Policy Analysis and Decision-Making with Emphasis on Chronic Non-communicable Diseases, Study notes of Public Policy

Download Policy Analysis and Decision-Making with Emphasis on Chronic Non-communicable Diseases and more Study notes Public Policy in PDF only on Docsity! 1 Policy Analysis and Decision-Making with Emphasis on Chronic Non-communicable Diseases Bridgetown, Barbados October 15-17, 2007 Public Policy Perspectives Cristina Puentes-Markides Health Policies and Systems Strategic Health Development Area PAHO/WHO PAHO-CPM/SHD/HP/2007 2 Key Points Nature of Public Problems Policy/Politics Policy Typology Policy-making The Policy Capacity of Governments Policy development frameworks Policy instruments 2 PAHO-CPM/SHD/HP/2007 3 The Nature of Public Problems They are “wicked”: complex and ill-defined. Shaped by the values, interests, motivations and positions of social actors. Cause and effect: not always obvious or even subject to manipulation. Solutions proposed: may not always be the best or the least expensive. The fairness of the solutions are difficult to measure. Consequences may not be identifiable before implementation Weimer and Vining 4 What is a public policy problem? A public policy problem is ”a condition or situation that affects a considerable number of people, produces needs or generates dissatisfaction among individuals or groups, for which relief or redress is sought.” It has broad effects that may reach groups beyond those directly concerned. The solution of a public policy problem requires a government decision. The definition of a policy problem may be “top down” or “bottom up”, but is most of the time a political process. 5 PAHO-CPM/SHD/HP/2007 9 Example of the hierarchy Policy 1. Private 2. Public a. Foreign policy b. Domestic/national) a. Social i. Education ii. Employment iii. Social Security iv. Health (Public health, health care) Health promotion and disease prevention Health care (organization, financing, etc.) Human resources in health Environmental health Epidemiological surveillance Health services research Occupational health Etc. PAHO-CPM/SHD/HP/2007 10 Governments use public policies to correct market failures, and for political, moral, ethical or economic reasons 6 PAHO-CPM/SHD/HP/2007 11 Public policies address public policy problems. Public policy (and its various tools): communicate objectives, principles, strategies and rules of decision used by government administration and legislation. Provide authority, incentives or capacity to influence perceptions, values and behavior.(… “to make people do things that otherwise they would not do.”) 12 Sources of Government Failure: A Summary (Weimer and Vining) Fiscal Externalities (inequitable distribution of local public goods) Diffuse Authority (implementation problems) Problems Inherent in Decentralization Bureau Failure as Market Failure (inefficient use of organizational resources) Ex Ante Rules Including Civil Service Constraints (inefficiency due to inflexibility) Limited Competition (dynamic inefficiency) Difficulty Valuing Output (allocative and X-inefficiency) Agency Loss (X-inefficiency) Problems Inherent in Bureaucratic Supply Posturing to Public Attention (restricted agendas and distorted perception of costs) Electoral Cycles (socially excessive discount rates) Geographic Constituencies (inefficiency pork-barrel allocations) Influence of Organized and Mobilized Interests (inefficiency through rent seeking and rent dissipation) Problems Inherent in Representative Government Preference Intensity and Bundling (minorities bear costs) Paradox of Voting (meaning of mandate ambiguous) Problems Inherent in Direct Democracy 7 Source: Weimer and Vining. 13 A Procedure for Linking Market and Government Failure to Policy Interventions Analysis of type and nature of government failure Analysis of traditional market failures and other limitations of the competitive framework Government failure: consider deregulation, legalization, privatization, etc. Market failure and government failure: search for superior government interventions and compare their costs to the cost of market failure Market failure: compare costs of market failure to costs of optimal government intervention Market can be improved by eliminating government failure. Is there also “ passive” government failure?” Is there evidence of market failure? Does theory suggest there would be market failure if operating market? Does government intervention correct market failure? Government works! Search for incremental improvements. Is there an operational market? Also government failure? Market optimal Market works! Leave it alone Market failure Yes Yes No No No Yes Yes No Yes No No Yes PAHO-CPM/SHD/HP/2007 14 What makes a policy “public”? The government is the agent of decision about goals and means. It is developed within a