in the decision-making process, in addition to understanding the basis for their inclusion.

5.4 GOVERNMENT ACTORS While policy formulation usually involves a wide variety of interests, driven by competing ideological assumptions of the public sectorâ&#x20AC;&#x2122;s appropriate roles in society, dynamics of the policy-making process depends on each type of government institutions (UNDP, 2012). These government institutions can be divided into three broad categories or branches: legislative, executive, and judicial branches.

o The legislature is the body which represents the people, enacts laws that govern the people and oversees the executive which is the leadership of the country (i.e. the president and or prime minister and other ministers).

o The judiciary is primarily responsible for ensuring that the government acts within the laws passed by the legislature and delivers judgment on inevitable disputes that occur in the interpretation of laws in practice.

o The executive branch. In parliamentary systems, the executive is chosen by the legislature from among its members (i.e. ministers are members of the parliament or assembly) and

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 57

remain in office as long as it has majority support among legislators. In presidential systems, the executive is separate from the legislature, elected separately by the public and need not have the support of the majority of members of the legislature to govern. These differences have important implications for the way policy is developed (Hall & Taylor, 1996). In presidential systems, the executive (president and his administration) can propose policy but the approval of the legislature (the majority may not be from the same political party) is required for policy to become law. This means that the policy development process is more open than in parliamentary systems with more room for interest groups to use influence (Hall & Taylor, 1996). In parliamentary systems, while there may be some dispute and bargaining behind the scenes over policies within the governing political parties, the executive can normally rely on its majority in the legislature to obtain support for the policies it wishes to enact. The judiciary system also affects the government policy process. In government systems based on a written constitution, often including statements on human rights, there is typically an autonomous body, such as a supreme court, charged with judging and advising in the case of disputes between different tiers of government and with ensuring that the policies are consistent with the principles of the constitution (Hall & Taylor, 1996).

5.4.1 Contribution of the bureaucracy The appointed officials who administer the system of government are referred to as civil or public servants. Although referred to as â&#x20AC;&#x2DC;servantsâ&#x20AC;&#x2122; of the politicians, their role extends beyond serving to managing processes in many areas of policy making. There are far too many responsibilities for the executive (ministers), so that many are delegated to bureaucrats to carry out in their name. Civil servants also have influence because of their expertise, knowledge, and experience. Governments come and go, but in most countries bureaucrats remain in the system of government, no matter what political party rules. However, the power of bureaucrats vs. politicians differs from country to country, over time and from sector to sector.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 58

Chapter 5

5.4.2 Expanding the boundary of the health sector The greatest contributions that governments can make to health lie outside the health sector and have nothing to do with doctors, hospitals or vaccines. Some of the main roles are:

o Creating a supportive political environment. It is important for a government to create for the health sector an environment in which public and private actors can work in an orderly and effective manner. This requires following action: (1) policy development, (2) regulations to enforce policies and (3) gathering and disseminating information.

o Directing roles in health care financing and provision. This requires: (1) ensuring adequate health care expenditure, (2) avoiding excessive health care expenditure, (3) regulating the health insurance market, and (4) paying for the poor.

o Improving population health. There is a need for increased focus on public health not individual health, by investing in disease surveillance, health promotion and disease control and prevention. On average throughout the world 95% of the health sectorâ&#x20AC;&#x2122;s budget goes to care at best 5% is left for public health (Simonet, 2014).

o Supporting health research. The government needs to support research and development in the health sector, especially in those areas where the private sector lacks interest, such as:

â&#x20AC;˘ Basic research (which does not necessarily lead to specific products i.e. drugs), and

â&#x20AC;˘ Research on products for which the market is small or ill defined (i.e. tropical diseases occurring in developing countries and diseases of the poor in developed countries)

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 59

5.4.3 Future roles of government Desirable trends in the role of the government during the coming decades are:

o Clearer and more articulate thinking on the role of the government in the health sector,

o Retreat by some governments from being major health care service providers,

o Strengthening the role of government as financier of health services,

o Greater emphasis on governments as purchaser and providers of population health services,

o Continue the role of governments in regulating the use/misuse of medical technologies, and

o A major expansion in the number of governments that work together proactively to deliver global public goods.

5.5 BUSINESS ACTORS The pharmaceutical industry plays a vital role in preventive and curative health care and related research. Following challenges in public health, support from the private biomedical industry is crucial. Novel antimicrobial agents will be required to control infectious diseases. Biomedical innovation is a crucial contributor to employee wellness, therefore, supportive business and economy. In addition, chronic non-communicable diseases (NCDs) will challenge an aging global population. The new global burden presents a formidable challenge to society that biomedical innovation will play a key role in solving. In meeting the challenges of an aging population, infectious diseases and productive communities, the pharmaceutical research industry is indispensable. For the industry to discover and develop medicines a fair regulatory environment is required including the following:

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 60

Chapter 5

o Good intellectual property protection and patent laws, o Efficient

regulatory process emphasizing dissemination of reliable information, and

safety

and

o Substantial national investment in basic biomedical research Today, private philanthropic foundations serve an important role in financing global health initiatives, especially disease eradication programs, and their role is growing (Cleveland & Laroche, 2007). As legal entities set up by individuals or institutions for the purpose of distributing funds over a period of time, foundations usually focus on specific funding priorities that remain fairly consistent to achieve measurable results (Forrest, 1999). Because they have complete discretion over which projects or programs they support, at times soliciting grant proposals and at times selecting programs directly, and because they can move swiftly when the need arises, they can sometimes make a crucial difference. Some are also able to bring very substantial resources. The Bill and Melinda Gates Foundation, for example, has channeled about $800 million a year to global health programs, nearly the same amount as the World Health Organization's annual budget. The Gates Foundation is a partner in both the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Global Alliance for Vaccines and Immunization. Other major foundations that support global health initiatives in various ways include the Ford Foundation, the Kaiser Family Foundation, the Robert Wood Johnson Foundation, the Packard Foundation, the Rockefeller Foundation, the MacArthur Foundation, and the Welcome Trust. Added to these are pharmaceutical company foundations that donate drugs or funds for specific purposes, such as the Merck Company Foundation donating drugs for the prevention and treatment of river blindness--a debilitating and parasite-borne disease since 2000. Similarly, the Pfizer Foundation supports efforts related to HIV/AIDS, such as the construction of medical training facilities, the implementation of prevention programs, and the provision of treatment drugs.

5.6 NON-PROFIT ACTORS New realities require new thinking and hopefully lead to new opportunities. Recent epidemiological research findings suggest that only

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 61

10% of potential health improvements in developed countries will come from advances in health technology and management. About 40% will come from improved preventive personal health care activities and the remaining 50% will come from improvements in the environment (Burns et al., 2002). The non-profit sector traditionally is concerned about the broader social impacts of health conditions; this manifest itself in areas such as awareness raising, support of belief systems and nurturing of values (Walker, 2007). Further, the roles of civil society organizations (CSOs) and nongovernment organizations (NGOs) receive increasing importance in public policy and health policy over the past decade. As more financial and other resources were invested in this sector, the profile of its constituent groups changed. Different agencies define CSOs and NGOs differently. There is need for clarity in understanding the heterogeneity of this sector, and to recognize the unique roles of different constituents for global health promotion (Gostin & Powers, 2006). NGOs in the 1960s and 1970s were largely not-for-profit voluntary organizations working towards integral development. In the health sector, they included medical service through hospitals, health centers, and mobile clinics run by charities, missions and philanthropic organizations (Gostin & Powers, 2006). With experience and reflection this group developed a deeper community based understanding of the dynamics of health, health care and development in different sociocultural situations. They were often able to achieve what governments in resource poor situations could not (Gostin & Powers, 2006). With professional and social skills developed through working in difficult circumstances, they became alternative experts, and the sector soon became an additional policy option. With growing recognition, money and influence, the profile of NGOs and new entrants to the sector changed. NGOs now include corporate NGOs, with companies setting up Trusts and Societies, building brand images, obtaining tax benefits, and blurring the profit and not-for-profit sector. Government NGOs (GONGOs) and other new entities developed to overcome the bureaucracy of government (Smith, 1994). Professional associations and research bodies with a high degree of knowledge and expertiseâ&#x20AC;&#x201C;such as the International Union for Health Promotion, and Educationâ&#x20AC;&#x201C;comprise another important section (Smith, 1994). NGO networks developed at national and global levels with a

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 62

Chapter 5

specific focus on health. During the past decade a global people’s health movement emerged with a strong focus on health determinants and a right’s based approach to health care. The potential for partnerships are thus many. Including those that can impact on health determinants provide a strategic option to global health promotion (Verschuere et al., 2012). NGO coalitions with communities, governments and other organizations can mobilize human, political, financial, and scientific resources to make health promotion the backbone of health care systems and services (Koliba et al., 2011). There is a need for the health promotion community to develop and sustain working links with local communities, groups, and movements working beyond the traditionally defined health sector in order to influence health determinants (Verschuere et al., 2012). Working for equity in health would involve challenging powerful interests. Public health ethics requires that this be done.

5.7 GLOBAL ACTORS There are various actors in international public health such as United Nations organizations (i.e. WHO), private sector organizations (i.e. pharmaceutical companies), non-government organizations (i.e. Gates Foundation), regional organizations (i.e. Asian Development Bank) and governmental agencies that contribute to international health development (i.e. Japan International Cooperation Agency). Although some of these agencies’ mandate might not address directly health, they do have an impact on population health status. In 1997, WHO’s Jakarta Declaration stated that: “We must break through traditional boundaries, within government sectors, between government and non-government organizations and between the public and private sector.” Partnerships can be a powerful means by which the Jakarta Declaration could be achieved. Strategic alliances and partnerships could provide opportunities to initiate social change. However, partnerships do not occur automatically, they require faith, trust and willingness to seek new paradigms (Arifeen et al., 2013). Shaping the global health agenda of tomorrow requires getting away from narrow individual sector and regional agendas and creating multilateral partnerships to strengthen civil society throughout nations and peoples. This means accepting political decentralization of governments,

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Stakeholders and Policy Actors in Health

Page 63

transferring authority, decision-making, responsibility and resources for health from central to local levels, and fostering partnerships to fill the gaps a government alone cannot fill (Sachs, 2012). An essential function of public-private partnership is to facilitate transfer by putting tools for change and decision-making in the hands of those closest to the problems and most directly affected by the solutions (Walzer & Sudhipongpracha, 2012). It becomes interesting to see the changes that took place over time at the international scene of actors in public health in terms of contributions. Prior to the establishment of the United Nations, private foundations contributed significantly, but declined as multilateral agencies took over. After the Gates Foundation joined the scene in the 21st century, private foundations and their bilateral partners reemerged and now dominate the global public health scene.

5.8 GROUP ACTIVITY The overarching objective of this group activity is to enable students to use the stakeholder analysis framework to analyze a case study on environmental resource management and health.

o Students are divided into small groups. Before coming to class, each group will have to prepare for class by reading a case study on â&#x20AC;&#x153;Virtual Water Policy: A Case of Saudi Arabiaâ&#x20AC;? (Appendix B).

o Based on the stakeholder analysis framework, each group of students is required to answer the following questions: 1. Identify government actors, business actors, non-profit actors, and global actors in the case. Try to come up with as many actors as possible. 2. With the fully developed list of actors, use the stakeholder analysis framework (three steps) to design a water policy reform strategy. Make sure to explicitly show your work for each of the three SA steps. o After 30 minutes, each group will be asked to briefly present an analysis of the case, stakeholder matrix, and an advocacy plan for a sustainable water management policy.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 64

Chapter 5

5.9 WRAP-UP QUESTIONS o What is stakeholder? In the public policy and health sectors, why do we need to analyze “stakeholders”? How does stakeholder analysis (SA) help with policy making and policy advocacy? o Use the three steps in SA to explain how we can advocate for the low-sugar and low-starch diets in your country. Describe in detail what is needed and what must be done in each step. o Explain how each main government institution – the legislature, the executive branch, the judiciary, and the bureaucracy—is involved in public health policy making. o Discuss the role of business philanthropic foundations and the business sector’s philanthropic activities (e.g., corporate social responsibility activities) in the public/global health context. o Identify key policy actors/organizations at the global health level. Discuss their roles and interactions in the pursuit of equitable health services.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

CHAPTER 6 Public health Leadership and policy execution Topics and Concepts Policy implementation models Principal-agent theory “HiAPs” leadership Current leadership challenges in the health sector

Learning Objectives Understand and use the policy implementation models in cases related to health policy formulation and implementation Describe and critically appraise the current challenges facing health professionals and health policymakers in the 21st century

Teaching and Learning Techniques Problem-based learning Introductory and summarizing lectures Group discussion

Materials and Equipment PowerPoint file for presentation Flipcharts and markers Case study: “Health for All” or “Health by All (?)” Developing Health Management Capacity Indicators for Local Governments in Thailand (Appendix C)

Additional Learning Resource Sihto, M., Ollilaa, E., & Koivusalo, M. (2006). Principles and Challenges of Health in All Policies. In T. Stahl, M. Wismar, E. Ollila, E. Lahtinen, T. Melkas, & K. Leppo, Health in All Policies: Prospects and Potentials (pp. 3-20). Finland: Ministry of Social Affairs and Health.

Page 66

Chapter 6

6.1 INTRODUCTION Much government reform is currently focused on trying to improve systems that increase the likelihood that public policies will be implemented in the way intended by government agencies. Leadership is key to the successful implementation of policies and programs. This chapter deals with what happens between policy expectations and policy results. The literature offers much attention on agenda setting, policy formulation, and decision-making processes. Yet, the changes that follow policy decisions have been neglected for quite a while. However, more recently, it has become apparent that many public policies do not work in practice as well as expected.

6.2 MODELS OF POLICY IMPLEMENTATION 6.2.1 Top-down model The top-down model to understanding policy implementation is guided by a linear model of understanding sequences of activities, with a clear division between policy formulation and policy execution, whereas policy formulation is seen as political and execution as largely technical, administrative and managerial. The key assumptions in the top-down model is that goals are clearly defined and widely understood, the necessary political, administrative, technical and financial resources are in place, a clear chain of command is established from central to peripheral, and communication and control systems are in place. Conditions believed to be required for success: o Clear, logical, and agreeable objectives; o Policy is based on a valid theory of cause and effect (how actions lead to desired outcomes); o The relationship between cause and effect is direct; o Adequate time and resources are available; o The required combination of resources are available;

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Public Health Leadership and Policy Execution

Page 67

o Tasks are fully specified and in correct sequence; o Implementation structured to enhance compliance (incentives and sanctions); o Committed and competent officials; o Effective communication and coordination is in place; o Support from interest groups and legislature; and o No changes in socio-economic conditions that undermine support The weakness of this model is its assumption that policy objectives are clear and consistent. In fact, most policy objectives are unclear, inconsistent, and hence rarely fulfilled. Therefore critics believe that the model is not good in describing what happens in practice and also not useful to guide improvement of the implementation process.

6.2.2 Bottom-up model The bottom-up view on policy implementation is based on the belief that implementers often play an important role in the 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. Policy makers should bear with this insight in mind, as policies are made. Even in a highly centralized system, as power is usually delegated to subordinate agencies and their staff, these policy implementers may change the way policy is implemented. In the implementation process, they even redefine the policy objectives. This policy-making role of implementers is referred to as the â&#x20AC;&#x153;street-level bureaucracyâ&#x20AC;? phenomenon (Lipsky, 1980). Insights from the bottom-up perspective on policy implementation guided various studies on how central, regional, and local agency relationships influence health care policy. The ability of the central level to control lower levels of the system varies widely, depending on factors, such as where the funds come from and who controls them. These relationships between the central level and the periphery in health systems influence policy outcomes.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 68

Chapter 6

6.3 PRINCIPAL-AGENT THEORY In this theory, the quality of policy implementation is the result of the structure of government institutions in which decision makers (principals) have to delegate responsibility for policy implementation to their officials (civil servants) and other “agents” (e.g. managers, health personnel, private contractors) whom they only indirectly and incompletely control and who are difficult to monitor. These “agents” have discretion in how they operate on behalf of “principals” and may not even see themselves as primarily engaged in making a reality of the wishes of these “principals.” This creates potential for ineffective and inefficient translation of policy into practice, since “agents” have their own views, ambitions, loyalties, and resources which can hinder policy implementation. The problem for principal officials is to get compliance of their officials and others who are contracted to deliver services at all levels (Guston, 1996). The more levels of organizational hierarchy there are, the more principal-agent relationships exist, and the more complex the task of controlling the process of implementation. In addition, the degree of complexity of principal-agent relationships is affected by the nature of the policy problem (ill-defined or clearly defined), context of the problem (political, economic, or legal), and organization of policy implementation (single agency or network of agencies) (Gauld, 2007). As a result of these factors, officials who normally remain longer in position than politicians often become subject area experts and are able to exercise considerable freedom of judgment. Politicians and principal officials are thus dependent on the goodwill of their “agent” officials. In public services, especially in the public health sector, the conventional role of governments as direct providers of health and healthcare services is critically reviewed in many countries, with the aim to improve efficiency and responsiveness of services (Denhardt & Denhardt, 2003). The catch-phrase – “the government should be steering not rowing the ship of the state” –suggests that governments should only do what they do best. As a result, some services that were directly provided by the public sector are contracted out to private for-profit or non-for-profit providers (Lindsey et al., 2014).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Public Health Leadership and Policy Execution

Page 69

6.4 “HiAP” LEADERSHIP The global burden of disease is changing. The determinants of health and health inequalities increasingly lay beyond the direct influence of the health sector and health policies (Davies, 2001). Countries are also increasingly connected and interdependent (Milio, 2001). Issues such as globalization, socioeconomic inequality, environmental degradation, food insecurity, migration, and urbanization directly impact a growing portion of the world’s population (Sachs, 2012). Social movements and new technologies are also spreading rapidly (Davies, 2001). To advance HiAP, the health sector must learn to work in partnership with other sectors (Adler & Newman, 2002). Jointly exploring policy innovation, novel mechanisms and instruments, as well as better regulatory frameworks, will be imperative. This requires a health sector that is outward oriented, open to others, and equipped with the necessary knowledge, skills and mandate (Steenkamer et al., 2017). This also means improving coordination and supporting new types of leaders within the health sector itself (Powers & Chaguturu, 2015). Although governments, as a whole, bear the ultimate responsibility for the health of their citizens, health authorities at all levels (national, regional, and local) are key actors in promoting HiAP (Leppo & Tangcharoensathien, 2013). As previously discussed, leadership and coordination are crucial during all stages of the policy cycle (Simmons, 2011). Windows of opportunity are missed or may never emerge without astute health policy-makers supported by a functional health ministry (Adler & Newman, 2002).

6.5 CURRENT LEADERSHIP CHALLENGES IN THE

HEALTH SECTOR 6.5.1 Limited political influence To address the social determinants of health, health professionals must have the political influence to convene meetings of all relevant sectors and stakeholders to discuss and address the health implications of their respective activities (Elbel et al., 2013). In many countries, the political influence of the health profession is limited by its low status and scarce

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 70

Chapter 6

resources in comparison with other portfolios. Often, the health sector is viewed as a drain on government revenue rather than a contributor to socioeconomic well-being and prosperity. To deal with this challenge, health professionals can help to make the arguments about prioritizing health in policy discourse. It is also imperative to seize the rare windows of opportunity that do come up if regular intersectoral collaboration and stakeholder engagement is not possible (Forrest, 1999). As discussed in Chapter 4, windows of opportunity can sometimes coincide with political campaigns, changes in the governmentâ&#x20AC;&#x2122;s balance of power, as well as health hazards, crises, and disasters. Lastly, it is important to remember that there are many structures and mechanisms, both formal and informal, that can be used to promote intersectoral collaboration and stakeholder engagement.

