Reform and policy development: An overview

Health care reform is driven by several salient overarching objectives which every health system strives to achieve through the changes it promulgates. These can be summarised as the pursuit of universal access to all its population through various mechanisms of health care coverage, improving choice and quality of services, ensuring a sustainable health care system through cost-effective and value-for-money measures as well as creating a more transparent and accountable health system.

2.11.1 Constituting reforms

There is no widely accepted definition of what constitutes reform in health care. Cassals (1995) defined health care reform as activities concerned with changing health policies and the institutions through which these changes are implemented. Hence, reform is both about changing or refining health policies and changing the structures responsible for reforms, to be in a better position to deliver these policies.

To achieve these ambitious aims, health reform can also be defined as a process that involves sustained and profound institutional and structural change, which is usually, but not necessarily, led by governments, but which always seeks to attain a series of clear explicit policy objectives. Saltman and Figueras (1997) outline an analytical model to capture the characteristics of what constitutes a real or true health reform:

- Process

• Structural rather than incremental or evolutionary change;

• Change in policy objectives, followed by institutional change rather than redefinition of objectives alone;

• Purposive rather than haphazard change;

• Sustained and long term rather than one-off change;

• Political top-down process led by national, regional or local government.

- Content

• Diversity in the measures adopted;

• Determination by country-specific characteristics of health systems.

This analytical model leaves very little doubt as to the far-reaching and profound changes that are implicit for real reform to occur. However, not all proponents of change would agree that reform needs to be so cataclysmic, as many other different models of change have been postulated. The Burke-Litwin Model of Change (Burke & Litwin, 1992) portrays change through a transformational process or through a transactional process. Whilst the former may be considered more revolutionary in nature, health care change management processes are more consistent with the latter process, since this entails a less dramatic change. Another major model of change developed in recent times is the concept of organisational development (Beckhard & Pritchard, 1992), (Koeck, 1998), (Huntington, Gilliam & Rosen (2000). Organisational development is focused upon empowering organisations to manage their own change. It views change in three phases, that of unfreezing (removal of expectations, dealing with the anxiety of change and conversion of anxiety into motivation to change), moving (creating a new role model and new relevant formation) and refreezing (consolidation of new structures and networks). It is a model often subscribed to in the UK NHS. A similar model of change is based upon the transformational change process as first described by Lewin (Lewin, 1958), where he was concerned with social change and, more particularly, with effective, permanent social change, believing that the motivation to change was strongly related to action.

Business process re-engineering is a more established model of change, championed by major manufacturing industries in Japan and the US. Whilst its conceptual framework is robust, and it has indeed proven to be a major driver for change, its applicability and appropriateness in health is questionable since it presupposes a completely clean sheet to start the change, a situation that is rarely encountered in health. Whilst Saltman and Figueras (1997) subscribe to the notion that reform is a radical and profound change in the process and content of health systems, experience has otherwise shown that reform or policy development and change could also and

indeed, is more often, gradual and incremental, less planned in origin and less purposeful in scope.

Policy change can be instigated from within or can be brought about due to changes in the external environment. It is usually, but not necessarily, driven by government, using a top-down approach. However, reform is more often about healthcare politics and less about reform of health systems (Giaimo & Manow, 1999), (Freedom, 2000).

Finally, health reforms have been described in four phases over the last four decades. The 70’s and 80’s saw an emphasis upon cost containment at the macro level. Micro- efficiency and responsiveness were the main impetus for reforms in the early 1990’s, whilst the turn of the century heralded the era of rationing and priority-setting (Ham, 1997). The more recent reforms have placed quality improvements and safety in health care as priority areas. These provided a basis for policy development throughout these years and each period reflected the different priorities in policy making.

2.11.2 Models of policy development

As already noted, policy development is a multifaceted iterative process, involving many actors and influenced by many factors. It is an art as well as a scientific means to take important decisions and whilst public policy making invariably involves the State, governments do not have a monopoly of policy development. Having said this, Anderson (1975, p. 2) views policy making as the role governments play in taking decisions and adhering to a course of action in order to address a specific social or economic challenge, and in so doing, the State adopts specific strategies to implement the policy at hand. In fact, he defines policy as ‘a purposive course of action followed

by an actor or series of actors in dealing with a problem or matter of concern.’