legal framework of procedures and processes and governmental institutions. It is legitimated by legislations and/or regulations (normative/regulatory enforceable contents). They are expressed as laws, rules, regulations, operational decisions, judicial decisions, etc. They result in institutional and individual behavioral changes. (e.g. buildings that must have a ramp to enable access for the disabled, people are not allowed to smoke in public places, etc.) 10 PAHO-CPM/SHD/HP/2007 19 What is politics? Activities and relations that refer to the State Processes that establish structures and authority within the government Patterns of control, power, influence and authority to “achieve own objectives or to impede that others achieve theirs” Struggle for Power in decision making often related to ideologies, political parties, economic interests, motivations, etc. Influence to persuade (through various means) others to follow their advise, ideas, suggestions or orders. Any pattern of influence (control, power, authority) that involves persistent human relations. (Dahl) Source: 20 Political Strategies shape the political feasibility of options: To change the POWER of supporters and opponents To change the POSITION of supporters and opponents To change the PLAYERS who are mobilized in the policy debate To change the PERCEPTIONS of the problem and the policy. 11 PAHO-CPM/SHD/HP/2007 21 In sum, Policy Reference to the product of formulation The frames of reference, the legislative, executive, judicial Laws, regulations, standards, etc. Politics Lobbying Ability to vote Power, money, position Patterns of influence Spheres of control Persuasion “the game” Both occur in the context of a political system –that is, the complete set of institutions, political organizations, interest groups, the relationships among them as well as the norms and rules that govern their functions. PAHO-CPM/SHD/HP/2007 22 REDISTRIBUTIVE: Provide benefits to special social groups or organizations in order to satisfy a social objective. They include broad categories of citizens where resources from one group are “taken” and redistributed to provide benefits to other groups through income, taxes or services (public health services, education or food vouchers) REGULATORY: How the executive interpret and implement law, designed to influence the actions, behaviors and decisions of other actors through direct approaches. Represent limits that also restrict unacceptable behaviors. Different types: 1. Restrictions from entry to the market (e.g. accreditation of professionals) 2. Price controls (changes of services, water, health, pharmaceuticals) 3. Quality control in the delivery of services (regulations related to safety and efficacy of drugs and medical technology) 4. Controls that preserve the market (anti-monopolic) 5. Social regulation (e.g. social security laws, occupational safety, immunization, environmental pollution) DISTRIBUTIVE: Governmental decisions to provide direct benefits to specific groups or activities (e.g. research, national parks, highway and airport construction). Policy Typology Based on how benefits and costs are distributed (Theodore Lowi, The End of Liberalism (New York: W. W. Norton, 1969). Degre of Conflict Degre of Conflict 12 Source: 23 Possible Effects of Different Types of Policy Private goodsPublic and Private GoodsPublic CoodsLimits TYPE OF POLICY Tangible and symbolic TangibleSymbolicTangibility Wefare reform, tax reformEnvironmental pollution control, food safety, Highway and airport construction, public safety, worksite safety, research. Example ManyManyFewConflicts Very highDependsLowVisibility BroaderDependsLowImpact REDISTRIBUTIVEREGULATORYDISTRIBUTIVE Policy-making 15 Source: 29 Problem recognition – Congress and President will examine a problem that is facing the nation and try to devise a policy idea that will help solve the problem. Agenda setting – Congress takes the initiative in determining when to deal with new policies, through debating in committees and subcommittees. The leaders of Congress can also speed up or slow down the process, and interest groups can lobby to do the same. Policy formation – The legislation writes the bills and initiates the process of passing the bills. Interest groups and bureaucrats can influence the legislators in their development of the policy. Policy adoption –Congress will vote on the bill and if it passes, it will move on to the President who will sign or veto it. Interest groups will again try to influence Congressmen and the President during this stage. The White House staff will try to have Congress vote for or against this bill by pressuring them with the threat of a veto. Policy implementation – The bureaucracy is vital in this stage. Bureaucrats sometimes can drift away from the policy they are supposed to implement, and