6.5.2 Constrained resources and staff turnover Health agencies in all countries are arguably constrained by resources, but many face a scarcity that seriously impinges on their ability to provide a minimum level of health (Turnock, 2001). This shortage of resources also impacts on the health ministryâ&#x20AC;&#x2122;s capacity to formulate and implement evidence-informed policy (Burns et al., 2002). High turnover of staff is also challenging as well-trained health professionals are either promoted and move up the hierarchy or quit the ministry due to low incentives, poor motivation, low morale, bureaucratic inertia, and lack of social recognition. The long-term sustainability of institutional capacities is then at risk. Addressing this challenge is as difficult as the problem is serious. However, a focus on universal health coverage, a commitment to develop national public health institutes, and the gradual systemic development of capacity can make a difference (Guttman, 2000).

6.5.3 Working in vertical, fragmented units Too often, health sectors are highly compartmentalized based either on levels of medical care or different categories of disease (Guttman, 2000). Health policy-makers are also often overwhelmed by day-to-day crisis management. Expertise is frequently too narrow, comprising the medical and nursing staff, lawyers, finance professionals, and statisticians necessary for administration of health. The HiAP approach requires a wider professional mix: people with broad understanding and knowledge of modern public health and staff trained in economics and policy sciences (Guttman, 2000).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Public Health Leadership and Policy Execution

Page 71

6.5.4 Difficulty gathering and disseminating evidence Health ministries, especially in developing countries, can have difficulties gathering and disseminating evidence in support of taking action on health issues. However, this is an essential capacity, linked to evidence-informed policy-making, and especially critical when it comes to monitoring the health and health inequity impacts of other sectors and stakeholders. Evidence gathering for informed policy decisions can often be carried out by research institutes in the ministry of health or by academic bodies specializing in policy research. Effective publicizing and dissemination of evidence are essential for bringing together all stakeholders and gradually forming public opinion. Good examples include global efforts to raise awareness of road safety and the dangers of tobacco and excise drinking.

6.5.5 Politicization of the bureaucracy, corruption, and regulatory capture Given health is distributed along a gradient, which reflects the unfair distribution of wealth and power in society, targeting health inequities is a deeply political issue and not simply a technical matter (Powers & Chaguturu, 2015). Without positive discrimination measures that prioritize the needs of the underprivileged, health services are likely to be disproportionately used by better educated and wealthier sections of society, and health inequalities may rise (Labonte et al., 2002). In principle, the politicization of the bureaucracy can bring about pro-poor policies as sometimes occurs after political upheavals and the formation of populist governments. Politicization more often means health policy is subjugated to private interests. This can lead to appropriation of health funds and the appointment of officials based on their political affiliations (Hogwood & Peters, 1983). Regulatory capture is common in settings with poor governance and leads to regulatory agencies becoming indirectly dominated and controlled by those they are supposed to regulate. This results in the regulator acting in the interests of the regulated partner, which is often a commercial entity, and the regulator failing to protect the public interest (Rootman et al., 2001). Public services, including health, often benefit the better educated and wealthier sections of society because they have the greater means to

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 72

Chapter 6

access these services than those who are poor or less educated. Positive discrimination measures that prioritize the needs of underprivileged and thereby address inequities should be an essential part of public health policy (Walt, 2001).

6.5.6 Political commitment and discontinuity Improving population health and health equity normally takes much longer than most government tenures. Therefore, time frames and sustainability may pose particular difficulties for HiAP. Some of the ways that the health agencies can mitigate this challenge is through effective publicizing and dissemination of evidence for action, building alliances, and using multiple structures and mechanisms of intersectoral collaboration and stakeholder engagement (Evans et al., 1994).

6.6 GROUP ACTIVITY Students are divided into small groups. Before coming to class, each group will have to prepare for class by reading a case study on “Health for All” or “Health by All (?)”: Developing Health Management Capacity Indicators for Local Governments in Thailand (Appendix C). During class, students work with their designated groups to answer the following questions: o Based on the case study, which policy implementation model (s) can be used to assist the Thai policymakers in designing an effective (and efficient) public health decentralization process? If your group decides to use both models, what is your rationale, and how do the two models interact in the case of public health decentralization? o Use the principal-agent theory and concept to explain the Thai central government officials’ concerns with local health management capacity. In this case, who are the “principals” and the “agents”? o Besides the potential accountability problem in the decentralized public health system, identify other challenges facing both national and local public health officials.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Public Health Leadership and Policy Execution

Page 73

o What are the characteristics of local government managers or leaders who can deal with the decentralized public health system in Thailand? Each group will be asked to appoint one group speaker who will present the answers.

6.7 WRAP-UP QUESTIONS o Create a table that compares and contrast the top-down and bottom-up models of policy implementation based on the three following criteria: (1) underlying assumption about policy goals, (2) the “street-level” officials, and (3) ability of the central government to exercise control over local officials.

o Based on the principal-agent theory, why do we have to be concerned about the “agents”? What must be put in place for the “principals” to deal with those concerns?

o In your view, what is the most important challenge facing the current health sector? Explain your reason.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

CHAPTER 7 Intersectoral collaboration in health Topics and Concepts Collaboration Whole-of-government approach to health Whole-of-society approach to health

Learning Objectives Describe and differentiate each type of intergovernmental collaboration in the public health sector Explain and differentiate the whole-of-government and whole-of society approaches to health Identify the roles of non-government and private sector actors and organizations in the health policy cycle

Teaching and Learning Techniques Problem-based learning Introductory and summarizing lectures Group discussion

Additional Learning Resource Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. (Chapters 5 & 6).

Intersectoral Collaboration in Health

Page 75

7.1 INTRODUCTION Historically, the principle of government responsibility for the health of its population has been central to public health. In most countries, the efforts of government have been fundamental to addressing the social, economic and environmental determinants of health. The redistributive powers of government have also been critical for redressing health inequalities. The governmentâ&#x20AC;&#x2122;s role in health is therefore a matter of principle and pragmatism. Since the 1970s, there has been a shift in the discourse of public policy and governance, which has attempted to minimize the responsibility of government for the health of its people (Pollitt, 1991). This ideological shift, which has close ties to managerialism and neoliberalism, has led in some countries to greater deregulation and privatization in the health sector (Nash, 2012). More generally, the push toward â&#x20AC;&#x153;small governmentâ&#x20AC;?, including limiting interventions in the economy and spending on social welfare has restricted policy space and permitted inequalities to increase. At the same time, social movements in many countries have called for greater participation, transparency and accountability in policy decisionmaking and the number of health actors has increased, especially at the international level (Brandsen & Pestoff, 2006). As a consequence, health is an increasingly contested and congested policy space. Given government responsibility for health and the complexity of many contemporary health challenges, governments have several crucial roles to play in the HiAP approach, which emphasizes intersectoral and intergovernmental collaboration.

7.2 INTERSECTORAL COLLABORATION Intersectoral collaboration refers to the coordinated efforts of two or more sectors within government to improve health outcomes. This can include working across different levels of government, such as district, provincial, and national jurisdictions (Davies, 2001). The term intergovernmental is sometimes used to refer to these horizontal and vertical linkages between levels of government within a country. Healthy public policies, whole-of-government, and joined-up government are similar terms commonly used in the HiAP literature (Milio, 2001).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 76

Chapter 7

However, collaboration can vary significantly from no collaboration to temporarily working together to permanent collaboration (Figure 6). Figure 6. Degree of Collaboration

Source: Boston (2011) In the intergovernmental context, there are many possible forms of intersectoral collaboration (Boston, 2011):

7.2.1 Cabinet secretaries Cabinet committees allow ministers to engage with policy issues of cross-departmental significance and offer a mechanism for ministers to work with outside interests (McQueen et al., 2012). Cabinet secretariats coordinate and facilitate collective decision-making on behalf of all government ministers and directorates to ensure that proper and timely collective consideration of policy is carried out before decisions are taken (Boston, 2011). While some governments may use more informal mechanisms to facilitate cross-departmental engagement, cabinet committees are recognized for being able to facilitate dialogue and reach agreement on shared policy issues. Owing to the confidential nature of

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Intersectoral Collaboration in Health

Page 77

cabinet committees, the evidence to support their ability to influence governance actions for HiAP is necessarily limited to anecdotes. However, as cabinet committees and secretariats are one of the highest decisionmaking bodies, they have the potential to promote and implement an HiAP approach, especially in the presence of competent and charismatic political leaders and policy champions/entrepreneurs. Cabinet committees and secretariats are likely to have the most notable influence on the agendasetting and policy formation stages of the policy cycle (Boston, 2011).

7.2.2 Parliamentary committees In democratic countries with robust debate, parliamentary committees of elected representatives can play a role in agenda setting, promoting wider political ownership of issues and reviewing policy decisions (Morgan et al., 2010). Committees consisting of multiple parties, including the opposition, can enhance the potential influence of findings and can support the longevity of an issue as a political priority despite a change of government (McQueen et al., 2012). Parliamentary committees are likely to have the most notable influence on the agenda setting and policy review stages of the policy cycle.

7.2.3 Inter-ministerial/inter-departmental committees Interdepartmental committees and units are two of the most common mechanisms for intersectoral collaboration (McQueen et al., 2012). They operate at the bureaucratic level and aim to re-orient ministries around a shared priority. Both interdepartmental committees and units are primarily made up of civil servants. However, committees can include political appointees and units can include people from outside of government (Morgan et al., 2010). The appeal of such committees and units is that they provide a forum for problem solving and debate. The effectiveness of interdepartmental committees and units depends heavily on the context, particularly the relative importance of the issue and level of political support. This mechanism for intersectoral collaboration can potentially influence the entire policy cycle (Kang, 2016).

7.2.4 Joint Budgeting The term â&#x20AC;&#x153;joint budgetingâ&#x20AC;? can itself cover a number of quite different mechanisms, involving two or more government departments and/or levels of government, in order to help achieve one or more shared

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 78

Chapter 7

goals (Milward & Provan, 1998). They can range from fully integrated budgets for the provision of a service or policy objective to loose agreements between sectors to align resources for common goals, while maintaining separate accountability regarding the use of funds. Another limited approach can be to have jointly funded posts to help coordinate intersectoral policies (Agranoff & McGuire, 1999). Agreements on joint budgeting can be mandatory or voluntary in nature and operate at a national, regional and/or local level. They may be accompanied by legislation and regulatory instruments (Milward & Provan, 1998). While challenging to implement because it needs to be well planned with clear objectives, roles and responsibilities, joint budgeting is a promising way to promote and implement HiAP (Agranoff & McGuire, 1999). This is especially the case where other sectors will co-benefit and the health sector, which is usually a relatively large spender of government revenue, offers a large share of the joint funding. This mechanism has the potential to mainly influence the implementation stage of the policy cycle (Milward & Provan, 1998).

7.2.5 Intersectoral policy making This category groups many of the remaining bureaucratic measures to promote intersectoral collaboration and includes procedures, such as impact assessments and policy proposals circulating through multiple ministries for comment prior to review by the responsible minister (Leppo & Tangcharoensathien, 2013). These procedures differ significantly between countries and can be mandatory or voluntary. Such mechanisms tend to influence the policy formation stage and represent a relatively low but regular level of intersectoral action (Turnock, 2001).

7.2.6 Non-government stakeholder engagement Government engagement with non-government stakeholders is a crucial component of the HiAP approach (Elbel et al., 2013). While nongovernment stakeholders can play a role at all stages of the policy cycle, stakeholder engagement as a government mechanism is most common during the agenda setting, policy formation and policy implementation stages (Ottersen, et al., 2014) Each type of intersectoral collaboration has distinct mechanisms at different stages in the policy cycle (Buse et al., 2005) (Table 5).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Intersectoral Collaboration in Health

Page 79

Reporting

Evaluation

Policy Enforcement

Policy review

Monitoring

Policy implementation

Policy execution

Policy Formulation/guidance

Negotiation

Developing options and strategies

Advocacy

Policy formulation

Research

Agenda setting

Problem identification

Table 5. Mechanisms of Intersectoral Collaboration

1. Cabinet secretaries 2. Parliamentary committees 3. Interministerial/ interdepartmental committees 4. Joint budgeting 5. Intersectoral policy making 6. Nongovernmental stakeholder engagement

7.3 WHOLE-OF-GOVERNMENT SOCIETY APPROACHES

AND

WHOLE-OF-

Governments are responsible for the health of their peoples and have a critical leadership and stewardship role in the organized effort by society to promote health and well-being. However, the social determinants of health imply that many non-government stakeholders have an interest or concern in health. While labor unions have an interest in ensuring safe working conditions, the activities of certain private companies can cause considerable harm to human health. Thus, governments have a crucial role to play in the HiAP approach by engaging stakeholders within and beyond government. In this chapter, intersectoral collaboration or internal government is referred to a whole-of-government approach. On the other

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 80

Chapter 7

hand, Chapter 5 looks at external non-government stakeholder engagement, which is a referred to as a whole-of-society approach. This is where government involves a range of actors in the development, implementation, and monitoring of health issues. Even though nongovernment stakeholders play an instrumental role within the agenda setting and policy formulation stages, their involvement can occur at all stages (Buse et al., 2005)

7.3.1 Civil society and HiAP Civil society is a broad term that can encompass many actors including non-government organizations, faith-based groups, philanthropic foundations, labor unions, professional associations, cooperatives, and research institutes. The single characteristic that these actors share is that they are not-for-profit. Alongside civil society, private firms are also important actors in the health policy cycle. Unlike civil society, the characteristic that the private sector ultimately shares is the pursuit of profit. This creates a complicated, often conflictual relationship with the public health sector, given the principles of health as a matter of social justice and a public good. On the one hand, the private sector might have considerable resources, expertise, and technology to potentially direct towards public health. However, there are numerous issuesâ&#x20AC;&#x201D;such as neglected diseases and the commercial determinants of healthâ&#x20AC;&#x201D;that should suggest skepticism and caution about the private sectorâ&#x20AC;&#x2122;s involvement in public health matters. Some of the ways in which private sector interests can be powerful in permeating the policy dialogue and undermine government actions (Reich, 2002):

o Casting doubt on scientific evidence and misleading the public by denying negative health effects.

o Promoting ineffective policy solutions. For example, the alcohol industry has promoted corporate social responsibility, a policy intervention that has been proven to be ineffective as the incentives favor irresponsibility rather than responsibility.

o Permeating and, at times, infiltrating other sectors or decisionmaking levels by lobbying policy-makers and politicians or recruiting former civil servants with credibility among their peers. Tobacco lobbyists might also reach other sectors (e.g. trying to persuade policy-makers of benefits for tobacco

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Intersectoral Collaboration in Health

Page 81

growersâ&#x20AC;&#x2122; livelihoods or of potential revenue losses following a tax increase) and ultimately permeate their political discourse.

o Using litigation at national and international levels to challenge policy decisions.

o Creating alliances with other business sectors, for example, hospitality, gambling, retail and advertisingâ&#x20AC;&#x201D;in the case of the tobacco industry.

o Moving to countries with the least resistance. Markets are dynamic so regulatory efforts in one country can lead to expanding markets in others. Actors can accept decreases in one region as long as overall consumption of harmful products increases. For example, reductions in North American or some European markets may be compensated for by aggressive marketing elsewhere.

7.3.2 Principles of stakeholder engagement Not all stakeholders have the same importance and necessary involvement in the formation, development, and evaluation of health policies (Buse et al., 2005). There are two broad categories of stakeholders (Walzer & Sudhipongpracha, 2012). A primary stakeholder is one who, without continuing participation, the policy or issue could not succeed or be addressed. For example, schools might be a primary stakeholder when dealing with the issue of healthy foods for children. A secondary stakeholder is one who has some influence or is affected by the policy or issue. However, their engagement is not essential to address the issue or to take policy action. For example, car manufacturers might be a secondary stakeholder when addressing road safety and drink driving. In principle, a governmentâ&#x20AC;&#x2122;s engagement with external stakeholders increases accountability to its citizens and is an indicator of good governance (Walzer & Sudhipongpracha, 2012). There are also practical policy benefits, such as:

o Assessing support and opposition to a policy; o Giving government activities visibility and legitimacy; o Empowering the marginalized;

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 82

Chapter 7

o Increasing collaboration and more efficient use of resources; and

o Ensuring the sustainability of interventions. Engaging with supportive external stakeholders—such as research institutions and non-government health organizations—can also help accumulate evidence and public support for radical measures to improve population health. This can be especially important for health ministries with limited political influence and resources.

7.3.3 Challenges of stakeholder engagement A comprehensive multi-stakeholder process can give high legitimacy to an initiative, but it also entails significant transaction costs (Carman, et al., 2013). The more stakeholders at the table, the more difficult and timeconsuming the process can be to reach a common understanding and position. Some additional challenges or risks of stakeholder engagement include: prolonging policy-making, increasing costs of intervention, polarizing interest groups, and creating unmanageable expectations. One of the balances to find in consulting with external actors is between speed and legitimacy (King & Cruickshank, 2012). Fewer actors make policy formulation and implementation faster but stakeholders may be reluctant to accept or support a policy in which they had no say or influence.

7.4 GROUP ACTIVITY Students will be asked to continue their discussion on the case study entitled, “Health for All” or “Health by All (?)”: Developing Health Management Capacity Indicators for Local Governments in Thailand. But, the discussion must be framed in the context of intersectoral collaboration. Below is a list of questions for the discussion:

o Use the Whole-of-Government approach and the Whole-ofSociety approach to explain current public health practices in the two good-practice communities in the case study. Compare and contrast the good-practice communities to the comparison communities.

o Identify potential collaborative programs/projects/activities between local governments and national/regional government

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Intersectoral Collaboration in Health

Page 83

agencies. Discuss how such collaborative partnerships can help build public health capacity at the local level in Thailand and beyond

o Identify potential non-government actors/agencies for local public health programs/projects/activities. How can these nongovernment actors contribute to capacity building at the local level?

7.5 WRAP-UP QUESTIONS o Explain the differences among different levels of collaboration. Provide several sample projects/programs that involve shared resources and shared responsibilities.

o Explain the differences between the Whole-of-Government approach and the Whole-of-Society approach to health.

o Discuss the roles of civil society and private sector organizations in the public health sector.

o Explain each type of intergovernmental collaboration (e.g., interministerial committees, cabinet secretaries, parliamentary committees) at each stage of the health policy cycle.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

CHAPTER 8 Negotiation and advocacy for health Topics and Concepts Basis of policy negotiation Approaches to policy negotiation Stages of the negotiation process

Learning Objectives Explain the scope of policy negotiation in the health context Distinguish different approaches to policy negotiation Apply the policy negotiation techniques in a simulated case

Teaching and Learning Techniques Lecture Class dialogue Simulated case (Mock WTO debate)

Additional Learning Resource Hirono, K., Haigh, F., Gleeson, D., Harris, P., & Thow, A. M. (2015). Negotiating Healthy Trade in Australia: Health Impact Assessment of the Proposed Trans-Pacific Partnership Agreement. Liverpool, Australia: Centre for Health Equity Training Research and Evaluation, part of the Centre for Primary Health Care and Equity, Faculty of Medicine, UNSW Australia.

Negotiation and Advocacy for Health

Page 85

8.1 INTRODUCTION Arguments on the intrinsic value of health or health’s contribution to sectoral or societal gains can be useful in discussions with politicians and policy-makers across sectors. This chapter is about policy negotiations in the health context, beginning with a background on policy negotiations, including common approaches and the major stages of the process. Negotiation techniques – such as detailed preparation, sharing information, and offering multiple agreement opportunities – will be emphasized. A large part of the chapter is dedicated to applying the policy negotiation techniques to a role play of a case study.