Many view policy development as a process rather than as a stand-alone event, since policy varies according to the level it is fashioned and is not only considered a starting point but also an incremental cycle of decision making and change (Rose, 1976), (Jenkins, 1978). Rose (1969) had already made such an argument when stating that policy making is best conveyed by describing it as a process, rather than as a single,

upon the context in which policy is formulated. Such contextual factors have a crucial influence upon the content of a policy. The same policy may change with changing circumstances, since this is primarily a ‘political’ process. The context may refer to the political system, the socio-economic situation, the values and other cultural factors that influence societal changes, local and international-based legislation, structural and organisational factors, the geo-political dimension and historical perspective, as well as religious and environmental factors. Policy is also determined by ‘actors,’ acting either individually or more often together. Actors steer, conduct, implement and evaluate the policy process. It is important to appreciate that actors are not value-free and always form part of an interest group.

At a local level, the most influential actor is of course the government of the day, in addition to the political parties, the legislature, the judiciary, the executive, the public service and external expert advisors. International organisations, such as WHO, CION, the World Bank, International Monetary Fund and OECD are increasingly becoming influential in shaping national, regional and even international policies. The media is no longer a mere spectator but with today’s technology and social networking, the media has evolved into becoming one of the key players in influencing the policy agenda. Finally, the academic community is slowly but surely making inroads when it comes to swaying policy decisions which are more knowledge-based and grounded in evidence, rather than all the other aforementioned shaping factors.

The above mentioned four areas have been amply elucidated upon by Walt (1994) in her seminal work on the political process of policy making. She argued that policy development could be viewed in four different but interlinked dimensions, pertaining to policy content, the context within which a policy is created, the policy process and finally, the actors involved in the drawing up of the policy.

Another policy change model is that promulgated by Kingdon in his ‘multiple streams’ model of change (Kingdon, 1984); (Rawat & Morris, 2016). Kingdon developed the multiple streams model as an off-shoot of the Garbage Can model of Cohen, March and Olsen (Cohen, et al., 1972). He postulated that change is instigated by a

indirectly. More importantly the processes or streams refer to the confluence of three aspects: those of problems, policies and politics. Once there is convergence of these three streams in a timely manner, then Kingdon postulates that change would occur, in what he terms as a ‘policy window’. This is important to consider in health care as serious problems occur frequently but potential solutions and the political will to tackle the problem is not always evident. HSPA interjects in this process but highlighted the problems or gaps in the system and offering potential solutions.

2.11.3 Approaches to policy development

The literature presents a large number of approaches in policy making, including the rational approach (Vedung, 2000), the incremental approach (Lindblom, 1959), the mixed scanning model (Etzioni, 1967), group theory, elite theory (Prewitt & Stone, 1973), pluralist theory (Hirst, 1993) and the political system model (Duverger, 1980).

The rational approach presupposes that policy is determined primarily through a rigorous scientific approach based on identification of the problem and need, setting clear objectives, an optional appraisal (considering alternatives and consequences) and making a choice that maximises the attainment of the goals identified beforehand. On the other hand, the incrementalist approach is based upon the premise that new policy is formulated on past policies and experiences, through a selection of goals determined by past and present policies and closely linked to the means of implementation. The options chosen in this scenario differ only marginally from the status quo and the best option is often that which achieves the widest agreement or consensus amongst policy- makers. This approach is invariably used in international settings such as the WHO or EU.

A combination of some approaches has also been advocated over time. These pertain to the approaches promulgated by Simon (1957) (Bounded Rationality), that of Disjointed Incrementalism or ‘muddling through’ as proposed by Lindblom (1959), the Mixed Scanning (broad angle then zoom) approach of Etzioni (1967) and the Extra-rationality or Normative Model by Dror (1989).

a confluence of coalitions which work together and seek a coordinated approach to policy solutions. This enables complex policy problems involving several actors and different levels of state and non-state involvement to be resolved, in spite of the presence of uncertainty and ambiguity. This theory is influential in that it provides a framework for complex policy solutions, where it is postulated that policy change and reforms are instigated by the competitive forces between these coalitions.