they do this out of self-interest. Bureaucrats can also be captured by the interest groups to delay policy implementation. Congress, however, has oversight of the bureaucracy to make sure they implement the policy accordingly. Policy analysis/Evaluation – The bureaucracy is again very important. They are the first to examine how effectively the policy works. Congress has oversight and can try to fix the policy if it is not working effectively. Interest groups are stronger in this process, and professionals in the field the policy effects play a larger role. The idea is to determine how effective the policy is, and if it is not effective, to make the necessary changes that will allow the problem to be solved. Example from the United States PAHO-CPM/SHD/HP/2007 30 Multiple human and social needs. External and internal factors and events. Individual and collective social actors with different perspectives and often conflicting values and interests. Limited resources. Changing contexts of decision, varying degrees of uncertainty and risk. Each problem has different solutions, which may imply contradictory selection (or priority) criteria. Precise decisions are often made with imprecise information. Yet, policymaking processes are not linear, simple or neat 16 Source: Gaston Sorgho, Harvard SPH 31 Policy Formulation and Legitimation Implementation Design and Organizational Structuring Resource Mobilization Progress/Impact Monitoring Constituency Building Agendas Decisions Issues = primary linkage = secondary linkage Politically dominated Technically led PAHO-CPM/SHD/HP/2007 32 Policy making as practice build the argument (‘rational choice’?) build constituency (to drive implementation) build capacity (because of uncertainty) 17 Source: UK Cabinet Office. Better Policy Making, 2001 33 Characteristics of Modern Policy-making Forward looking: takes the long view Outward looking: learns from elsewhere Innovative and creative: questions the status quo Evidence-based: uses best evidence available Inclusive: takes account of the interests of all Joined-up: works across institutional boundaries Reviews: keeps policy under review Evaluates: builds evaluation into the policy process Learns lessons: learns from experience of what works PAHO-CPM/SHD/HP/2007 34 The Policy Capacity of Governments 20 Polidano, M. 39 World Development Indicators Straightforward indicatorsAid as % of GDP, central government expenditure Aid dependency World Development Indicators, Government Finance Statistics Yearbook Pressure on government finances, coupled with impact of prolonged wage restraint Overall deficit/surplus as % of GDP, central government expenditure; rate of inflation Economic crisis BERI, Economist Intelligence Unit, PRS, Moody ’s, Standard and Poor’s Direct indicators of political instability Political instability/ social conflict/regime legitimacy/ military influence in politics Political instability PRS, Standard and Poor’s Impact of public concern on politics Democratic accountability/ political responsiveness World Development Indicators Indirect indicator of concern with public affairs Daily newspaper circulation, no. of radios per 1,000 people Civil society BERI, PRS, Standard and Poor’s Extent of cleavages and political impact Ethnic fractionalization/ tensions/politically significant social cleavages Ethnic/regional fragmentation Data source(s)What it measuresIndicatorEnvironmental factor Summary of proposed indicators of the enabling environment (Polidano, 1999) Policy Development Frameworks (Frameworks, theories and explanatory models of public policy) 21 PAHO-CPM/SHD/HP/2007 41 Decision making frameworks Models that help decision makers to identify the most important elements that intervene in the process of policy making and analysts to generate the necessary questions for the analysis. (Ostrom, 1997) Rational Incremental Political There are many, we will look at a few… PAHO-CPM/SHD/HP/2007 42 Rational Model Assumptions: System is stable The government is a rational and unitary actor and that its actions are perceived as rational choices The policy problem is unambiguous. Well defined objectives are established; alternatives and consequences are known; preferences are clear; there are no limitations of time or cost. Policy as maximum social advantage that also maximizes the economic advantages. 