8.2 BASIS OF POLICY NEGOTIATION Negotiation may be defined as a process whereby two or more parties seek an agreement to establish what each shall give or take, or perform and receive in a transaction between them. Alternatively, it is an act of discussing an issue between two or more parties with competing interests, with an aim to identify acceptable trade-offs for coming to an agreement (Bhattacharya, 2005). Negotiations are relevant to both wholeof-government and whole-of-society approaches (Bhattacharya, 2005). Given the nature of contemporary health challenges, which are complex and influenced by multiple sectors as discussed in Chapters 1 and 2, dialogue and collaboration between health and other stakeholders is critical. Further, adopting an HiAP approach as explained in Chapter 2 means health policy-makers must acquire negotiating skills (Fuller, 2003). To recapitulate Chapter 7, intersectoral action or a whole-ofgovernment approach refers to the coordinated efforts of two or more sectors within government to improve health outcomes. This can include working across different levels of government such as district, provincial, and national jurisdictions. A whole-of-society approach, in contrast, refers to coordinated efforts to improve health by multiple stakeholders within and outside government that can also be from several sectors. It cannot be taken for granted that sectors and organizations will bring the same priorities, interests, and attitudes to the negotiation table (Fuller, 2003). It also cannot be taken for granted that different parts of the health sector can agree on an HiAP approach (Bhattacharya, 2005).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 86

Chapter 8

Therefore, it is essential that the policy champions and advocates involved in the HiAP process acquire the negotiating skills necessary to move the HiAP agenda forward. This means “negotiating across” to achieve national policy coherence through a whole-of-government approach and negotiating “out” for a whole-of-society approach, which means building coalitions with diverse actors (Fuller, 2003). It also means negotiating “within” the health sector (Figure 7). Figure 7. The Scope of Negotiation for Health

While negotiations can occur at any time during the policy cycle, they frequently take place at the policy formulation stage (Rollans et al., 2013).

8.3 APPROACHES TO POLICY NEGOTIATION While there are many ways to break down the policy negotiation process, it can generally be classified into four different approaches (Kilmann & Thomas, 1977). These four approaches can be plotted on a twodimensional diagram with the X-axis denoting degrees of cooperation with stakeholders and the Y-axis denoting degrees of assertiveness (Figure 8).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Negotiation and Advocacy for Health

Page 87

Figure 8. Four Main Approaches to Policy Negotiation

Source: Kilmann and Thomas (1977). o Competitive. The premise of this approach is to maximize one’s gains and minimize concessions to other parties. This amounts to taking as much of the “pie” as possible. Competitive negotiators assume a “zero-sum” game and behave in an assertive and non-cooperative manner. o Haggling. This common approach to negotiating, which often lies somewhere between the competitive and cooperative approaches, aims to secure a pre-determined position by making trade-offs or concessions. This amounts to getting as much of the “pie” as possible but being prepared to give up some. Haggling negotiators assume a “zero-sum” game and behave in a guarded and manipulative way. o Avoidance. The aim of this approach to negotiation is to defer or postpone decisions on difficult or unfavorable issues. This amounts to stopping the negotiating parties from discussing the “pie.” Avoidance negotiators are usually dynamic and reply on a combination of subtlety and assertiveness to divert or derail the negotiations.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 88

Chapter 8

o Cooperative. This approach to negotiating seeks mutual gains for all parties by joint problem solving. It amounts to searching for ways to make the “pie” bigger so everyone gets a larger piece. Cooperative negotiators assume there are “win-win” solutions and behave in an open and collaborative way.

8.4 STAGES OF THE NEGOTIATION PROCESS While there are many ways to breakdown the negotiation process, it generally includes the following stages (Harris et al., 2014):

8.4.1 Understanding a problem raised in agenda setting Negotiations occur after a problem or opportunity has been identified, which corresponds to the agenda-setting stage of the policy cycle (Bhattacharya, 2005). At the beginning of the negotiation process, it is also fundamental to determine whether negotiations are necessary or possible. On rare occasions, a single actor might be able to address an issue unilaterally (Fuller, 2003). For example, a health minister might ban a product scientifically linked to health problems. In contrast, there might be situations where this same actor has limited policy space or other priorities. The negotiation process and successful outcomes are closing linked to windows of opportunity (Fuller, 2003).

8.4.2 Identify stakeholders and their interests Once the problem is well understood, one has to identify who may benefit and who may lose in the negotiation (Rollans et al., 2013). It is particularly important to recognize whether there are any powerful interest groups that may either support the efforts to negotiate a solution to the problem or strongly oppose the negotiations. A stakeholder analysis is used in this stage of the negotiation process (Rollans et al., 2013).

8.4.3 Consult with stakeholders Once stakeholders and their interests have been identified, it is important to plan and organize an effective consultation process to further understand their needs and gather information to develop a negotiating agenda and determine a position on each of the issues to be negotiated (Harris et al., 2014). This stage of the negotiation process might be delayed

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Negotiation and Advocacy for Health

Page 89

until or repeated after a negotiation agenda is clearly established and before negotiations commence. Consultation with stakeholders, especially those that are supportive or neutral, is important for building coalitions (Harris et al., 2014).

8.4.4 Establish negotiation agenda Before negotiations can begin an agenda defining the issues open for discussion is usually agreed upon by the parties (Fuller, 2003). Often, this agenda is set by a politician or senior decision-maker overseeing the process. On other occasions, this agenda might be set by external events or negotiated by the stakeholders themselves voluntarily coming together to address an issue (Fuller, 2003). At the same time as establishing a negotiation agenda, it is normal to designate representative negotiators for the participating stakeholders and decide upon a format for the process, including location, timing, and resources for facilitation.

8.4.5 Develop positions and strategies On the basis of available information, continuing analysis and consultations, negotiating positions, and strategies may be formulated (Harris et al., 2014). The selection of a negotiating objective at the very beginning of this step is highly recommended in order to provide a clear focus for both the preparatory work leading to a negotiation and to the management of the negotiation itself (Harris et al., 2014). Steps involved in developing a negotiating strategy may include:

o Establishing outcomes and priorities for oneself; o Estimating outcomes and priorities for other parties; o Identifying and assessing major trade-offs; and o Constructing and evaluating as many possible combinations of outcomes and consequences. A strategy or approach to the negotiations is decided upon at this point (Harris et al., 2014). However, it is important to note that strategies can change during negotiations. Evaluating the consequence of a failure to reach an agreement can be an overlooked challenge of negotiation planning (Harris et al., 2014).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 90

Chapter 8

8.4.6 Negotiate with stakeholders It is during this stage that the stakeholders implement their strategies, propose agreements, offer concessions and compromises are reached (Walls et al., 2015). The chosen negotiation strategies of the stakeholders, as discussed below, will heavily influence the tone of the discussions and the potential agreements that can be reached (Walls et al., 2015).

8.4.7 Assess proposed agreement After the actual negotiation has finished and the elements of an agreement have been put together, a short evaluation of the whole outcome becomes necessary to decide whether a successful agreement is possible or whether another round of negotiations might be needed (Walls et al., 2015). Individuals external to the negotiation, especially technical experts and lawyers, are sometimes involved in making this assessment to ensure the proposed agreement is legal and viable (Walls et al., 2015).

8.5 GROUP ACTIVITY 8.5.1 Assignment detail This class session will conclude with a simulated case study on â&#x20AC;&#x153;Effects of the Global Pharmaceutical Drug Trade on Multi-drug Resistance Tuberculosis (MDR-TB) in India.â&#x20AC;? Students will be asked to work in groups to represent India and other countries in a mock WTO summit. Each group of students will serve as a countryâ&#x20AC;&#x2122;s delegation consisting of three members. Each group is required to prepare a 1-2 page position paper, which states the position of the country that will be represented during the mock negotiation process. It is recommended that the position paper includes: o A brief introduction to the country and its history concerning the issue, o How the issue affects the country, o Actions taken by the government regarding the issue,

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Negotiation and Advocacy for Health

Page 91

o What the country would like to accomplish during the negotiations, and o Statistics that support the countries’ positions on the issue.

8.5.2 Debate procedures The mock WTO negotiations will proceed in the following steps: o Setting the agenda. During the first negotiation round, the committee will have to set the agenda for the negotiations. Setting the agenda means discussing what the delegates consider to be the most relevant issues regarding the scope of their committee. Students are expected to represent their designated countries’ positions on the international pharmaceutical drug trade. The goal of setting the agenda is to create a priority list of 4-5 issues which shall be discussed during the second negotiation round. In case of a lack of consensus among the delegates, a voting procedure can be set into motion by the chair or upon request of one of the delegates. A two-third majority is required when voting for the agenda setting. o Making a motion. After the agenda has been set, the chair will call for the start of the negotiations. The delegates will make motions to open the debate on a specific topic. For any motion to be accepted, a simple majority of the votes is needed. Once the debates on a specific issue have been opened, delegates can either motion for a moderated or an unmoderated caucus. This can be done by raising their placards and waiting for the chairperson to call them out. Voting on the motions requires a simple majority for a motion to pass. To allow for a fruitful discussion and for all delegates to become acquainted with the positions of the various countries, the chairperson will call for opening speeches in which each delegate must state the position of their country on the topic that is going to be discussed. Examples of a motion are as follows: 1. “I motion to open the debate on the issue of…..” 2. “We motion for a moderated/unmoderated caucus of 15 minutes on the issue of….”

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 92

Chapter 8

8.5.3 Moderated Vs. unmoderated caucus o Moderated caucus. During the moderated caucus, delegates are called out by the chairs after raising their placards, to talk about the issue that was proposed. Due to formality, delegates should refrain from using the â&#x20AC;&#x153;Iâ&#x20AC;? form at any moment. Furthermore, as the time for the negotiations will be limited, when called out, delegates must try to express their thoughts or debate the issues in a concise manner. It is at discretion of the chairs to interrupt a delegate who is holding a speech which is not within the topic or is considered invaluable to the debate. During an unmoderated caucus, only one delegate is allowed to speak at a time. o Unmoderated caucus. After a few moderated caucuses, a motion for an unmoderated caucus can be raised by a delegate. The procedure for the acceptance of such a motion is the same as for a moderated caucus. During the unmoderated caucus, delegates are allowed to walk around the negotiation room and talk to other delegates about possibilities of concrete resolutions. It is recommended to write down the ideas that come up during an unmoderated caucus. Since a resolution will need full consensus, it is recommended that all the delegates work together on ideas, or that the work is split up during these types of caucuses. The number of unmoderated caucuses will be determined by the chair.

8.5.4 Working paper The process of a resolution can be divided into 3 main phases: a working paper, a draft resolution, and a final resolution. The working paper represents the first gathering of ideas for the final resolution. The working paper has no formal requirements and just serves as a guideline for the delegates to remember and discuss about aspects that have already been negotiated. This, however, does not mean that delegates are limited to the issues that are discussed in the working paper. Further elements can be added throughout the negotiations. Committees can use the time to discuss issues, while writing a working paper to negotiate with the other delegates or even across committees. Working papers shall be submitted to the chairperson to be reviewed. It is also recommended that the delegates use an online document, such as Dropbox or Google Folder, which is shared by

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Negotiation and Advocacy for Health

Page 93

all the members in a committee and the chairperson to allow for a transparent development of the negotiations. Since a working paper is not subject to any formal requirements, it is up to the delegates to decide on the formatting of this document. Multiple working papers can be submitted to the chairs and later merged with the consent of all delegates of the committee. However, only one draft resolution will be allowed to pass on to the voting procedure.

8.5.5 Draft resolution For a paper to be validated as a draft resolution, formal requirements must be fulfilled. A draft resolution consists of: a heading, pre-ambulatory clauses and a declaration. o The heading is simply the title of the draft resolution. The heading has to include the name of the committee, as well as the date. For example, “Declaration of the Committee on … of the 29th of September 2000.” o The pre-ambulatory clauses serve as a declaration of intent of the parties as well as a declaration of the reasons why the parties have come to the agreement that will follow. This section of a draft resolution may include or refer to: • Existing WTO agreements, • Reference to specific articles, • Reference to past ministerial conferences, • Information about the importance of the resolution, and • Statements made by any WTO body. The pre-ambulatory clauses shall be formulated as one sentence and using commas to separate the single parts which must start with words used for the same purposes in past agreements. The delegates are encouraged to have a look at past declarations and resolutions of the WTO to refer to these words. The declaration of the draft resolution forms the most substantial part of the document. Within this section the actual actions that the committee decided upon must be stated. This part of the document can include: amendments to existing articles, creation of

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 94

Chapter 8

working groups for specific purposes, creation or expansion of new committees (the tasks of these committees would then have to be stated), elimination of articles, and encouragements to member states. Only once all formal requirements are met and the paper has been checked by the chairs, will the document be considered a draft resolution. Furthermore, the draft resolution is not considered to be the final document which will be put to vote, as amending this document is still possible during the next part of the negotiations.

8.5.6 Final resolution Before concluding negotiations, all points on the agenda (if possible) must have been discussed and included in the draft resolution. Once the chairperson gives green light on a draft resolution the amending procedure may start. At that moment, any changes to the draft resolution can be proposed. A full consensus within the committee is needed for an amendment to be valid and to be integrated into the final resolution paper. It is recommended that delegates also check the wording of the declaration as (in a real case scenario) once the resolution is passed by the committee, it becomes binding for all the member states, which have participated. Small changes in the wording, can allow for more or less mobility within the scope of an agreement. When all amendments have been made to the draft resolution, the paper is submitted once again to the chairperson for a final check and the committee may move into the final voting procedure.

8.5.7 Closing the debate When coming to the end of a day, the debate must be adjourned to the next session. To do this, any delegate in a committee may introduce a motion to close the debate for the day or to adjourn the negotiations for after lunch break. For example, “Motion to adjourn/postpone the meeting for tomorrow.” In the same way, once the first issue on the agenda has been concluded or the topic has been exhausted, a motion to move on to close and conclude the current topic, as well as to open the debate for the next agenda item is required. For example, “Motion to close the debate on this issue of and open the debate for the next element on the agenda.” The same procedure is needed for the opening of the negotiations in the new session or after a lunch break.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Negotiation and Advocacy for Health

Page 95

8.5.8 Voting procedure In the real WTO negotiations, the final step of the negotiations consists in voting on the acceptance of the final resolution. Two main voting rounds will take place during the conference. The first voting round is internal to each committee. For substantial votes, such as passing resolutions or amendments, a full consensus is needed. The final resolutions of each of the committees will then be presented at the second voting round at the WTO headquarters. All delegations will be present and vote on the acceptance of the resolution. The resolution will need full consensus to pass.

8.6 WRAP-UP QUESTIONS o Define negotiation, negotiation “within” the health sector, negotiation “across,” and negotiation “out.” Why are negotiating skills necessary for those working in the health sector? At which stage in the policy cycle does negotiation usually take place? o What are the four main approaches to policy negotiation? How is “competitive” negotiation different from “avoidance” negotiation? Provide a couple of real-world examples to back up your answer. o How many steps are involved in policy negotiation? What does it mean by “establishing negotiation agenda”? What factors can lead to an agenda? Further, identify the necessary steps for formulating the negotiation strategy.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

CHAPTER 9 Monitoring and evaluation (M&E) Topics and Concepts Definition of M&E and cycle of health monitoring Health impact assessment (HIA) Health lens analysis (HLA)

Learning Objectives Describe the basic principles of M&E and cycle of health monitoring Distinguish different M&E approaches Apply the M&E techniques in a simulated case

Teaching and Learning Techniques Problem-based learning Introductory and summarizing lecture Class dialogue Simulated case (Mock WTO debate)

Materials and Equipment PowerPoint file for presentation Flipcharts and markers Video clip “Sustainable Development in Brazil” (Available on YouTube.com) Case study: “Bringing Electronics Manufacturing to Curitiba” (Appendix D)

Additional Learning Resource Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. (Chapters 9&10).

Monitoring and Evaluation (M&E)

Page 97

9.1 INTRODUCTION Monitoring can be defined as the systematic collection of data about an indicator or variable of interest. In contrast, evaluation involves a judgment about the value of or change in that variable (Nutbeam, 1998). Monitoring and evaluation (M&E) can focus on different aspects of health and health policy making, such as population health (e.g. incidence of disease and life expectancy), epidemiology (e.g. risk factors and exposure levels), determinants of health (e.g. income and living conditions), health system performance (e.g. access and quality of health services), and health policy (e.g. impact on health outcomes and health inequity) (Lai et al., 2014). From the HiAP perspective, the purpose of M& E is to determine the impact of policies, programs, and practices (Nagel, 2002). Generally speaking, the five stages of the cycle of health monitoring are: (1) selecting relevant indicators, (2) obtaining data, (3) analyzing data, (4) reporting results, and (5) implementing changes. As M and E focus on different aspects of health and policy making, indicators often correspond to different stages of a policy intervention and can be categorized as a “results chain” (Figure 9) (Crabbe & Leroy, 2008). Figure 9. Results Chain Analysis

For instance, the “results chain” framework can be used to evaluate the universal health coverage program (Frye & Hemmer, 2012). It can be used to explain how the social determinants of health influence health system inputs, outputs, and how health system users use health services

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 98

References

(Herian et al., 2012). Based on this broad framework, this chapter will introduce students to two M&E approaches: (1) Health Impact Assessment (HIA) and (2) Health Lens Analysis (HLA).

9.2 DEFINITION OF M&E AND CYCLE OF HEALTH MONITORING Monitoring can be defined as the systematic collection of data about an indicator or variable of interest (Crabbe & Leroy, 2008). In contrast, evaluation involves a judgment about the value of or change in that variable. Health monitoring is the process of tracking the health of a population and the health system that serves that population (Lai et al., 2014). Generally speaking, there are five stages of the cycle of health monitoring (Figure 10): Figure 10. Stages of the Cycle of Health Monitoring

o Selecting relevant indicators. The M&E process begins by identifying indicators that are relevant to the monitoring approach. These measures can be quantitative or qualitative (Lai et al., 2014). The appropriate selection can often be a complicated task that requires consideration of what is easily monitored, analytically robust, and communicates the issue directly to the public and other policy-makers.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Monitoring and Evaluation (M&E)

Page 99

o Obtaining data. Data collection should occur regularly. The methodology for this collection will depend on the purpose of the M&E and could include, for example, scientific research and trials, epidemiological studies, household surveys, analysis of policy processes, interviews, and project case studies (Lai et al., 2014).

o Analyzing data. This means interpreting the data and can involve preparing summary statistics, modeling, literature reviews and political analysis of policy processes and issues, such as the social determinants of health and barriers to health care access (Hirono et al., 2015).

o Reporting results. Reporting can come in many forms, ranging from internal memos to press releases, technical reports and academic publications, each including various methods of presenting data, such as tables, graphs, maps, and text (Hirono et al., 2015). The goal should be to ensure that the results of the monitoring process are communicated effectively, and can be used to inform policies, programs and practice.

o Implementing changes. Based on monitoring results, changes may be implemented that will improve health policy, maximize the net health benefits of activities outside the health sector, enhance population health, and reduce health inequities (Hirono et al., 2015).

9.3 HEALTH IMPACT ASSESSMENT (HIA) Many of the determinants of health and health inequities in populations have social, environmental and economic origins beyond the direct influence of the health sector and health policies (Shojaei et al., 2016). Thus, it is important to monitor the activities of other sectors for significant health consequences. As the WHOâ&#x20AC;&#x2122;s Commission on Social Determinants of Health recommends, routine consideration of health and health equity impacts in policy development is one way to achieve a reduction in health inequalities (Shoaf et al., 2003). A health impact assessment (HIA) is a common approach to achieve this.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 100

References

9.3.1 Definition and purpose of HIA An HIA is a combination of procedures, methods, and tools that assess the potential effects of a policy or project on the health of a population and the distribution of those effects within the population (Shojaei et al., 2016). HIAs also identify appropriate actions to manage those effects. Many different people and organizations offer a variety of definitions for HIAs (Shoaf et al., 2003). Each definition is similar, differing through the emphasis given to particular components of HIA (Prasad et al., 2015). What is presented in this chapter is only a simplification of HIA. HIAs do not only look for negative impacts in order to prevent or reduce them, but also for impacts favorable to health. Generally speaking, HIA is based on the following governance values (Prasad et al., 2015):

o Democracy – allowing people to participate in the development and implementation of policies, programs or projects that may impact on their lives;

o Equity – HIA assesses the distribution of impacts from a proposal on the whole population, with a particular reference to how the proposal will affect vulnerable people (in terms of age, gender, ethnic background and socioeconomic status);

o Sustainable development – that both short- and long-term impacts are considered, along with the obvious and less obvious impacts; and

o Ethical use of evidence – the best available quantitative and qualitative evidence must be identified and used in the assessment. A wide variety of evidence should be collected using the best possible methods. These values provide decision makers with options to strengthen and extend the positive features of a health program/project, with an ultimate goal of improving the health of the population (Shoaf et al., 2003). HIA is an important and useful tool within the health policy sector, as it provides a tangible way for government departments and their partner sectors to work together rather than just talking about improving population health (Shojaei et al., 2016). The flexibility of an HIA approach allows these projects, programs, and policies to be assessed at either a local, regional, national or international level – making HIA suitable for

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Monitoring and Evaluation (M&E)

Page 101

almost any proposal. However, choosing the right time to perform an HIA is important (Prasad et al., 2015).

9.3.2 HIA Procedure At the policy formulation stage, an HIA consists of the three following steps (Prasad et al., 2015)::

o Screening – establishing health relevance of a policy or project and determining if HIA is required;

o Scoping – identifying key health issues and public concerns, establishing TOR, and setting boundaries of a policy, project, and program; and

o Appraisal – in-depth assessment of health impacts using available evidence, especially who will be affected, baseline, prediction, significance, and mitigation. At the policy implementation stage, HIA involves the following activities (Prasad et al., 2015):

o Reporting – making conclusions and recommendations to remove/mitigate negative impacts on heath (or to enhance positive impacts); and

o Monitoring – Monitoring actual impacts to enhance existing evidence.

9.4 HEALTH LENS ANALYSIS (HLA) 9.4.1 Definition and purpose of HLA Health Lens Analysis (HLA) builds on traditional health impact assessment methodology by incorporating additional methods, such as economic modeling, to accommodate the policy imperatives and cultural context in which a health policy, program, and project operate (Lawless et al., 2012). HLA allows the M&E to deliver both rigor and flexibility. As a result, the methodology used for an HLA can modified for each population group and different social contexts (Baum et al., 2013).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 102

References

9.4.2 HLA Procedure The emerging methodology for HLA, which is being promoted in South Australia and South Africa, consists of a series of steps (Baum et al., 2013): o Engage – establishing and maintaining strong collaborative relationships with other sectors to determine policy focus; o Gather evidence – establishing impacts between health and the policy area under focus, and identifying evidence-based solutions or policy options; o Generate – producing a set of policy recommendations and a final report that are jointly owned by all partner agencies; o Navigate – helping to steer the recommendations through the policy-making process; and o Evaluate – determining the effectiveness of the HLA.

9.5 GROUP ACTIVITY The purpose of this group activity is to allow students to gain a practical understanding of the steps involved in an M&E for a healthrelated policy. The policy scenario provided is that of a model sustainable city, Curitiba in Brazil—which is well-known for its environmentally friendly public transportation, effective garbage recycling program, and comprehensive social welfare activities for low-income households in the urban slum areas. Suggested activity: o Suppose, the current Curitiba mayor is deciding whether to put itself forward as the new site of a large electronics manufacturing factory. He asks you and your team to help him prepare a Health Impact Assessment (HIA) report or a Health Lens Analysis (HLA) o Students should be divided into small groups. A case study policy scenario (Appendix D) will be distributed to each group. After becoming familiar with the scenario, students should set the scope

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Monitoring and Evaluation (M&E)

Page 103

of the HIA/HLA by identifying stakeholders to engage and the potential health risks and other issues that should be assessed. As part of preparing the terms of reference (TOR) for the HIA/HLA, the participants should try to identify indicators or measures for data collection as well as questions they might ask different stakeholders (See Appendix D for a template). Figure 11. â&#x20AC;&#x153;Sustainable Development in Brazilâ&#x20AC;? (URL: https://youtu.be/r4sumpEqnlY)

o Students will have around 30 minutes to draft their TORs, which

they will then share with the group. Students should remember to include benefits and possible unintended consequences from various determinants of health. o Some of the stakeholders that the groups might list could include,

are not limited to, local government representatives, trade and foreign affairs departments, environment department, transport/infrastructure department, tourism department, manufacturing workers union(s), and technical colleges. o The health impacts and other issues might include transformation

of the landscape, increase in the amount of waste generated, primary benefits of jobs, pressure on housing, schools, hospitals if

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 104

References

workers come from elsewhere, potential for technology transfer, secondary economic benefits such as parts suppliers, deterioration in air and water quality, potential pressure on city’s utilities, and sustainability of electronics manufacturing industry. o Some of the indicators and questions that the HIA might

investigate could include: • Air pollution and CO2 emissions – what amounts of

pollution and CO2 emissions are likely? • Noise levels – what levels of noise will the factory create and

during what hours? • Volume of waste – how much waste and of what kind will be

produced? • Worker profile – what kind of workers are likely to be

employed? Where will they come from? • Population – what additional public services might be

required to support a larger population? • Economic growth – which businesses will benefit from the

factory’s presence? For how long?

9.6 WRAP-UP QUESTIONS o How is policy monitoring different from policy evaluation? Does policy monitoring use different methodologies than policy evaluation? o Explain the five stages involved in the M&E procedure. Do these five stages differ from the policy cycle? o What is health impact assessment (HIA)? What is the main purpose of performing an HIA? What factors are taken into consideration when an HIA is conducted? o What governance values constitute the foundations of HIA? Explain the HIA procedure. How does each step in the HIA procedure correspond to each governance value underpinning the HIA?

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Monitoring and Evaluation (M&E)

Page 105

o Explain the HLA procedure. What are the differences between Health Impact Assessment (HIA) and Health Lens Analysis (HLA)?

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

References Adler, N. E., & Newman, K. (2002). Socioeconomic Disparities in Health: Pathways and Policies. Health Affairs, 1(21), 60-76. Agranoff, R., & McGuire, M. (1999). Managing in Network Settings. Policy Studies Review, 16(1), 19-40. Ansoff, H. I. (1988). Corporate Strategy. London: Penguin Books. Ansolabehere, S., & Iyengar, S. (1995). Going Negative: How Attack Ads Shrink and Polarize the Electorate. New York : Free Press. Arifeen, S. E., Christou, A., Reichenbach, L., Osman, F. A., Azad, K., Islam, K. S., et al. (2013). Community-based Approaches and Partnerships: Innovations in Health-service Delivery in Bangladesh. Lancet, 382, 2012-2026. Aubrun, A., & Grady , J. (2000). How Americans Understand Teens: Findings from the Cognitive Interviews. Washington, DC: FrameWorks Institute. Bales, S. N. (1998). Effective Language for Discussing Early Childhood Education. Washington, DC: Benton Foundation with the Human Services Policy Center at the University of Washington. Barry, P. (2002). Structuralism. Manchester: Manchester University Press. Baum, F., Lawless, A., & Williams, C. (2013). Health in All Policies from international ideas to local implementation: policies, systems and organizations. In C. Clavier, & E. De Leeuw, Health Promotion and the Policy Process: Practical and Critical Theories (pp. 188-217). Oxford: Oxford University Press. Berkman, L. F., & Kawachi, I. (2000). Social Epidemiology. New York: Oxford University Press. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, Health, and Cost. Health Affairs, 27(3), 759-769. Best, J. (1995). Images of Issues. New York: Aldine de Gruyter. Bhattacharya, D. (2005). Least Developed Countries in Trade Negotiations: Planning Processes and Information Needs. Asia-Pacific Trade and Investment Review, 1(1), 71. Bifulco, R., & Ladd, H. F. (2006). Institutional Change and Coproduction of Public Services: the Effect of Charter Schools on Parental Involvement. Journal of Public Administration Research and Theory, 16(4), 553-576. Birkland, T. (1997). After Disaster: Agenda Setting, Public Policy, and Focusing Events. Washington, DC.: Georgetown University Press.

References

Page 107

Birkland, T. (2007). Agenda Setting in Public Policy. In F. Fischer, G. J. Miller, & M. S. Sidney, Handbook of Public Policy Analysis: Theory, Politics, and Methods (pp. 63-78). New York: CRC Press. Bjorklund, A., Svensson, T., & Read, S. (2006). Holistic and Biomedical Concepts of Health: A Study of Health Notions among Swedish Occupational Therapists and a Suggestion for Developing an Instrument for Comparative Studies. Scandinavian Journal of Occupational Therapy, 13(3), 141-150. Boston, J. G. (2011). Joint or Shared Accountability: Issues and Options. Retrieved September 1, 2017, from Institute of Policy Studies: http://igps.victoria.ac.nz/publication/files/83e71189c2b.pdf Bovaird, T. (2007). Beyond Engagement and Participation: User and Community Coproduction of Public Services. Public Administration Review, 67(5), 846-860. Bovaird, T., & Loeffler, E. (2013). The Role of Coproduction for Better Health and Wellbeing: Why We Need to Change? In E. Loeffler, G. Power, T. Bovaird, & F. Hine-Hugues, Coproduction of Health and Wellbeing in Scotland (pp. 20-27). Birmingham: Governance International. Brandsen, T., & Pestoff, V. (2006). Coproduction, the Third Sector, and the Deliver of Public Services. Public Management Review, 8(4), 493-501. Bullock, H., Mountford, J., & Stanley, R. (2001). Better Policy Making. London: Center for Management and Policy Studies. Burns, S., Boyle, D., & Krogh, K. (2002). Putting the Life Back into Our Health Services. London: New Economics Foundation. Buse, K., Mays, N., & Walt, G. (2005). Making Health Policy: Understanding Public Health. New York: McGraw-Hill. Butterfoss, F. D., & Kegler, M. C. (2012). A Coalition Model for Community Action. In M. Minkler, Community Organizing and Community Building for Health and Welfare (pp. 309-328). New Brunswick, New Jersey: Rutgers University Press. Carman, K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., et al. (2013). Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies. Health Affairs, 32(2), 223-231. Clemens, R., & McBeth, M. (2001). Public Policy Praxis. Upper Saddle River: Prentice Hall. Cleveland, M., & Laroche, M. (2007). Acculturation to the Global Consumer Culture: Scale Development and Research Paradigm. Journal of Business Research, 60(3), 249-259.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 108

References

Cockburn, R., Newton, P. N., Agyarko, E. K., Akunyili, D., & White, N. J. (2005). The Global Threat of Counterfeit Drugs: Why Industry and Governments Must Communicate the Dangers. PLoS Med, 2(4), e100. Cohen, D. A., Scribner, R. A., & Farley, T. A. (2000). A Structural Model of Health Behavior: A Pragmatic Approach to Explain and Influence Health Behaviors at the Population Level. Preventive Medicine, 30(2), 146-154. Connolly, W. E. (2007). Democracy, Pluralism, and Political Theory. London: Routledge. Crabbe, A., & Leroy, P. (2008). The Handbook of Environmental Policy Evaluation. Trowbridge, England: Cromwell Press. Davies, J. K. (2001). Back to the Future? Prospects for Healthy Public Policy. Public Health Medicine, 3(2), 62-66. Denhardt, J. V., & Denhardt, R. B. (2003). The New Public Service: Serving not Steering. Armonk, New York: M.E. Sharpe. Elbel, B., Taksler, G. B., Mijanovich, T., Abrams, C. B., & Dixon, L. B. (2013). Promotion of Healthy Eating through Public Policy: A Controlled Experiment. American Journal of Preventive Medicine, 45(1), 49-55. Engel, G. L. (1989). The Need for A New Medical Model: A Challenge for Biomedicine. Holistic Medicine, 4(1), 37-53. Evans, R., Barer, M., & Marmor, T. (1994). Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. New York: Aldine de Gruyter. Fischer, F., Miller, G. J., & Sidney, M. S. (2007). Handbook of Public Policy Analysis: Theory, Politics, and Methods. Boca Raton, FL: CRC Press. Forrest, M. (1999). Using the Power of the World Health Organization: the International Health Regulations and the Future of International Health Law. Colum. JL & Soc. Probs, 33, 153. Freeman, B. (2013). Revisiting the Policy Cycle. Melbourne, Australia: Northern Metropolitan Institute. Frey, R., Powell, L., & Gott, M. (2013). Care vs. Care: "Biomedical" and "Holistic" Worldviews of Palliative Care. European Journal of Integrative Medicine, 5(4), 352-364. Frumence, G., Nyamhanga, T., Mwangu, M., & Hurtig, A.-K. (2013). Challenges to the Implementation of Health Sector Decentralization in Tanzania: Experiences from Kongwa District Council. Global Health Action, 6(20983). Frye, A. W., & Hemmer, P. A. (2012). Program Evaluation Models and Related Theories. Medical Teacher, 34, e288-e299.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

References

Page 109

Fuller, J. (2003). Intercultural Health Care as Reflective Negotiated Practice. Western Journal of Nursing Research, 25(7), 781-797. Gamson, W. (1992). Talking Politics. Cambridge: Cambridge University Press. Gauld, R. (2007). Principal-Agent Theory and Organizational Change: Lessons from New Zealand Health Information Management. Policy Studies, 28, 17-34. Gilliam , F. D., & Bales, S. N. (2002). Strategic Frame Analysis and Youth Development: How Communications Research Engages the Public. In R. M. Lerner, F. Jacobs, & D. Wertlieb, Handbook of Applied Developmental Science: Applying Developmental Science for Youth and Families. Thousand Oaks: Sage Publications. Gilliam, F. D., & Bales, S. N. (2001). Strategic Frame Analysis. Social Policy Report, 4, 1-23. Gostin, L. O., & Powers, M. (2006). What Does Social Justice Require for the Public's Health?: Public Health Ethics and Policy Imperatives. Health Affairs, 25(4), 1053-1060. Guston, D. H. (1996). Principla-agent Theory and the Structure of Science Policy. Science and Public Policy, 23(4), 229-240. Guttman, N. (2000). Public Health Communication Interventions: Values and Ethical Dilemmas. Thousand Oaks: Sage Publications. Hall, P. A., & Taylor, R. C. (1996). Political Science and the Three New Institutionalism. Political Studies, 44(5), 936-957. Harris, B., Eyles, J., Penn-Kekana, L., Thomas, L., & Goudge, J. (2014). Adverse or acceptable: negotiating access to a post-apartheid health care contract. Globalization and Health, 10, 35. Heath, R. I. (1997). Strategic Issue Management: Organizations and Public Policy Challenges. London: Sage. Herian, M. N., Hamm, J. A., Tomkins, A. J., & Zillig, L. M. (2012). Public Participation, Procedural Fairness, and Evaluations of Local Governance: the Moderating Role of Uncertainty. Journal of Public Administration Research and Theory, 22(4), 815-840. Hertzman, C., & Power, C. (2006). A Life Course Approach to Health and Human Development. In J. Heymann, C. Hertzman, M. L. Barer, & R. G. Evans, Healthier Societies: From Analysis to Action (pp. 83-106). Oxford University Press. Hill, M. (1997). The Policy Process: A Reader. London: Prentice Hall. Hirono, K., Haigh, F., Gleeson, D., Harris, P., & Thow, A. M. (2015). Negotiating Healthy Trade in Australia: Health Impact Assessment of the Proposed Trans-Pacific Partnership Agreement. Liverpool,

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 110

References

Australia: Centre for Health Equity Training Research and Evaluation, part of the Centre for Primary Health Care and Equity, Faculty of Medicine, UNSW Australia. Hofrichter, R. (2003). Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. San Francisco: Jossey-Bass. Hogwood, B., & Peters, G. B. (1983). Policy Dynamics. Ann Arbor, MI: Wheatsheaf Books. Howard, C. (2005). The Policy Cycle: A Model of Post-Machiavellian Policy Making. Australian Journal of Public Administration, 64, 3-13. Howlett, M., & Ramesh, M. (2003). Studying Public Policy: Policy Cycles and Policy Subsystems. Don Mills, Ontario: Oxford University Press. Iyengar, S. (1991). Is Anyone Responsible? How Television Frames Political Issues. Chicago: University of Chicago Press. Jann, W., & Wegrich, K. (2007). Theories of the Policy Cycle. In F. Fischer, G. J. Miller, & M. S. Sidney, Handbook of Public Policy Analysis: Theory, Politics, and Methods (pp. 43-62). Ann Arbor, MI: Wheatsheaf Books. Johansson, H., Weinehall, L., & Emmelin, M. (2009). "It Depends on What You Mean": A Qualitative Study of Swedish Health Professionals' Views on Health and Health Promotion. BMC Health Services Research, 9(1). Joshi, M., Erb, N., Zhang, S., & Sikka, R. (2016). Leading Health Care Transformation: A Primer for Clinical Leaders. New York: CRC Press. Kang, E. (2016). Intersectoral Collaboration for Physical Activity in Healthy Cities. Health Promotion International, 31(3), 551-561. Kilmann, R. H., & Thomas, K. W. (1977). Developing a Forced-Choice Measure of Conflict-Handling Behavior: the "Mode" Instrument. Educational and Psychological Measurement, 37(2), 309-325. Kindig, D. (2007). Understanding Population Health Terminology. Milbank, 85(1), 139-161. King, C., & Cruickshank, M. (2012). Building Capacity to Engage: Community Engagement or Government Engagement? Community Development Journal, 47(1), 5-28. Kingdon, J. (1984). Agendas, Alternatives, and Public Choices. Ann Arbor: University of Michigan. Koliba, C. J., Mills, R. M., & Zia, A. (2011). Accountability in Governance Networks: An Assessment of Public, Private, and Nonprofit Emergency Management Practices Following Hurricane Katrina. Public Administration Review, 71(2), 210-220. Kuh, D., & Hardy, R. (2002). A Life Course Approach to Women's Health. Oxford University Press.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