22 PAHO-CPM/SHD/HP/2007 43 Rationalist Approach to Public Policy PAHO-CPM/SHD/HP/2007 44 What is wrong with this framework? Difficult to apply in the public sector. Social problems are complex, ill-defined and interdependent. Conflict arises over appropriate role of government, and over the social value of an intervention. It is difficult to forge consensus and in the end, policies are the result of compromise. Time, knowledge, resources and “predicibility” are always limited. There is always pressure to select the first solution that seems “good”. Time is short to produce results (political time?) 25 PAHO-CPM/SHD/HP/2007 49 An example from D. Stone. According to this author… “Numbers never stand by themselves in policy debates, they are clothed in words and symbols and carried in narrative stories…” Counting is political: Includes decisions about inclusion and exclusion Implies norms about how much is too much, too little or just right Allow for ambiguity Tells stories Create illusion of control, boil complex issues down to numbers. Source: D. Stone. 50 The Political Policy Process Goals: Equity Efficiency Security Liberty Solutions: Inducements Rules Facts Rights Powers Problems: Symbols Numbers Causes Interests Decisions Values, Institutions & Representation Evaluation & Feedback: Program Evaluation Economic & Social Analysis, Election Political Participation, Advocacy Legal Review Strategic Representations of Situations Ongoing Strategies for Structuring Relationships and Coordinating Behavior to Achieve Collective Purposes Continuously Constructed and Ambiguous Concepts Evoking Common Goals with Conflicting Interpretations, and Provoking Intense Debate 26 Public Policy Instruments PAHO-CPM/SHD/HP/2007 52 Public policies use tools or instruments to Prohibit behaviors that are considered risks to society (e.g. banning smoking from hospitals and schools) Protect certain behaviors or population groups (e.g., disabled people, ethnic/racial minorities) Permit and promote activities of value to the governments Stimulate activities through increases or reduction in taxes (e.g. reduce teenage smoking through increase in taxes to cigarettes). Provide direct benefits to citizens in order to assist/help them (e.g. social security payments) 27 Howlett & Ramesh, 1995:82 53 A Spectrum of Generic Policies/Policy Instruments VOLUNTARY INSTRUMENTS MIXED INSTRUMENTS COMPULSORY INSTRUMENTS Level of State Involvement Low High Fa mi ly & Co mm un ity Pr iva te M ar ke ts Inf or ma tio n & Ex ho rt at ion Su bs idi es Ta xe s & Us er Ch ar ge s Re gu lat ion Re gu lat ion Pu bli c E nt er pr ise s Pu bli c E nt er pr ise s St at e P ro vis ion St at e P ro vis ion Source: Pal, L. There ought to be a law. 54 Summary of Instruments Inventory 30 Birkland, 2001. 59 ELEMENTS TO CONSIDER IN PUBLIC-POLICY DESIGN (cont.) 3. Tools of the Policy § What instruments will be used to implement the policy? § What is the degree of coercion? § Will tools rely on incentives? Persuasion? Information? Capacity -building? 4. Targets of Policy § Whose behavior is supposed to change? § Are there direct and indirect beneficiaries? § What assumptions about the target population underlie the choice of tools? 5. Implementation of the Policy § How will policy/program be implemented? § Who will define the criteria for implementation? § Who will enforce the implementation? PAHO-CPM/SHD/HP/2007 60 In conclusion… The process of formulation (policymaking) and the process of analysis (policy analysis) are different. Policymaking is an essentially political process. Policy analysis is rather a cognitive process that occurs during policymaking (thus in highly political environments. Policy makers (make decisions); policy analysts (provide policy- relevant advice). Policy decisions represent distribution of power and resources (tangible or intangible), and they also express the values. Policies are always formulated to achieve “someone’s” objectives. Policy makers are expected to act on the basis of the perceptions of the public interest or of beliefs about what is appropriate or ethically correct in public policy. Not always so. A good decision is not the same as a good result. 31 PAHO-CPM/SHD/HP/2007 61 Suggested Reading(s) Aday, L. A et al. (2005) Evaluating the Healthcare System. Effectiveness. Efficiency and Equity. Ann Arbor, MI: Health Administration Press. Third edition. Pp. 1-56. (Introduction to Health Services Research and Policy Analysis) PAHO. Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases. (2006) Pan American Health Organization, Washington DC. August 31, 2006. http://www.paho.org/english/gov/cd/CD47-17rv-e.pdf Polidano, C Measuring Public Sector Capacity. (2002) World Development 28 (5): 805-822.(Earlier version available from Institute for Development Policy and Management. University of Manchester. http://www.sed.manchester.ac.uk/idpm/research/publications/archive/ppm/ppm_wp12.htm Walt, G. and L. Wilson. (1994). Reforming the health systems in developing countries. The Central Role of Policy Analysis. Health Policy and Planning 9(4) : 353-370. Patton, C. y D. Sawicki. (1993) Basic Methods of Policy Analysis and Planning. Englewood Cliffs, NJ: Prentice Hall. Second edition. Pp. 1-39 (The Need for Simple Methods of Policy Analysis and Planning, The Policy Analysis Process).