References

Page 111

Labonte, R., Woodard, G. B., Chad, K., & Laverack, G. (2002). Community Capacity Building: A Parallel Track for Health Promotion Programs. Canadian Journal of Public Health, 93(3), 181-182. Lai, T., Habicht, T., & Jesse, M. (2014). Monitoring and Evaluating Progress towards Universal Health Coverage in Estonia. PLOS Medicine, 11(9), e1001677. Lakoff, G. (1987). Women, Fire, and Dangerous Things: What Categories Reveal about the Mind. Chicago: University of Chicago Press. Lakoff, G. (1996). Moral Politics: What Conservatives Know tht Liberals Don't. Chicago: University of Chicago Press. Lakoff, G., & Johnson, M. (1979). Metaphors We Live By. Chicago: University of Chicago Press. Laverack, G., & Wallerstein, N. (2001). Measuring Community Empowerment: A Fresh Look at Organizational Domains. Health Promotion International, 16(2), 179-185. Lavis, J. N., Ross, S. E., Hurley , J. E., Hohenadel, J. M., Stoddart, G. L., & Woodwart, C. A. (2002). Examing the Role of Health services Research in Public Policy Making. Milbank Quarterly, 80, 125-154. Lawless, A., Williams, C., Hurley, C., Wildgoose, D., Sawford, A., & Kickbusch, I. (2012). Health in All Policies: Evaluating the South Australian Approach to Intersectoral Action for Health. Canadian Journal of Public Health, 103(1), S15-S19. Lee, K., Buse, K., & Fustukian, S. (2002). Health Policy in a Globalizing World. Cambridge: Cambridge University Press. Lee, Y. C. (2012). Socio-Scientific Issues in Heath Contexts: Treading a Rugged Terrain. International Journal of Science Education, 34(3), 459-483. Leppo, K., & Tangcharoensathien, V. (2013). The Health Sector's Role in HiAP. In K. Leppo, Health in All Policies: Seizing Opportunities, Implementating Policies. Finland: Ministry of Social Affairs and Health. Lindsey, C., Osborne, S. P., & Bond, S. (2014). The 'New Public Governance' and Employability Services in an Era of Crisis: Challenges for Third Sector Organizations in Scotland. Public Administration, 92(1), 192207. Lipsky, M. (1980). Street-Level Bureaucracy. New York: Russell Sage Foundation. Lyons, M. (2006). National Prosperity, Local Choice, and Civic Engagement: A New Partnership between Central and Local Government for the 21st Century. London, United Kingdom: Her Majesty's Stationery Office.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 112

References

McQueen, D., Wismar, M., Lin, V., & Jones, C. M. (2012). Intersectoral Governance for Health in All Policies: Structures, Actions, and Experiences. Copenhagen: World Health Organization Regional Office for Europe. Milio, N. (2001). Healthy Public Policy. Epidemiological Community Health, 55, 622-623. Milward, H., & Provan, K. (1998). Principles for Controlling Agents: the Political Economy of Network Structure. Journal of Public Administration Research and Theory, 8(2), 203-222. Morgan, A., Ziglio, E., & Davie, M. (2010). Health Assets in a Global Context: Theory, Methods, Action. Springer Science and Business Media. Mulvaney-Day, N. E., Alegria, M., & Sribney, W. (2007). Social Cohesion, Social Support, and Health among Latinos in the United States. Social Science and Medicine, 64, 477-495. Mutz, D. C., & Soss, J. (1997). Reading Public Opinion: the Influence of News Coverage on Perceptions of Public Sentiment. Public Opinion Quarterly, 61, 431-452. Nagel, S. S. (2002). Handbook of Public Policy Evaluation. London: Sage. Nash, D. B. (2012). Population Health and Health Reform-Inseparable Concepts. Prescriptions for Excellence in Health Care, 1(16), 1. Nash, D. B., Reifsnyder, J., Fabius, R. J., & Pracilio, V. P. (2011). Population Health: Creating a Culture of Wellness. London: Jones and Bartlett Learning. National Academies of Sciences, Engineering, and Medicine. (2016). Why Frames Matter? Framing the Dialogue on Race and Ethnicity to Advance Health Equit: Proceedings of a Workshop (pp. 37-44). Washington, DC.: The National Academies Press. National Association of County & City Health Officials (NACCHO). (2014). Exploring the Roots of Health Inequity: Essays for Reflection. NACCHO. Nutbeam, D. (1998). Evaluating Health Promotionâ&#x20AC;&#x201D;Progress, Problems and Solutions. Health Promotion International, 13(1), 27-44. O'Sullivan, A., & Sheffrin, S. M. (2003). Survey of Economics: Principles and Tools. London: Prentice Hall. Ottersen, O., Dasgupta, J., Blouin, C., Buss, P., Chongsuvivatwong, V., Frenk, J., et al. (2014). The Political Origins of Health Inequality: Prospects for Change. Lancet, 333, 630-667. Pollitt, C. (1991). Managerialism and the Public Services: the Anglo-American Experience. New York: Blackwell Publishing. Porter, R. (1995). Knowledge Utilization and the Process of Policy Formation: Toward a Framework for Africa. Washington, DC.: USAID.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

References

Page 113

Powers, B. W., & Chaguturu, S. K. (2015). Optimizing High-Risk Care Management. JAMA, 313(8), 795-796. Prasad, A., Kano, M., Dagg, K. A.-M., Mori, H., Senkoro, H. H., Ardakani, M. A., et al. (2015). Prioritizing Action on Health Inequities in Cities: An Evaluation of Urban Health Equity Assessment and Response Tool (Urban HEART) in 15 Cities from Asia and Africa. Social Science and Medicine, November 145, 237-242. Pulzl, H., & Treib, O. (2007). Implementing Public Policy. In F. Fischer, G. J. Miller, & M. Sidney, Handbook of Public Policy Analysis: Theory, Politics, and Methods (pp. 79-87). New York: CRC Press. Reich, M. (2002). Public-Private Partnerships for Public Health (Harvard Series on Population and International Health). Cambridge, MA: Harvard University Press. Rollans, M., Schmied, V., Kemp, L., & Meade, T. (2013). Negotiating policy in practice: child and family health nursesâ&#x20AC;&#x2122; approach to the process of postnatal psychosocial assessment. BMC Health Services Research, 13, 133. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D. V., Potvin, L., Springett, J., et al. (2001). Evaluation in Health Promotion: Principles and Perspectives. WHO Regional Publications, Europen Series, 92. Sachs, R. (2012). Making Intellectual Property Work for Global Health. Harvard International Law Journal, 53, 106. Shannah, E. A., Jones, M. D., & McBeth, M. K. (2011). Policy Narratives and Policy Processes. Policy Studies Journal, 39(3), 535-561. Shoaf, C., Genaidy, A., Karwowski, W., & Huang, S. H. (2003). Improving Performance and Quality of Working Life: A Model for Organizational Health Assessment in Emerging Enterprises. Human Factors and Ergonomics in Manufacturing and Service Industries, 14(1), 81-95. Shojaei, P., Karimlou, M., Mohammadi, F., & Malekafzali, H. (2016). Health Impact Assessment of Urban Development Project. Global Journal of Health Science, 8(9), 224-233. Sidney, M. (2007). Policy Formulation: Design and Tools. In F. Fischer, G. J. Miller, & M. S. Sidney, Handbook of Public Policy Analysis: Theory, Politics, and Methods (pp. 89-107). New York: CRC Press. Sihto, M., Ollila, E., & Koivusalo, M. (2006). Principles and Challenges of Health in All Policies. In T. Stahl, M. Wismar, E. Ollila, E. Lahtinen, T. Melkas, & K. Leppo, Health in All Policies: Prospects and Potentials (pp. 3-20). Finland: Ministry of Social Affairs and Health.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 114

References

Simmons, R. (2011). Leadership and Listening: the Reception of User Voice in Today's Public Services. Social Policy and Administration, 45(5), 539-568. Simonet, D. (2014). Assessment of New Public Management in Health Care: the French Case. Health Research Policy Systems, 12(57), 1-9. Siyanbola, W., Adeyeye, A., Olaopa, O., & Hassan, O. (2016). Science, Technology, and Innovation Indicators in Policy Making: the Developing Countries' Experience. Palgrave Communications, 16015, 1-9. Smith, D. H. (1994). Determinants of Voluntarry Association Participation and Volunteering: A Literature Review. Nonprofit and Voluntary Sector Quarterly, 23(3), 243-263. Spector, M., & Kitsuse, J. (1977). Constructing Social Problems. Menlo Park: Cummings Publishing. Steenkamer, B. M., Drewes, H. W., Heijink, R., Baan, C. A., & Struijs, J. N. (2017). Defining Population Health Management: A Scoping Review of the Literature. Population Health Management, 20(1), 74-85. Sutton, R. (1999). The Policy Process: An Overview. London: Overseas Development Institute. Tannen, D. (1999). The Argumment Culture: Stopping American's War of Words. New York: Ballantine Books. Turnock, B. J. (2001). Public Health: What It Is and How It Works. Gaitherburg: Aspen Publishers. United Nations Development Program (UNDP). (2012). Institutional and Context Analysis: Guidance Note. New York: UNDP. Verschuere, B., Brandsen, T., & Pestoff, V. (2012). Coproduction: the State of the Art in Research ad the Future Agenda. Voluntas: International Journal of Voluntary and Nonprofit Organizations, 23(4), 1083-1101. von Thiele Schwarz, U. (2016). Co-care: Producing Better Health Outcome through Interactions between Patients, Care Providers and Information, and Communication Technology. Health Services Management Research, 29(1-2), 10-15. Walker, A. (2007). Society Quality and Sustainable Welfare Regimes. In The Second Asian Conference on Social Quality and Sustainable Welfare Societies (pp. 1-4). Taipei: National Taiwan University. Walls, H. L., Smith, R. D., & Drahos, P. (2015). Improving regulatory capacity to manage risks associated with trade agreements. Globalization and Health, 11, 14. Walt, G. (1994). How Far Does Research Influence Policy? European Journal of Public Health, 4, 233-235.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

References

Page 115

Walt, G. (2001). Health Policy: An Introduction to Process and Power. London: Zed Books. Walzer, N., & Sudhipongpracha, T. (2012). Structures, Approaches, Stakeholders, and Program Outcomes. In N. Walzer, & H. Gisele, Community Visioning Programs: Processes and Outcomes (pp. 33-52). London: Routledge.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

APPENDIX A Effects of the Global Pharmaceutical Drug Trade on Multi-drug Resistance Tuberculosis (MDR-TB) in India1 OVERVIEW What started out as a perfect day where everything was in order, ended in a catastrophe, with a sudden turn of events. The roaring and deafening noise like an angry lion was heard. Then, it clicked: the trembling noise heard earlier was an earthquake. Suddenly, you were aware something was not right. A course of action was needed. "Run!” was all we could hear at the moment when we saw a high wall of water came crashing over the reef towards us at a speed of 40-50 kilometers per hour. This was how Multi-drug resistance Tuberculosis (MDR-TB) was going to affect infectious disease management if no comprehensive policies and regulations were implemented. MDR-TB was like a silence Tsunami; it had taken people by surprise. Antimicrobial resistance (AMR) occurred when microorganisms— such as bacteria, viruses, fungi, and parasites—changed in ways that rendered the medications used to cure the infections they cause ineffective (Cockburn et al., 2005; WHO, 2016). These microorganisms were usually referred as “superbugs” when they became resistant to more than one antimicrobial. Threatening the effective prevention and treatment of an ever-increasing range of infections—especially, HIV, malaria, and tuberculosis—AMR led to prolonged illness, deaths, and disabilities with important economic consequences to low- and middle-income countries (Eliopoulos et al., 2003). In recent years, there was a rise of counterfeit drugs in the market, and South Asia accounted for the biggest share of counterfeit pharmaceutical drug trade (Howard et al., 2003; Cockburn et al., 2005). Counterfeit drugs were hindering progress in tackling AMR unless comprehensive trade policies were implemented (Laxminarayan et al., 2013)

Chotsilakul, J., Rukanda, I., Mupanguri, L., Nkala, P., Banjara, R., & Chidzurira, R. (2017). Effects of the Global Pharmaceutical Drug Trade on Multidrug Resistance Tuberculosis (MDR-TB) in India. NIDA Case Research Journal, 9 (1), 101-118.

Appendix A

Page 117

One example of AMR was multidrug-resistant tuberculosis (MDRTB). MDR-TB referred to a type of tuberculosis infection that did not respond to isoniazid and rifampicin—two most powerful anti-tuberculosis drugs. In 2015, approximately 10.4 million people were infected with MDRTB. Of this number, about 1.8 million died (WHO, 2016). In India, China, and Russia alone, the estimated number of patient infected with MDR-TB was 580,000—accounting for 45% of all reported MDR-TB cases around the world (WHO, 2016). MDR-TB and other types of drug resistance were caused by the prevalent use of counterfeit medicines (Laxminarayan et al., 2013). In addressing this health-threatening issue, countries and international agencies—such as the World Trade Organization (WTO) and World Health Organization (WHO)—joined their efforts in regulating the global pharmaceutical drug trade. The WTO adopted the Trade-Related Aspects of Intellectual Property Rights (TRIPS), which established the ground rules for patent protection on pharmaceutical drugs, despite concerns that such regulatory framework might affect the vulnerable populations’ access to affordable drugs. ANTIMICROBIAL RESISTANCE SITUATIONS AT A GLANCE Global AMR Situation The magnitude of AMR accounted approximately for 700,000 cases/ year (Figure 1). Only 5% were diagnosed and treated, with only 3% of all cases treated with good quality drugs (O’Neil, 2016). Since AMR became an important global public health issue, it required an action across all government health sectors to collaborate. Patients with infections caused by drug-resistant bacteria were at an increasing risk of adverse clinical outcomes and death, and consumed more healthcare resources than patients infected with non-resistant strains of the same bacteria (Cars, 2005).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 118

Appendix B

Figure 1. Major Causes of Death at the Global Level Source: O’Neil (2016) AMR Situation in India India is a country in South Asia sharing borders with Myanmar and Bangladesh to the east, Pakistan to the west, and China, Nepal and Bhutan to the northeast. India is bounded by the Indian Ocean on the south, the Arabian Sea on the southwest, and the Bay of Bengal on the southeast. The country is the world’s seventh largest country by area of 2.97 million km2 and the second most populous country with over 1.31 billion people. The majority of people (67.25%) reside in the rural areas with an average life expectancy of 68 years. In 2015, the country’s adult literacy rate is 72.23%. In the same year, per capita income stood at $1,581.59, which was ranked 169th out of 197 countries worldwide. On average, the Indian government invests around 5% of its GDP on health, while most of health investments were the private sector’s contributions. In 2013, around 80% of private health contributions came from out-of-pocket expenditures mostly for medications (WHO, 2013).This trend strains India’s economy, as AMR and other health-related issues are becoming too complicated for the country’s existing health service system.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix A

Page 119

THE POLITICAL ECONOMY OF TUBERCULOSIS DRUG TRADE Counterfeit Drug Trade and International Actions In recent years, there was a rise in counterfeit drugs in the market. In 2009, 20 million pills, bottles, and sachets of counterfeit and illegal medicines were seized in a five-month operation coordinated by the International Criminal Police Organization (INTERPOL) across China and seven of its Southeast Asian neighbors (WHO, 2016). These counterfeit drugs exacerbated resistance to many infectious diseases. Asia accounted for the biggest share of the trade in counterfeit medicines where most of the new cases of MDR-TB emerged (Cockburn et al., 2005). An important obstacle to tackle AMR was the lack of regulatory enforcement in many countries due to the illegal drug industryâ&#x20AC;&#x2122;s political influences (Sachs, 2012). Among different kinds of pharmaceutical products, drugs for treating TB infection attracted widespread attention among large pharmaceutical companies, particularly those in India and South Asia (Bate et al., 2014). Further, there were also quality issues with the Indian pharmaceutical firms on antibiotics and TB drugs produced by the Indian pharmaceutical firms and sold in Africa, India and other five middle income non-African countries (Udwadia and Moharil, 2014; Fojo and Dowdy, 2017; Law et al., 2017). This might have increased multi-drug resistant TB cases. World Trade Organization and TRIPS Agreement Efforts were made by international organizations, such as World Trade Organization (WTO), International Trade Organization (ITO), and World Health Organization (WHO) to regulate pharmaceutical drug trade among countries. For instance, the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement was a multilateral agreement on intellectual property under the WTO. TRIPS had been in effect since 1995 with the aim of promoting intellectual property rights and international actions against counterfeit merchandises (Udwadia et al., 2012). Not only did TRIPS focus on patented products, the agreement also covered other forms of intellectual properties, including copyrights, trademarks, and industrial designs. However, emphasis was placed on patented products, which were essential to medical and technological innovation. It was expected that technological advances would help supply poor countries with affordable and effective medical products. In other words, TRIPs laid down ground rules on intellectual property rights, which were seen as a

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 120

Appendix B

way to introduce a system in which disputes over the intellectual property right issues can be settled systematically. Challenges to the Campaign against Counterfeit Drug Trade Protection and enforcement of the intellectual property rights varied widely around the world (Maron et al., 2013; Hoffman et al., 2015). As they became more important in trade, the variations became a source of tension in international economic relations. Prior to TRIPS and during TRIPS negotiations, developing countries opposed the protection for patented pharmaceutical products due to fear of an increase the prices for patented pharmaceutical products, accessibility to the pharmaceutical technology, and strong social movements led by international NGOs and diverse interest groups (Azam, 2015; Price et al., 2015). In 2005, the Indian government adopted an amendment to the patent protection legislation to comply with TRIPS, which required patents to be granted on new medicine. The introduction of the TRIPS agreement became devastating for countries that relied on India as a source of affordable quality medicines. Low-income countries unable to grant patents on pharmaceutical products faced technical and financial difficulties to produce their own generic medicines. As such, TRIPS-related legislation in India and other manufacturing countries effectively cut the lifeline of affordable drugs for low-income countries. Evidence suggested that new drug prices would increase by 200% due to the TRIPs patent requirement (WHO, 2013). However, the TRIPS Agreement was interpreted and implemented in a manner that protected public health and, in particular, to promote access to medicines for all. The impact of patents on access remains a complex issue and an area of particular focus. Although the policy options was to minimize barrier to access, but equally the absence of an enforceable patent right does not guarantee effective access (Udwadia et al., 2012). In response to the AMR situation around the world, WHO came up with a global action plan for the prevention, caring, and control of MDR-TB. The plan aimed to end the global TB epidemic by reducing the TB-induced deaths by 95% and by cutting new cases by 90% between 2015 and 2035 (WHO, 2016). The strategy included integrated, patient- centered care, and preventive approach focusing on early detection, treatment, and prevention for all TB patients, including children. It was to ensure that all

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix A

Page 121

TB patients had equal, unhindered access to affordable services and early diagnosis of TB, including the universal drug susceptibility test and systematic screening of contacts for high-risk populations. Also, the WHO guidelines also aimed to ensure the quality and standards of MDR-TB drugs by requiring that its member states produced quality medicines and control counterfeit drugs. Rise of Medical Technology to Combat “Superbugs” Recent developments showed that nanotechnology appeared to be most promising way to fight against the so-called “superbugs” (Varshney and Shailender, 2012). The use of nanoparticles was a promising strategy to reduce AMR because nanoparticles could overcome existing drug resistance mechanisms, including decreased uptake and increased efflux of drug from the microbial cell, biofilm formation, and intracellular bacteria. Finally, nanoparticles could target antimicrobial agents to the site of infection, so that higher doses of drug were given at the infected site, thereby overcoming resistance (Ghasemi et al., 2009). However, the use of nanotechnology in developing new drugs to combat against the superbugs experienced low success rates with the poverty-related diseases, such as TB. These diseases came as a challenge for the pharmaceutical sector due to high prevalence rates of patient non-compliance (Pelgrift and Friedman, 2013). An ideal drug delivery system should be able to target and to control the drug release. Targeting and controlled release would increase efficiency of the drugs and reduce their side effects (Andrade et al., 2013; Aruguete et al., 2013; Natan and Banin, 2017). Therefore, the nanotechnologicallydriven drug delivery system might offer a number of advantages over the conventional dosage forms by improving drug efficacy, reducing toxicity and side effects, enhancing bio-distribution, and enhancing patient compliance (Varshney and Shailender, 2012). INDIA’S NATIONAL EFFORTS AGAINST THE TB EPIDEMIC Globally, about nine million people were infected with TB each year. In this figure, one-and-a-half million died. Low- and middle-income countries, in particular, bore the greatest burden of the TB epidemic with 95 percent of TB cases in 2013. One-quarter of all TB patients in the world were reported in India alone (2.2 million people) (Figure 2). Several conditions within India increased its citizens’ risk of TB infection: rapid urbanization, high population density, and poverty. The WHO estimated

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 122

Appendix B

that approximately one million TB patients in India were not aware of their status. Despite high treatment success rate of 88%, the current number of patients with MDR-TB was 63,000 in 2013 (Figure 2).

Figure 2. TB Epidemic in India Source: Jha (2015) The “WHO End TB” campaign involved policy formulation and implementation to combat the TB epidemic in poor countries (WHO, 2013). In India, the campaign resulted in health and social policies, including universal health coverage, social protection, and safety nets (Sharma et al, 2008). These measures were designed to tackle an increase in MDR-TB cases among poor and vulnerable populations, people living with HIV-AIDS, and migrant workers (WHO, 2016). Politics, however, played an instrumental role in regulating the pharmaceutical sector in both developed and developing countries (Nair, 2008). Ineffective law enforcement mechanisms led to illegal drug manufacturing and marketing, which consequently exacerbated the global AMR situation (Azam, 2005). In India, the rise of MDR-TB was due to the lack of a comprehensive public health policy (Nair, 2008). Also, because of a weak regulatory system, the country’s pharmaceutical industry suffered from transparency issues from a variety of fronts, including drug licensing, coordination among regulatory agencies, and patent protection. As a result, WHO banned the TB drugs produced by several Indian pharmaceutical companies because these drugs did not meet the international manufacturing standard (O’Neil, 2016). After the emergency of TRIPS, the Indian pharmaceutical industry woke up to the challenges of new intellectual property regime (Nair, 2008).

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix A

Page 123

Research programs, such as the Drug Discovery Program, were set up to keep up with the new international regulatory system. As the WTO member states, India adopted TRIPS and strengthened the patent protection standard on pharmaceutical drugs (WHO, 2016). Yet, scientific studies consistently found the large gap in the prices between generic and brandname pharmaceutical drugs. As such, India adopted the long-term vision of “TB Free India” with the goal of establishing universal access to quality TB diagnosis and treatment (WHO, 2016). VULNERABLE POPULATIONS AND MDR-TB Low- and middle-income countries faced challenges in the availability of drugs, diagnostics, clinical expertise, laboratory capacity, financial constraints, and law enforcement. The emergence of new scientific knowledge, such as nanotechnology, helped improve accessibility, affordability, and availability of essential drugs. Yet, although the Indian government allocated more resources for disease prevention and outbreak control in recent years, research and development for the MDR-TB drugs and other antimicrobial medicines in India remained relatively underfunded compared to other government projects. This resulted in lowquality antimicrobial drugs that were too expensive for the poor households who could not afford to buy an adequate supply of the necessary medications. Even if a new drug was introduced, the low-income households in India might not be able to afford it since the second- and third-line antimicrobial drugs were still too expensive for them. This reflected the public sector’s limited resource allocations for health and healthcare services in India, which in turn was linked to the country’s widening gap between the rich and poor households. Several attempts were made at the international level to deter the counterfeit drug trade, such as TRIPS. For instance, TRIPS aimed to make the global economy more conducive to intellectual property by prohibiting counterfeit goods, protecting intellectual property rights, and providing legal basis for effective enforcement of such rights. In addition, international agreements like TRIPS helped countries enforce the intellectual property rights in their respective territories. Not only did these legal measures intend to foster innovation and create incentives for the pharmaceutical companies to invest in research and development, they also sought to empower national governments to mitigate the AMR situation. Further, emphasis on the long-term drub patents encouraged the

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 124

Appendix B

pharmaceutical companies to invest in research and development of new drugs. Due to the WHO monitoring and surveillance of TB drugs in 2016, the TB drug made by an Indian pharmaceutical companyâ&#x20AC;&#x201D;Svizera Laboratoriesâ&#x20AC;&#x201D;was suspended. Svizera Laboratories were manufacturing the TB drugs, which were supplied to developing countries. It was discovered they were not up to the international manufacturing standards and quality. This reflected the low quality of regulatory frameworks and governance in India, especially with regard to the control and monitoring of the pharmaceutical sector, which led to the proliferation of ineffective medicines throughout the developing world and emergence of the TB epidemic in India. Regardless, the multilateral efforts made by the WHO, WTO, ITO helped countries and partner organizations in promoting the universal health coverage (UHC) and social safety net protection, which are integral to an effective response to MDR-TB (Forrest, 1999). In many country contexts, MDR-TB was addressed within the UHC and social safety net protection mechanisms. Further, the WHO provided training services and methodologies of how to measure the medical expenses, costs of seeking/staying in care, and income loss from MDR-TB. These methodological tools helped to identify and overcome the underlying causes of stopping treatment before complete cure. However, the hidden interests of large pharmaceutical companies were aggravating the MDR-TB situation in India and other developing countries. These large pharmaceutical companies argued that poor countries did not have adequate financial resources to pay for the imported drugs, even at discounted prices. More than 95% of TB cases were reported in developing countries, and this statistics explained why the large pharmaceutical companies did not have much interest in developing new and affordable TB drugs. This lack of interest in TB drug development was neglected worldwide, including in India. At the same time, the enforcement of TRIPS agreement and patent right helped to increase the prices of MDR-TB drug. Currently, India was attempting to amend the Patent Right Act to prohibit new forms or different formulations of known medicines and to enable other companies to patent new anti-microbial drugs.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix A

Page 125

WHAT IS THE NEXT STEP? International organizations and national governments around the world have made several efforts to deal with the AMR issue. It remained a challenge, however, in certain countries to implement those policy measures. Scholarly works showed that a single intervention had limited capacity to effectively mitigate the adverse consequences of AMR. Instead, intersectoral collaboration was regarded as a solution to fight drug resistance. The adoption of new technologies—such as a nanotechnology— was believed to help develop new drugs—particularly the anti-TB drugs— and to improve diagnostic tools for infectious diseases. Yet, an important question remained: how could the Indian government and the governments of developing countries address the structural issues of accessibility, affordability, and availability of essential drugs for vulnerable populations. A simple answer was that there was an urgent need to consider the social determinants of health, including poverty, living conditions, work environment, and education. Specifically, the Indian government ought to ensure that the vulnerable and marginalized groups had access to anti-TB drugs. In a majority of poor countries, public expenditures to meet the basic drug needs fell below the WHO recommendation of $2 per head per year. In India, for instance, where personal incomes were less than $2 a day, sustainable public health financing were required from the government appropriations and social security budgets. Yet, even with heavily subsidized prices, the anti-TB drug uptake rates remained low in India where there are fewer public health service providers than private (forprofit), not-for-profit, and community-based care providers. Thus, subsidized drug prices should not be restricted to the government sector, but also cover the non-governmental sectors and minority communities. The worst-case scenario was if no action was taken, things would go back to the times before invention of antibiotics where morbidity and mortality rates were high as a result of minor infections. Drug resistance was therefore a silent tsunami.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 126

Appendix B

REFERENCES Andrade, F., Rafael, D., Videira, M., Ferreira, D., Sosnik, A., & Sarmento, B. (2013). Nanotechnology and Pulmonary Delivery to Overcome Resistance in Infectious Diseases. Advanced Drug Delivery Reviews, 65(13), 1816-1827. Aruguete, D. M., Kim, B., Hochella, M. F., Ma, Y., Cheng, Y., Hoegh, A., et al. (2013). Antimicrobial Nanotechnology: Its Potential for the Effective Management of Microbial Drug Resistance and Implications for Research Needs in Microbial Nanotoxicology. Environmental Science: Processes and Impacts, 15(1), 93-102. Azam, M. (2015). The Experiences of Trips-Compliant Patent Law Reforms in Brazil, India, and South Africa and Lessons for Bangladesh. Akron Intell. Prop. J., 7, 61. Bate, R., Jin, G. Z., Mathur, A., & Attaran, A. (2014). Poor Quality Drugs and Global Trade: A Pilot Study. NBER Working Paper No. 20469. Cars, N. P. (2005). Antibiotic Resistance: the Faceless Threat. International Journal of Rik and Safety in Medicine, 17(3), 103-110. Cockburn, R., Newton, P. N., Agyarko, E. K., Akunyili, D., & White, N. J. (2005). The Global Threat of Counterfeit Drugs: Why Industry and Governments Must Communicate the Dangers. PLoS Med, 2(4), e100. Eliopoulos, G. M., Cosgrove, S. E., & Carmeli, Y. (2003). The Impat of Antimicrobial Resistance on Health and Economic Outcomes. Clinical Infectiou Diseases, 36(11), 1433-1437. Fojo, A. T., & Dowdy, D. W. (2017). Multidrug-resistance Tuberculosis in India: Looking Back, Thinking Ahead. The Lancet, 2(1), e8-e9. Forrest, M. (1999). Using the Power of the World Health Organization: the International Health Regulations and the Future of International Health Law. Colum. JL & Soc. Probs, 33, 153. Ghasemi, Y., Peymanib, P., & Afifi, S. (2009). Quantum Dot: Mahic Nanoparticle for imaging, detection, and Targeting. Acta Biomed, 80, 156-165. Hoffman , S. J., Rottingen, J. A., & Frenk, J. (2015). International Law Has a Role to Play in Addressing Antibiotic Resistance. The Journal of Law, Medicine, and Ethics, 43(3), 65-67. Howard, D. H., Scott, R. D., Packard, R., & Jones , D. (2003). The Global Impact of Drug Resistance. Clinical Infectious Diseases, 36(Supplement 1), S4-S10. Jha, A. (2015, February 24). Eliminating TB in India: Challenging and Innovations. Retrieved June 10, 2017, from HITLAB: Healthcare

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix A

Page 127

Innovation Technology: http://www.hitlab.org/healthyinnovations/2015/2/24/eliminating-tb-in-india-challenges-andinnovations Law, S., Piatek, A. S., Vincent, C., Oxlade, O., & Menzies, D. (2017). Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. The Lancet, 2(1), e47-e55. Laxminarayan, R., Duse, A., Wattal, C., Zaidi, A. K., Wetheim, H. F., & Sumpradit, N. (2013). Antibiotic Resistance: the Need for Global Solutions. The Lancet Infectious Diseases, 13(12), 1057-1098. Maron, D. F., Smith, T. J., & Nachman, K. E. (2013). Restrictions on Antimicrobial Use in Food Animal Production: An International Regulatory and Economic Survey. Globalization and Health, 9(1), 48. Nair, G. G. (2008). Impact of TRIPS on Indian Pharmaceutical Industry. Journal of Intellectual Property Rights, 13(9), 432-441. Natan, M., & Banin, E. (2017). From Nano to Micro: Using Nanotechnology to Combat Microorganisms and Their Multidrug Resistance. Fems Microbiology Reviews, 41(3), 302-322. O'Neil, J. (2016). Tackling Drug-resistant Infections Globally: Final Report and Recommendations. London: Ministry of Health, Britain. Pelgrift, R. Y., & Friedman, A. J. (2013). Nanotechnology as a Therapeutic Tool to Combat Microbial Resistance. Advanced Drug Delivery Reviews, 65(13), 1803-1815. Price, L. B., Koch, B. J., & Hungate, B. A. (2015). Ominous Projections for Global Antibiotic Use in Food-animal Production. Proceedings of the National Academy of Sciences, 112(18), 5554-5555. Sachs, R. (2012). Making Intellectual Property Work for Global Health. Harvard International Law Journal, 53, 106. Sharma, S., Sarin, R., Khalid, U., Singla, N., Sharma, P., & Behera, D. (2008). The DOTS Strategy for Treatment of Pediatric Pulmonary Tuberculosis in South Delhi, India. The International Journal of Tuberculosis and Lung Disease, 12(1), 74-80. Udwadia, Z. F., & Moharil, G. (2014). Multidrug-resistant-tuberculosis treatment in the Indian private sector: Results from a tertiary referral private hospital in Mumbai. Lung India, 31(4), 336-341. Udwadia, Z. F., Amale, R. A., Ajbani, K. K., & Rodriguez, C. (2012). Totally Drug-resistant Tuberculosis in India. Clinical Infectious Diseases, 54(4), 579-581.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 128

Appendix B

Varshney, H. M., & Shailender, M. (2012). Current Status in Pharmaceutical Science: A Review. International Journal of Therapeutic Applications, 6, 14-24. World Health Organization. (2013). Global Tuberculosis Report 2013. Geneva: WHO. World Health Organization. (2016). Treatment Guidelines for Drugresistance Tuberculosis: 2016 Update. Geneva: WHO.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

APPENDIX B Virtual Water Policy: A Case of Saudi Arabia2 Overview The whole chamber of parliamentarians adjusted their seats as they listened with keenness to the Minister of Water and Agriculture. They had all realized that if they continued with the “business as usual” modus operandi, it would be impossible to secure enough food to cater for the growing Saudi population which at that time was now standing at 30 million and still counting. Some critics from the opposition party eagerly waited for the question and answer segment. There had always been discontentment in the upper house of assembly that the agricultural policy was non-strategic and that the looming catastrophe was self-inflicted and engineered to benefit few elite minorities. “Ladies and Gentleman, the combination of agricultural and water resources management policies that we as government have spearheaded over the past decade have proved to be both non- strategic and unsustainable. Now as we face this global climate change threat we should think of a new way of doing business. My Ministry has gathered evidence of the depletion of our underground water aquifers, which has largely been due to extensive overhead irrigation to support wheat and alfalfa production. Can you imagine that, yearly we are drawing nearly five trillion gallons of water from the nonrenewable underground aquifers and at this rate, mathematical modelling has shown that we will run dry in the next 50 years. It is in light of this background, ladies and gentleman that I call upon a reform in policy, We should make a radical move towards virtual water trade….This policy option will help us to optimize water use and protect the little water resources that we have at the same time guard against food insecurity.”

Roongsawang, T., James, N., K.C., Chetan, Chaudhary, R., Gurung, S., & Sengal, K.T. (2017). Virtual Water Policy: A Case of Saudi Arabia. NIDA Case Research Journal.

Page 130

Appendix B

Soon after the minister gave an end note to his presentation, thunderous applause echoed from the whole august house, some parliamentarians clearing their throat to seek further clarity on the proposed and unfamiliar virtual water concept. This was back in 1999, and it landmarked the turning point in Saudi Arabia water and agriculture policy direction. About Saudi Arabia – Beyond the Edge of Water Shortage The Kingdom of Saudi Arabia is largest country in the Arabian Peninsula. The total population of Saudi Arabia is 24.6 million and the GDP per capita stands at US$ 20,813. The Saudi Kingdom is the world’s largest oil exporter and dominates the Organization of Petroleum Exporting Countries (OPEC). Oil revenues account for about 90 percent of export earnings and about 80 percent of government revenues. Saudi Arabia’s economy has been on the rise owing to the global economic recovery in oil prices, and enlarged fiscal spending by the government in oil exports (Ibrahim, 2013). While the country is making giant economic strides, the water scarcity remains a threat to its socio-economic development. This arid state covers an area of 2.15 million km2, and of this area, 1.01 million km2 is used for agricultural purposes (Franken, 2009). Temperatures are high in the summer and low in the winter characterizing its desert-related weather conditions. Saudi Arabia receives very low annual rainfalls with an estimate of 2,045 million cubic meters per year and has very limited fresh water supplies (DeNicola et al., 2010). The water resources in the country are divided in two—surface and underground deposits. Surface water comes from rainfalls which are found predominantly in the west and south-western regions of the country. Ground water is found in the basement rocks, and the thickness of these rocks is about 500m. Ground water is held in aquifers, some of which are naturally replenished, while others are non-renewable (Zaharani, 2011). According to the United Nations, Saudi Arabia is classified under the water scarce nations (Rijsberman, 2006). The country does not have permanent rivers or lakes. Being a desert country, rainfall, surface, and underground water are extremely limited. This situation has worsened by decades of extensive agricultural production, which has left the country’s aquifers almost depleted. Furthermore, climate change and exponential population growth have detrimental impact on water resources, thereby

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix B

Page 131

exacerbating the water scarcity situation in Saudi Arabia. It is estimated that at the current underground withdrawal rate, Saudi Arabia will run waterless in the next 50 years (Drewes et al., 2012). Water scarcity aggravates existing social problems, most notably poverty (Namara et al., 2010). The current water consumption scenario puts the future of this oilrich county at stake. Almost 90 percent of the water resource is used for agriculture whereas only nine and four percent are used by municipalities and industries, respectively (Napoli, 2016) (Figure 1).

Figure 1. Extracted Water Uses Distribution (Alan, 1997) Source: Allan (1997) Further, as shown in Figure 2, 31 percent of the water extracted is used to produce alfalfa and other fodder, which provide feed for the meat and dairy industries. Fruits (including dates), vegetables and cereals (including wheat) consume 41 percent of all water for agriculture (Woertz and Keulertz, 2015). This water use pattern and the water scarcity situation call for immediate actions with regards to sustainable water use. These actions might include Saudi Arabiaâ&#x20AC;&#x2122;s reduction in agricultural production and water management policy framework.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 132

Appendix B

Figure 2. Water Uses Distribution Source: Woertz and Keulertz (2015) What is the Virtual Water? The concept of virtual water is an emerging ideology in water resource management. It was first introduced by Tony Allan in the early 1990s. He defined it as the water which is used in and during the agricultural production process (Allan, 1997). Due to an exacerbated impact of climate change on water resources, virtual water has in the past decade begun to attract interests in many countries. The first international conference on virtual water was held in December 2002 in Delft, the Netherlands to discuss its applicability in fostering regional and global water security. This was followed by a special session at the Third World Water Forum in Japan, March 2003. Looking at it closely, virtual water refers to the hidden flow of water consumed during the production and processing of food items, such as meat, vegetables, and dairy products (i.e., agricultural produce) (Renault, 2003). For instance, we need 1,000 liters of water to produce one kilogram of wheat and 15,400 liters to produce one kilogram of prime beef (Allan, 1997). The virtual aspect arises from the fact that the real water used to produce the food is no longer contained in the food or a country in which

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix B

Page 133

the food is produced. This helps to understand the volume of water required to produce different goods and services. In discussing about virtual water in this globalizing world, another important concept is virtual water trade. This refers to the process of importing and exporting of goods and services, which require water for their production, as well as processing, such as fruits, vegetables, and livestock (Hoekstra, 2010). Virtual water trade is beneficial to arid countries like Saudi Arabia, Jordan, and Egypt (Allan, 1997). Notably, because in these arid countries there is a serious need to optimize the utilization of existing water resources and to promote cultivation of food, which requires less amount of water. Yet, supporters of the virtual water trade is said to be economically invisible and politically silent. However, these supporters struggle to find solutions for the water-scarce regions to avoid finding water within their territories to produce tons of waterintensive and politically sensitive commodities (Allan, 2001). Virtual water can be measured in water footprint calculations, where the water footprint refers to the amount of water used in and around our home, school, and throughout the day (Hanlon et al., 2013). Theoretically speaking, water footprint is the total use of household water the resources, minus the virtual water export flows, plus the virtual water import flows (Chapagain & Hoekstra, 2004). The footprint calculation is based on three different categories: • Blue water, such as fresh surface water from lakes, rivers, and undergrounds, • Green water stored in the form of precipitation in plants and soil, and • Grey water, which is the amount of water polluted during the production process of goods. Deductively, the virtual water concept can be constructed into two practical uses: (1) an instrument to achieve water security and efficient water use and (2) a linkage between consumption patterns and the impacts on water. In the first usage, virtual water can be an alternative source of water, which means it can relieve the pressure on the nation’s water resources where water is scarce. It can also help solve geopolitical problems between Saudi Arabia and neighboring countries (Wichelns,

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 134

Appendix B

2004). Based on the international trade theory, nations should export products, which possess relative or comparative benefits in production, while importing products with comparative disadvantage (Wichelns, 2004). For the second usage, which is basically the water footprint function, virtual water policy can help predict the environmental impact of water consumption. This is because knowing the water content of products offers information about which products have greater impacts on the water system and where water savings could be achieved. Optimal water use Saudi Arabia—which has neither rivers nor lakes—experiences low precipitations, and most of its aquifers are almost depleted. Against this background, optimal utilization of water resources becomes imperative. Optimal water use is one of the guiding principles of virtual water trade, called “the Best Alternative Use” Principle. In this principle, the virtual water trade is a sustainable strategy of water resource management with multiple steps to ensure that water is indeed used in the most appropriate way in the public interest. It is also consistent with the principle of integrated water resource management since water resource protection affects decisions related to water usage. For example, in a certain area, water has the best alternative use in an aquatic ecosystem. In other areas, this may not be the case. Thus, the use of water resources varies across different community contexts (Li et al., 2014). Virtual Water and Food Security Food security can be defined as “access by all people at all times to enough food for an active, healthy life” (Gang & Epstein, 2010: p.35). It is concerned with five components food availability, food accessibility, food sufficiency, individual, household and national food stability and food quality reliability. The concept of food security is a critical component at the center of all governments, especially in Saudi Arabia due to rapid population growth and economic performance in the 1980s (Roudi-Fahimi et al., 2002). Saudi Arabia’s current population is 3,251,469, and the government needs to create innovative food security initiatives to meet the growing demand in the face of water scarcity. Food security exists when all people have physical, social, and economic access to sufficient safe and nutritious food that meets their dietary needs and food preferences for an

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix B

Page 135

active and healthy life (Grindle et al., 2015). Food security, environmental health, and social equity are the rationales for adopting the virtual water trade as a water policy instrument. Countries might be better off by using their scarce water resources for economic activities that bring higher economic returns. These countries may opt to buy food instead of growing and producing on their own. In this vein, Saudi Arabia moves from being the worldâ&#x20AC;&#x2122;s sixth largest wheat exporter in the 1990s to virtually a net wheat importer. The social adaptive capacity of a country is vital to alleviate water scarcity and provide food security through virtual water trading. Saudi Arabia Situation Today- Toward the National Virtual Water Policy The virtual water policy first gained the public attention in Saudi Arabia in the late 1990s in response to a growing threat of the depletion of nonrenewable aquifers in the face of massive population growth. In order to address vital aspects of food security and sustainable development, the Saudi government adopted the virtual water policy option. However, there is no explicit policy document entitled virtual water in Saudi Arabia. Yet, the virtual water concepts and strategies are embedded within fragmented water and natural resource policies under the Ministry of Water and Agriculture. In Saudi Arabia, water distribution and water use are regulated by the government under the ministry of agriculture and water resources. Beginning in the 1970s, the government adopted a massive wheat and barley production in which private farmers were given subsidies to extract water from the aquifers, so that they could transform the desert into irrigated fields. An arid Saudi Arabia was turned into the worldâ&#x20AC;&#x2122;s sixth largest wheat exporting country (Elhadj, 2005). This government policy option was mainly driven by the need for self-dependency and food security. Saudi Arabiaâ&#x20AC;&#x2122;s strong economic base from oil reserves caused them to adopt liberal water management and unsustainable agricultural policies that led to the depletion of aquifers for this arid Arab state. Currently, the country faces critical water shortage with depleted aquifers and extinct renewable groundwater due to limited precipitation. It has been estimated that at the current rate of withdrawal, these water supplies will be gone in less than 50 years (DeNicola et al., 2015).

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 136

Appendix B

The massive population growth has created an enormous demand for water. The government has had to revise the 1970s policy to move to the virtual water option amid growing threat of water scarcity. The government has decreased the domestic production of water-intensive crops, such as alfalfa and wheat. In 2009, the Saudi Agricultural and Livestock Investment Co. (SALIC) was established to secure stable food supplies to avoid food shortages the Saudi population (Woertz & Keulertz, 2015). Virtual water trading countries with SALIC include Sudan and Ukraine and others in South America and Asia. This policy option is significantly reducing the demand for water from the agricultural sector. The Saudi government’s “Initiative for Saudi Agricultural Investment Abroad” launched in 2008 provides government credit and diplomatic support for the Saudi companies to buy foreign land and water to feed the Saudis. The Saudi investors have generous access to water and the right to export at least 50 percent of the harvest back to Saudi Arabia (Cotula, 2009). This arid Arab state is proud of the strategic move to virtual water policy (Lippman, 2010, p. 90): “Our policy is to help countries that have land and water,” said Abdul-Aziz al-Howaish, general director of the agriculture ministry’s international cooperation department. “We have the technology and capital. We will help them to produce, for them and for us.” Global Policy Environment – What are the Challenges with Virtual Water? The lack of a robust international framework for virtual water trade is a hindrance to a full-scale adoption of virtual water policy option both in Saudi and in an around the world. The world in general is facing water resource challenges owing to global warming, poor awareness of how to optimally use and save water, and lack of coordination and planning for the use of conventional water sources, such as ground water or rains (Gutub et al., 2013). The Global debate on plausibility of virtual water calculations, net import and net export benefits landscape, and food sovereignty continue to be sticky points around the virtual water dimension of water resource management. Theoretically, virtual water discourse aims to promote the global water resource governance with a fair resource allocation, mutual trade benefit, and sustainable development.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix B

Page 137

Virtual Water Trade â&#x20AC;&#x201C; Gaps The concepts of virtual water and virtual water trade have the potential to cushion the arid and semi-arid regions from catastrophic effects of water scarcity, consequently improving regional and global water use efficiencies. However, critics of the model argue that the current framework does not take into consideration international trade regimes and dependencies that shape the local social, economic, and cultural environment (Orlowsky et al., 2014). Moreover, there is limited consensus on the standards of virtual water measurements. Calculations of virtual water are inconsistent or inaccurate (Orlowsky et al., 2014). The proposed volumetric indicators do not take a blind eye on a number of important local socioeconomic factors related to water consumption. Those who do not support virtual water policy option argue that these calculations have the potential to harm vulnerable populations water (Wichelns, 2001). Application of the virtual water concept poses a threat to national sovereignty and autonomy. Exporting countries, which are in most cases richer countries, develop neo-colonial tendencies and might want to interfere with importing countriesâ&#x20AC;&#x2122; domestic politics. Without a proper international regulatory framework, the virtual water policy can destroy local agriculture and compromise individual familiesâ&#x20AC;&#x2122; right in deciding and controlling their diet. The dynamics of food security, food sovereignty, and culture makes it very difficult for policy makers to introduce rules or prices for the use of water (Wichelns, 2001). The question on self-sufficiency and independence from other countries continues to be a sticky point that introduces a political deadlock to the adoption of virtual water ideology. Virtual water trade has the potential to cause depletion of water resources in the exporting countries especially if it involves water intensive crops. A classic example is the depletion of the Colorado River and Ogallala aquifer in USA due to increased water demand exerted by increased Japanese consumers (Aldaya et al., 2010). The virtual water trade can ideologically be a tool to optimize global water use. However, without appropriate trade agreements and good governance it can end up being a vehicle to transfer water scarcity challenges from the importing to the exporting regions (Aldaya et al., 2010). Nevertheless, this concept thrives very well in countries that have sizeable foreign reserves and booming economic indicators, such as Saudi Arabia. It is often recommended that the net import of virtual water in a

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 138

Appendix B

water-scarce nation like Saudi Arabia can relieve the pressure on a nation’s own water resources (Gutub et al., 2013). However, the policy in virtual water trade should always consider the water scarcity-induced implications of food imports. Furthermore, the global political will to foster mutual trade benefits and sustainable resource management are prerequisites for successful implementation of the virtual water trade and policy. Conclusion It goes without say that, Saudi Arabia’s past agriculture polices can no longer be accommodated in the current water scarcity crisis that the country is facing along with the rest of the Arab region and the rest of the world. Scaling up virtual water as a hallmark of their water resource management does not only require its economic muscle to buy fields and produce food abroad. It calls for broader world trade regulations and advancement in virtual water scientific research. The climate change dent on both surface and underground water resources is enormous globally and cannot be ignored. The impact keeps growing and poses a huge threat to water as a public good, food security, and the very existence of the human species. Faced with this global water scarcity dilemma, could virtual water be the panacea for all those problems? References Aldaya, M. M., Allan, J. A., & Hoekstra, A. Y. (2010). Strategic importance of green water in international crop trade. Ecological Economics, 69(4), 887-894. Allan, J. A. (1997). 'Virtual water': a long-term solution for water short Middle Eastern economies? London: School of Oriental and African Studies, University of London. --. (2001). Virtual water—economically invisible and politically silent—a way to solve strategic water problems. International Water and Irrigation, 21(4), 39-41. Chapagain, A. K., & Hoekstra, A. Y. (2004). Water footprints of nations. De Delft, the Netherlands: UNESCO-IHE (Institute for Water Education). Cotula, L., Vermeulen, S., Leonard, R., & Keeley, J. (2009). Land grab or development opportunity. Agricultural Investment and International Land Deals in Africa, 130.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix B

Page 139

Drewes, J. E., Garduño, C. P. R., & Amy, G. L. (2012). Water reuse in the Kingdom of Saudi Arabia–status, prospects, and research needs. Water Science and Technology: Water Supply, 12(6), 926-936. DeNicola, E., Aburizaiza, Omar S., Siddique, Azhar, Khwaja, Haider, & Carpenter, David O. (2015). Climate Change and Water Scarcity: The Case of Saudi Arabia. Annals of Global Health, 81 (3), 342 – 35. Franken, K. (2009). Irrigation in the Middle East region in figures: AQUASTAT Survey 2008. Rome, Italy: FAO. Gang, I. N., & Epstein, G. S. (2010). Frontiers of economics and globalization. Bingley: Emerald. Grindle, A. K., Siddiqi, A., & Anadon, L. D. (2015). Food security amidst water scarcity: Insights on sustainable food production from Saudi Arabia. Sustainable Production and Consumption, 2, 67-78. Gutub, Saud A., Soliman, Mohamed F., & Asif uz zaman. (2013). Saudi Arabia confronts with water scarcity: An Insight International Journal of Water Resources and Arid Environment, 2 (4), 2013. Hoekstra, A. Y. (2010). The relation between international trade and freshwater scarcity. WTO Research Paper, January 2010, 1-25. Ibrahim, M. A. (2013). Financial development and economic growth in Saudi Arabia. Applied Econometrics and International Development, 13 (1), 133-44. Lippman, Thomas W. (2010). Saudi Arabia's quest for "food security.” Council on Foreign Relations: Middle East Policy, 17 (1), 90. Li, Y. P., Liu, J., & Huang, G. H. (2014). A hybrid fuzzy-stochastic programming method for water trading within an agricultural system. Agricultural Systems, 123, 71-83. Namara, R. E., Hanjra, M. A., Castillo, G. E., Ravnborg, H. M., Smith, L., & Van Koppen, B. (2010). Agricultural water management and poverty linkages. Agricultural Water Management, 97(4), 520-527. Napoli, B. W. Christopher. (2016). Policy Options for Reducing Water for Agriculture in Saudi Arabia. Riyadh, Saudi Arabia: King Abdullah Petroleum Studies and Research Center (KAPSARC). Orlowsky, B., Hoekstra, A. Y., Gudmundsson, L., & Seneviratne, S. I. (2014). Today’s virtual water consumption and trade under future water scarcity. Environmental Research Letters, 9(7), 1-10. Rijsberman, F. R. (2006). Water scarcity: fact or fiction? Agricultural Water Management, 80(1), 5-22. Roudi-Fahimi, F., Creel, L., & De Souza, R. M. (2002). Finding the balance: Population and water scarcity in the Middle East and North Africa. Population Reference Bureau Policy Brief, 1-8.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 140

Appendix B

Wichelns, D. (2004). The policy relevance of virtual water can be enhanced by considering comparative advantages. Agricultural Water Management, 66(1), 49-63. Woertz, E., & Keulertz, M. (2015). Food trade relations of the Middle East and North Africa with tropical countries. Food Security, 7(6), 11011111. Zaharani, M. S.-S. (2011). Water Conservation in the Kingdom of Saudi Arabia for Better Environment: Implications for Extension and Education. Bulgarian Journal of Agricultural Science, 17 (3), 389-395.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

APPENDIX C “Health for All” or “Health by All (?)” Developing Health Management Capacity Indicators for Local Governments in Thailand3 Overview “I am speechless,” Mr. Visanu lamented. Everyone kept quiet until the Deputy Prime Minister continued to express his thought: “I presided over this decentralization committee ten years ago, but we still argued with one another on the same issues until today.” Several months ago, the Prime Minister had asked Mr. Visanu if he would be willing to serve as chairman of the National Decentralization Committee—one of the key national planning agencies within the Prime Minister’s Office. Having led this committee during its early years (2002-2005), Mr. Visanu could not resist the opportunity to return to complete his unfinished task. For him, decentralization was an important requirement for a high-quality democracy and an experiment with networked governance whereby public services relied on interconnectedness among citizen groups, private sector firms, and government agencies of different levels. Upon resuming his chairmanship, Mr. Visanu instructed the committee’s secretariat to prepare a progress report on implementation of the National Decentralization Plan, which contained details about the transfer of administrative and fiscal responsibilities from the central bureaucratic agencies to the newly created local government units. The report and supplementary materials were submitted in due time and circulated among committee members before Mr. Visanu’s first meeting as the committee’s chairman. It was Mr. Visanu’s personal plan that decentralization ought to be implemented swiftly and efficiently under his leadership to help support the current administration’s national reform.

Sudhipongpracha, T. (2016). “Health for All” or “Health by All (?)” Developing Health Management Capacity Indicators for Local Governments in Thailand. NIDA Case Research Journal, 8 (2), 146-169.

Page 142

Appendix C

However, after Mr. Visanu finished reading the secretariat’s progress report on decentralization, he raised his eyebrows in disbelief and exclaimed with a strongly disappointing tone: I have been away from the Decentralization Committee for almost a decade and not much progress has been made in terms of devolving administrative functions and authority to local governments. The devolution of health and quality-of-life functions in particular was abysmally slow. Look at all these statistics: only ten out of 34 disease prevention and health promotion functions have been successfully devolved to the local level. And what is this? Only 0.40% of the community health centers were successfully transferred to local jurisdictions. In response to the Deputy Prime Minister’s concern, one of the committee members opined that the public still had doubts over local government capacity: “people are very concerned about handing over more public service responsibilities to local governments because of widespread political corruption and lack of management capacity at the local level.” As a result, the National Decentralization Committee developed managerial capacity indicators, protocols, and strategic plans for the public service functions that would be transferred to local governments. For the public health function, in particular, local governments had to be assessed against these capacity indicators to determine their management preparedness. Mr. Visanu nodded in agreement and went on to inform the entire committee of what he would like to accomplish in his first 100 days as chairman of this decentralization policy planning body. “The preparedness indicators for each devolved public service function must be reviewed and amended,” announced Mr. Visanu. “The committee must work closely with the local governments and related central government ministries to come up with a reasonable number of essential capacity indicators,” the Decentralization Committee chairman emphasized. The committee agreed that the indicator review process should begin with the public health function. Several local jurisdictions in Thailand’s Northeast were identified as case studies for developing a set of “workable indicators” for the next step in public health decentralization reform in Thailand.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 143

Thailand’s Public Health System Reform and Its Impact on Local Governments In Thailand, since the dramatic financial meltdown in 1997, structural reform measures have been adopted to rectify problems caused by a century of centralized administration. Among the reform initiatives, decentralization aims to empower citizens and the local governments to manage their communities4. After the ratification of the 1997 constitution and the 1999 decentralization legislation, the first national decentralization plan was formulated to guide the devolution process, including the transfer of health-related functions to the local level. However, compared to other countries in Asia, Thailand has a carefully sequenced decentralization strategy, but has been implementing it slowly. The decentralization of public health functions in particular was interrupted by the national health system reform that resulted in the formation of the National Health Security Fund (NHSF) in 2002.5 Before 2002, the public health ministry was responsible for providing public health services and for determining budget allocations for each type of health services. Citizens working in the formal private sector were covered by the National Social Security Fund (NSSF), while government officials were entitled to their medical services paid for by the Ministry of Finance. This system inadvertently left out more than half of the population who were not formal sector employees or government officials. Since the NHSF system was established in 2002, Thailand’s public health system has been governed by the purchaser-provider separation model in which the NHSF office, the NSSF office, and the Ministry of Finance’s Civil Servants’ Medical Benefit Scheme (Figure 1). Under this new system, the Ministry of Public Health no longer controls the funding sources for public

There are two main categories of local governments in Thailand: special-purpose and general-purpose local governments. Bangkok Metropolitan Authority (BMA) and Pattaya City are the only two special-purpose local governments. The general-purpose local authorities can be further divided into upper-level and lower-level local governments. Provincial administrative organizations are upper-level local governments responsible for the entire provincial areas, whereas municipalities and sub-district administrative organizations fall into the lower-level category with administrative responsibilities for the district and sub-district levels. 5 Jongudomsuk, P. and Srisasalux, J. (2009). A Decade of Healthcare Decentralization in Thailand: What Lessons Can Be Drawn? WHO Southeast Asian Journal of Public Health, 1, 347-356.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 144

Appendix C

health services. However, the ministry remains in charge of government health facilities, including hospitals and community health centers. In parallel with the national health system reform, the first two public health decentralization plans (2002-2011) were launched with two key features. First, the local health insurance funds were established in 2003 at the sub-district level across the country. Currently co-financed by the NHSF office and local governments, the funds channel resources to citizens and civic groups that carry out physical wellness activities. Yet, although a committee of citizen representatives and local officials manages each sub-district’s fund, past studies show that citizens do not actively participate in the fund management process.6 Second, the two public health decentralization plans included the transfer of government-operated community health centers to local governments. However, before the transfer could be authorized, each local government had to satisfy the “preparedness” criteria formulated by the public health ministry. Table 1 presents these criteria and their associated indicators. Empirical studies on health decentralization in Thailand point out that these criteria overemphasize the managerial aspect of local governance.7 The public health ministry’s inadequate attention to citizens’ preparedness has been cited as one of the main factors discouraging citizen involvement in the local public health management process.

Sunsern, R., Lawang, L., Timsuwan, B., Banterngsook, W., and Gadudom, P. (2010). Quality of Health Security System in the Community. Journal of Nursing and Education, 3(3), 92-105. Tongkaokaew, W. (2011). People's Participation in the Local Health Insurance Fund Operations, Yala Province (in Thai). Prince of Naradhiwas University Journal, 3(1), 16-32. 7 Jongudomsuk, P. and Srisasalux, J. (2009). Taearak, P. (2010). Synthesis of Health Service Decentralization Approaches (In Thai). Nonthaburi, Thailand: Health System Research Institute. Wongthanavasu, S., and Sudhipongpracha, T. (2013). Analysis of the Capacity and Preparedness of Local Administrative Organizations and Citizens in Health Management (in Thai). Khon Kaen, Thailand: Klang Nana Vitaya.

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 145

Table 1. The Thai Ministry of Public Health’s Criteria for Assessing Local Government Preparedness for the Transfer of Community Health Centers Preparedness Dimension 1. Local government involvement in health promotion activities

2. Existence of a local government’s public health management plan

Indicator Continuity of a local jurisdiction’s involvement in the Provincial Public Health Office’s activities A local jurisdiction’s health-related performance output Number of a local jurisdiction’s health promotion programs Amount of a local jurisdiction’s financial assistance to the community health centers prior to the transfer Comprehensiveness of a local government’s public health management plan (Does a local government have action/strategic plans related to disease control, health service quality assurance, and health promotion?)

3. Existence of an organizational structure for the public health functions

Number of public health staff Amount of budget allocations for a local jurisdiction’s public health agency

4. Local revenue generation capacity 5. Citizens’ opinion toward their local jurisdiction’s health management capacity

Amount of local own-source revenues Number of local residents approving the transfer of community health centers

Similar to other aspects of decentralization in Thailand, the transfer of community health centers was slowly implemented; 39 out of 9,762 community health centers were devolved to the local level. Compared to other regions, the Northeast has the smallest number of localities that passed the public health ministry’s preparedness criteria. Three community health centers were transferred to two local governments in the northeastern provinces of Udornthani and Buriram. In 2008, the two community health facilities in Buriram were the only decentralized community health centers in the country that were transferred back to the national government. On the other hand, the decentralized community health center in Udornthani has received multiple awards from various agencies since it came under the aegis of local government. These two

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 146

Appendix C

localities’ different experiences in the management of their community health centers raise an important question: in what way must the public health ministry’s preparedness criteria be altered for the next step in Thailand’s decentralization reform?

Figure 1. Current Public Health System in Thailand

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 147

The Northeast of Thailand: An Experiment with Public Health Decentralization The northeastern region in Thailand was the country’s most impoverished region with high infection rates of the neglected tropical diseases (NTDs). These diseases were parasitic illnesses affecting the world’s poorest population.8 Among the common NTDs, Cholangiocarcinoma (Biles duct cancer) was a serious public health problem in Thailand, affecting 42.5% of the Northeast population.9 The National Decentralization Committee’s secretariat selected four local communities from the Northeast (Table 2). Two communities in which local governments had taken an active role in health-related matters despite their limited authority were referred to as the “good practice” localities. Also, in these “good practice” communities, primary healthcare centers had been successfully transferred to the local government auspices. Since the decentralization reform officially began in 1997, Hibiscus city in Udornthani province had garnered many “good governance” and “excellence in public service” awards organized by government agencies in Thailand and abroad. In the same province, Mongosteen city boasted a similarly impressive record of awards from government and educational institutions, such as the “good governance and public management” awards from the Department of Local Administration between 2006 and 2008. Additionally, for the past several years, both Hibiscus and Mongosteen cities had consistently been honored by Thailand’s Office of the Royal Development Projects as model communities for sustainable development and quality-of-life enhancement. The good practice localities were compared against two jurisdictions with the inactive local governments (i.e., a comparison group) from a neighboring province—Nongbua Lumphu.

Hotez, P. J., Molyneux, D. H., Fenwick, A., Kumaresan, J., Sachs, S. E., Sachs, J. D., & Savioli, L. (2007). Control of Neglected Tropical Diseases. New England Journal of Medicine, 357(10), 1018-1027. 9 Sripa, B., Bethony, J. M., Sithithaworn, P., Kaewkes, S., Mairiang, E., Loukas, A., & Brindley, P. J. (2011). Opisthorchiasis and Opisthorchis-associated Cholangiocarcinoma in Thailand and Laos. Acta Tropica, 120 (Supplement 1), S158-S168.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 148

Appendix C

Table 2. Four Community Case Studies from Northeast Thailand

“Good Practice” Communities Comparison Communities

Province

Area (km2)

Populati on (2012)

Populati on Density (per km2)

Hibiscus

Udornthani

47.70

138,136

2,895

Magnolia

Udornthani

13,520

229

39.50

51,338

1,299

5,560

Name of Locality

Freesia Daffodil

Nongbua Lumphu Nongbua Lumphu

Lessons Learned from the Four Northeastern Communities A crucial question for the next steps of decentralization reform in Thailand was how to strengthen local government capacity before devolving substantial administrative responsibilities to a local level. To find out the appropriate measures for determining “local public health management capacity,” two “good practice” localities were compared against the neighboring communities with similar demographic attributes. Administrative Capacity Two interrelated issues had been analyzed to expose the administrative dimension of local public health capacity. First, the mayors’ understanding and attitudes towards public health reflected the quality of their political leadership in running local government. Second, a local jurisdiction’s administrative capacity was determined by whether it had an agency and staff with specific responsibility for public health management. Mayors from the four jurisdictions showed markedly different levels of public health knowledge. As the Magnolia City health department director opined, “in meetings or during press conferences, the mayor speaks so eloquently and with sufficient depth of knowledge about public health.” When asked why his city administration has invested so much in public health, the Hibiscus mayor responded:

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 149

I strongly believe that health means the overall quality of life. A healthy person is a happy person. That is why my city administration has concentrated a lot of efforts and resources in health matters because I want Hibiscus city to be a happy community. The Magnolia mayor similarly emphasized that good health, including physical and mental health, is essential to sustainable community development. On the contrary, mayors from the Freesia and Daffodil cities expressed less enthusiasm about local public health. They held the view that public health functions should belong to the public health ministry because of the advanced clinical and medical knowledge involved. The Freesia mayor in particular pointed out that his city government had already been given too many responsibilities: “if we must take over more public health functions, our city would definitely be in deep financial trouble.” Similarly, the Daffodil city mayor stated that: “The public health ministry can provide better health services than us. Of course, we can work with them. But I don’t think my city government is now ready for any more health functions.” Apart from their mayors’ public health knowledge, each of the “good practice” localities had a well-equipped public health workforce. In an attempt to provide healthcare services for a growing urban population, Hibiscus municipality had both medical and public health departments. All municipal healthcare centers in Hibiscus city were managed and supervised by the medical department, while the public health department was responsible for disease prevention and health promotion activities. Also, in terms of personnel, Hibiscus city health officials made up 25% of the municipal government workforce. In a similar vein, the Magnolia city— albeit its small budget and organizational size— made substantial investment in its city health department which was charged with overseeing a city health center and other health-related activities, such as preventive and promotional healthcare. The Magnolia city health officials accounted for almost 13% of all city government employees. On the other hand, the Freesia and Daffodil municipalities did not demonstrate as much commitment to public health as the “good practice” localities. Despite the presence of a municipal public health department, there was a limited range of public health services in Freesia city. A lack of

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 150

Appendix C

locally run health centers drove the Freesia city residents to travel to other areas for healthcare services. Also, unlike the size of municipal public health workforce in Hibiscus city, only 15% of the Freesia municipal government personnel were public health officials. The state of public health services in Daffodil city was equally problematic. Daffodil residents relied on the central and regional agencies for health services because their municipality did not have an agency specifically assigned for health administration. Neither did it have public health personnel on its municipal government payroll. Fiscal Capacity Apart from the administrative capacity, local authorities required adequate resources to finance their public health operations. The two “good practice” localities, especially the Magnolia city, appeared to have difficulty with revenue mobilization. Starting in 2009, the Magnolia city government experienced a sharp decline in own-source revenue per capita (Figure 2). This declining pattern stood in sharp contrast to a consistent and growing revenue stream in Daffodil city, which was also a sparsely populated rural community. On the other hand, the densely populated areas—Hibiscus and Freesia cities—did not significantly differ from each other in their per capita own-source revenue between 2008 and 2012. Only in 2009 did the Freesia city government’s own-source revenue per capita clearly exceed the amount of revenue collected by the Hibiscus city government.

Figure 2. Per Capita Own-Source Revenue Collected between 2008 and 2012

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 151

The above analysis suggested that the localities with active local government involvement in public health might not be as financially selfreliant and sustainable as the comparison communities. Magnolia city in particular experienced a serious problem with revenue collection. When each jurisdiction’s own-source revenue was calculated as a percentage of its total revenue, it was found that own-source revenue did not make substantial contributions to the Magnolia city’s coffer between 2008 and 2012 (Figure 3). Apart from Magnolia city, one of the comparison communities— Freesia city—faced an even worse revenue situation. Since 2008, a dramatic decrease in own-source revenue pressured the Freesia city government to depend on other financing sources, such as the national government grant. Nonetheless, contrary to past empirical works on fiscal decentralization, another comparison city—the Daffodil city government which had been inactive in community health management—enjoyed the strongest fiscal autonomy from 2008 to 2012. During the five-year period, Daffodil city’s financial self-reliance was even higher than that of Hibiscus city—a “good practice” locality from a heavily populous urban area. Despite much empirical and theoretical support, own-source revenue data alone did not accurately depict the fiscal dimension of local public health capacity. Since decentralization began, local revenue collection had always been an important challenge facing many Thai local authorities regardless of their organizational structure, population size, and local economic conditions.10 Besides, there is no guarantee that a local government with high fiscal autonomy would earmark substantial funds for public health services. Thus, apart from local own-source revenue stream, it was necessary to consider how much each of the four jurisdictions spent on public health programs.

Wongpredee, A., & Sudhipongpracha, T. (2014). The Politics of Intergovernmental Transfers in Northeast Thailand. Journal of Developing Societies, 30(3), 1-21.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 152

Appendix C

Figure 3. Own-Source Revenue as a Percentage of Total Revenue Collected (2008-2012)

Figure 4. Local Budget Allocations for Public Health Programs as a Percentage of Total Budget Allocations (2008-2012) Between 2008 and 2012, the Hibiscus and Magnolia city governments allocated more resources to public health programs than the Freesia and Daffodil city authorities (Figure 4). As previously discussed, Magnolia city had the smallest amount of per capita own-source revenue, compared to the other three cities. Yet, calculated as a percentage of each yearâ&#x20AC;&#x2122;s overall

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 153

budget, the amount of resources that the Magnolia city government dedicated to public health was larger than in other localities. Equally wellknown for its municipal health programs, the Hibiscus city government also set aside a substantial portion of its annual budget for public healthâ&#x20AC;&#x201D; second only to the Magnolia city government. Citizensâ&#x20AC;&#x2122; Public Health Management Capacity Formal and informal relationships among individual community members, local government agencies, and civil society groups served as an important catalyst for community development and decentralization reform. Residents in Hibiscus city had a tendency to form a variety of physical wellness activities, such as yoga, aerobic dance, zumba dance, Chinese martial arts, and bicycling. Despite the absence of formal management hierarchy, these exercise groups in Hibiscus city continued to expand their membership and had succeeded in soliciting financial and/or in-kind assistance from the municipal government. As one Hibiscus resident who regularly attended an aerobic dance group on mentioned; We get together for an aerobic dance at one of the municipal parks every evening. Our neighbors who do yoga do the same; they go to the parks near their homes and exercise with their friends. The exercises are fun and convenient. Apart from these exercises, it is also a great opportunity for us to socialize with one another. Residents in the Magnolia community also attended physical wellness groups on a regular basis. However, there was lesser diversity of wellness groups than in Hibiscus city. Further, instead of being formed by citizen groups, every physical exercise groups in Magnolia city was initiated by the city health department. Citizens were not directly involved in designing and managing exercise programs. People in the Magnolia community exercise on a daily basis. But, our exercises are simple. The women get together in an aerobic exercise every evening. The men jog or play soccer. The city government helps find and pay for aerobic dance coaches. Basically, we [the Magnolia residents] donâ&#x20AC;&#x2122;t have to do anything. These physical exercise groups are very useful: we exercise for free and get to chat with our neighbors.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 154

Appendix C

Not only did the informal physical wellness groups promote healthy lifestyle habits in both communities, they also helped strengthen social capital among the city dwellers. Residents from the Freesia and Daffodil cities, on the other hand, reported limited physical exercise activities in their communities. Also, in stark contrast with residents in the “good practice” cities, the Freesia and Daffodil community members did not participate in physical wellness groups: They exercise on their own. But, there were some aerobic dance groups in the past, but they didn’t last for more than two months. Though enthusiastic about these wellness groups in the beginning, the people stopped attending them in the following month. Moreover, the Freesia and Daffodil governments were not as supportive of the physical wellness activities as the municipal government authorities in the “good practice” communities. The Freesia and Daffodil city mayors were more concerned with road construction projects than other aspects of community affairs, including public health. A Daffodil city resident opined. It is difficult to gain support from our mayor for any public health programs. He [the mayor] is more interested in road constructions. I don’t know about other places. But, most politicians in Thailand like road construction projects more than other public service programs. In a similar vein, one of the Freesia community members pointed out that her mayor always expressed his concern with providing financial support to physical exercise groups. Since local government spending was subject to an annual financial audit by the Public Finance Audit Commission (PFAC), any new financial commitment that was not included in local government plan and budget was likely to undergo a thorough investigation by the PFAC. Fear of the PFAC made the city government reluctant to engage in new public health initiatives. Apart from participation in physical exercise groups, citizen involvement in government affairs was also a vital aspect of contemporary local governance in Thailand. In addition to the informal wellness groups, citizens in the Hibiscus and Magnolia cities were also involved in local

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 155

government affairs. Several Hibiscus city residents stressed the importance of attending the community health board meetings. One of the Hibiscus city residents stated: The mayor and municipal health officials were active in setting up and financing these community health boards. With these boards, we can propose new health promotion activities and programs and ask the city government for monetary support. So, I think it’s very important for us to get involved. According to a senior citizen, a large number of Hibiscus citizens willingly served on each precinct’s health management board and actively engaged in making important decisions. However, the Magnolia city residents showed a lesser degree of enthusiasm about getting involved in their city government’s decision-making process. Several of the Magnolia residents reported that they did not participate in the local government affairs because they had to tend to their cattle and rice paddies. In sharp contrast, the Magnolia resident stated that they “monitor the mayor’s policy initiatives, program implementation, and budget allocation on an ad hoc basis.” They also pointed out that the Magnolia community had not seen any political conflicts for many years. One of the Magnolia youth leaders stated: Most people here are farmers and not regularly involved in local government affairs. But, they do check how local officials work. Fortunately, the Magnolia residents never run into conflict. Our disagreements can always be solved through informal interpersonal dialogues. Nonetheless, levels of interpersonal relations and social activism were comparatively low in the Freesia and Daffodil communities. These two communities had no dynamic social groups or popular involvement in local government affairs. One Freesia city resident argued that the absence of social activism and citizen engagement in the city was caused by the citizens’ inadequate education: For instance, it is always a challenge to convince people of the importance of immunization. Even when they are sick, they don’t come to see the medical personnel, and the neighbors don’t even

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

Page 156

Appendix C

bother to let municipal government officials know about an outbreak of infectious diseases in their neighborhoods. While interpersonal dialogues were instrumental in resolving community conflicts in the Magnolia city, the Freesia and Daffodil residents did not show much interest in collective actions. Many Freesia and Daffodil residents voiced their opinion that conflicts over the city government budget occurred on a regular basis. A key informant from Daffodil community noted: Often time, our community and political conflicts over budget allocation cannot be resolved through debate. Over the past several years, for instance, regional government officials had to intervene in our community conflicts. There is always factional politics in the way our community is run. Although these conflicts never became violent, the Freesia city residents, particularly the youth leaders and village heads, clearly demonstrated their displeasure against one another, especially when they were asked to comment on disease prevention activities. In sum, residents in the “good practice” localities engaged in physical wellness activities on a regular basis and were inclined to participate in their communities’ social activities. They also demonstrated a high degree of political participation by attending local health board meetings and by frequently monitoring local public health programs. Local governments in these communities did not directly control, but provided support for their constituents’ physical wellness activities Way Forward Based on these four community cases, the National Decentralization Committee’s secretariat wished to examine which aspect of local government capacity must be nurtured for the next step in public health decentralization. As demonstrated above, three dimensions of local public health management capacity were identified and used to examine four local communities in Northeast Thailand. The “good practice” communities had won a number of awards for good governance, service quality, and active citizen engagement. Despite their budget and administrative constraints, the city governments in these “good practice” localities dedicated resources

Health Policy in Action

Tatchalerm Sudhipongpracha (2017)

Appendix C

Page 157

to develop public health programs and demonstrated the administrative capacity and fiscal commitment to public health. Their mayors possessed an understanding and a positive attitude towards public health and prepared their local governments’ organizational structures for the public health responsibilities. On the contrary, local governments in the comparison communities had inferior administrative capacity. Unsupportive leadership, inadequate public health personnel, and absence of a local public health agency complicated these local governments’ efforts in delivering public health services. Even though the quality of political leadership and adequate public health personnel were critical components of local public health management, not all fiscal indicators could explain local public health management capacity. Local governments with more own-source revenues were not necessarily committed to public health. Moreover, citizens’ health knowledge and behavior expressed through their regular physical exercises led to a high degree of political involvement in local government affairs. In the “good practice” communities, not only did the physical wellness groups provide an opportunity for local residents to engage in physical activities, they also facilitated the group members’ interpersonal relations. By participating in these wellness groups, citizens became assertive about the types of assistance they expect from their municipal governments. As Thailand was approaching the second decade of its decentralization reform process, the Secretariat of the National Decentralization Committee had been commissioned by the Deputy Prime Minister, Mr. Visanu, to develop a set of management capacity and preparedness measures. Based on the four community case studies from Northeast Thailand, the Director of the National Decentralization Committee’s Secretariat had asked you and your research team to compare and contrast the strengths and weaknesses of the four local jurisdictions and propose a set of local capacity indicators, as well as policy recommendations for Thailand’s ongoing local government reform.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action

APPENDIX D Bringing Electronics Manufacturing to Curitiba One of the largest electronics manufacturers in the region has announced a search for a new factory site, and the government of your country has put forward Curitiba as a candidate for the tender. Curitiba has to make the proposal during a sensitive period of economic transition. The proposal must reflect the main political drivers for your country, which are to attract more foreign direct investment and to increase both the profile and prestige of your country. These drivers are associated with including tax sweeteners in the proposal with the aim of making the proposal more attractive to the manufacturer. As economic development is one of the main priorities for your city, submitting a response to this tender fits with the cityâ&#x20AC;&#x2122;s strategy. In addition, this investment will create about 4,000 jobs, which will help reduce the unemployment currently being experienced in your city. This is especially important, since a significant industrial site near the city is about to close during the same time period. There appears to be substantial interest in this proposal and a range of stakeholders have asked for greater clarity about the potential economic, social and environmental impact of the construction and long-term presence of an electronics factory. To inform whether the city should tender for the project, the mayor has commissioned an impact assessment and asked for the assistance of the federal health ministry to analyze the direct and indirect benefits and risks to health. You and your colleagues in the HIA team of the health ministry have been tasked with submitting draft terms of reference for a health HIA. You are asked to: o Identify stakeholders that should be consulted. o List the primary issues that must be considered to conduct a robust HIA and the secondary issues that ideally would be included if time and resources permitted. o Outline a methodology describing some of the questions you plan to ask the identified stakeholders and the data you plan to collect.

Appendix D

Page 159

HIA Term of Reference Template Issue Stakeholders to Engage

Issues to Investigate

Methodology

Indicators/Measures

Detail 1. 2. 3. Primary Issues: 1. 2. 3. Secondary Issues: 1. 2. 3. 1. 2. 3. 1. 2. 3.

Tatchalerm Sudhipongpracha (2017)

Health Policy in Action