Health Policy นพ.ทักษพล ธรรมรังสี Thaksaphon Thamarangsi International Health Policy Program (IHPP) Ministry of Public Health, Thailand

What is ‘policy’? a course of action or inaction (Heclo 1972) a course of action adopted and pursued by a government, party, rulers, statesman (Oxford English Dictionary) a set of interrelated decisions … concerning the selection of goals and the means of achieving them within a specified situation … (Jenkins 1978) decisions taken by those with authority and responsibility for a given policy area (Buse et al 2005) any course of action followed primarily because it is expedient or advantages in a material sense Policy Strategy Plan Program of work นโยบาย ยุทธศาสตร์ แผน

What is ‘public policy’ Public policy is whatever governments choose to do or not to do. Failure to decide or act on a particular issue also constitutes policy (Dye 2001) Public policy is the policy originated through the decisions of governmental agencies including legislative institutes to retain the status quo or to introduce changes in a policy domain (Howlett and Ramesh 2003) นโยบายสาธารณะ (public policy) หมายถึง ความตั้งใจ (intention) หรือคำประกาศ (statements) หรือการกระทำหรือละเว้นไม่กระทำอย่างใดอย่างหนึ่งโดย Government หรือ ผู้ปกครอง (Parsons 1995) ‘the most important choices’ (Lasswell, 1951) ‘an action which employs governmental authority to commit resources in support of preferred value’ (Considine, 1994) ‘a particular object or goal, a desired course of events, a selected line of action, a declaration of intent and an implementation of intent’ (Ranney, 1968)

Differentiating Policy By importance High politics issues Low politics issues By level International level Regional level National level Local level By type Distributive Regulatory Self-regulatory Re-distributive By instrument Statements Regulations Laws By importance High politics issues: maintenance of core values, long-term objectives of the state; elitist eg: HEALTH CARE REFORMS Low politics issues ‘politics as usual’, much more open process of consultation; (pluralist) eg: CONDOMS POLICY By type (or effect) distributive policies provision of services or benefits to the population that don’t result in any obvious disadvantage or reduction to other groups EG: CHW SCHEME regulatory policies involve the imposition of limitations or restrictions EG forbidding nurses to do private practice; licensing pharmacists self-regulatory generally sought by a particular organisation to control its own interests EG IFPMA – Code of Practice re-distributive policies are deliberate government attempts to change the distribution of wealth or income EG progressive taxation

ระดับของนโยบาย นโยบายระดับชาติ นโยบายระดับพื้นที่ นโยบายระดับองค์กร นโยบายของรัฐบาล-แถลงการณ์ของนายกฯ กฎหมาย พรบ พรก กฎกระทรวง ประกาศ แผนพัฒนาเศรษฐกิจและสังคมแห่งชาติ แผนแม่บทแห่งชาติ บัญชียาหลักแห่งชาติ ชุดสิทธิประโยชน์ของระบบประกันสุขภาพ นโยบายระดับชาติ กฎหมาย กฎระเบียบในระดับจังหวัด แนวทางระดับเขตตรวจราชการ มติของคณะกรรมการจังหวัด อำเภอ นโยบายระดับพื้นที่ แนวทางการคัดเลือกเวชภัณฑ์ของโรงพยาบาล Clinical Practice Guidelines, Standard Operating Procedures (SOP) เช่น Laboratory manuals การจัดงานประชุมวิชาการ นโยบายระดับองค์กร

Types of policy Distributive Redistributive Regulatory Example: how to tackle the problem of low vegetable and fruit diet ? Distributive Public campaign, Vitamin supplementary, support research Redistributive Vegetable Tax cut/ increase tax on non vegetable & fruit to raise fund Regulatory Ban of snack diet

What is bad policy? Let’s discuss ….

What do we mean by ‘good policy’? Six dimensions of good policy Effectiveness Efficiency Adequacy Equity Responsiveness (Accountability) Appropriateness (inc. feasibility) Dunn, 1994

Policy diagram By product Output Outcome Effect Impact Short term Long term Input Process By product Input Human resources Financial resources Instruments Technical knowledge

The Policy Triangle Context Actors Content Process Walt G and Gilson L, Reforming the health sector in developing countries: the central role of policy analysis, Health Policy and Planning 1994; 9: 353-70

Development Models Resource allocation models Trigger-down effect Pro-poor/ For-underprivileged policy Discussion Establishing a new dentistry school (public/private) Allocation of dental unit/ equipment

OOP as % monthly income by per capita income deciles, prior to UC (1992-2000) and after UC 2002 The Gaps of inequity of out of pocket payment on health by poorer and richer deciles has gradually decreased during pre-UC period of 1992 to 2000 and UC period in 2002. This is the performance of successive governments in Thailand, in coverage extension, started first with the poor, then to the elderly, children under 12 years, the disable, as well as voluntary public subsidize health insurance scheme, and extension of social health insurance coverage to smaller size of establishments. Interestingly, it should be noted that UC demonstrates a merit of closing the gap of inequity among the poor, in deciles one to four. Source: Data in 1992-2000 from Thailand Health Profile 1999-2000. Data in 2002 from analysis of Socio-Economic Survey 2002 conducted by NSO. Remark: Health expenditure of household was percentage out of income.

กระบวนการนโยบาย policy process ขั้นตอนของกระบวนการ การตั้งวาระนโยบาย agenda setting การออกแบบนโยบาย Policy formulation การประเมินผลEvaluation การนำไปปฏิบัติImplementation ผู้มีส่วนเกี่ยวข้อง Policy actors บริบทของนโยบาย Policy context

Policy agenda setting Agenda setting is the process by which problematic conditions come to receive governments’ attention, and the potential for policy alteration Kingdon’s - 3 Stream model Problem Policy (Solutions) Politics (Political will) No Change No Change No Change ACTION

Policy formulation 2-pronge process: options formulation, decision making (legislation) Rationalism What do we mean by ‘rational policy decision’ Evidence-based policy Incrementalism Significant change is the accumulation of small changes The roles of non-policy makers

Research-policy nexus งานวิจัย>> ข้อมูลเชิงประจักษ์ >> การตัดสินใจเชิงนโยบาย กลไกการเชื่อมโยงระหว่างภาควิชาการกับนโยบาย Link between policy and research communities บริบทของการตัดสินใจ Political context ความน่าเชื่อถือของข้อมูล Credibility of evidence Young J, Research and policy: parallel universe?, Oversea Development Institute Annual Report 2002/3 The power of discourse & format

Policy implementation The role of policy implementer as ‘mediator’ The role of policy makers as ‘system administrator’ ‘implementation failure’ or ‘implementation deficit’ Top down: focus on how effective the policy is implemented? Bottom up: focus on the role of implementer

Policy actors Is policy process manipulable? Who can influence/ manipulate policy process? Who is policy actors? Power and interest The concept of actors: policy network, interest groups The role of mass media? How those voiceless people can involve in policy process? The confusing state of GO and NGO: (full-blown GO, GO-like NGO, NGO-like GO, full-blown NGO) Discussion: who are stakeholders in the problem of caries in children

Policy evaluation Monitoring and evaluation When does policy evaluation start? What to be evaluated? policy in different dimensions (i.e. equity, effectiveness, efficiency, etc) component of policy process (i.e. input, process, output, by product) Monitoring Evaluation Alternative terminology Formative evaluation Summative evaluation Priority Effectiveness of implementation Achievement of policy output Focus on Information Value

CONTEXT Systemic factors which may have an effect on policy Situational factors (transient, impermanent), e.g. war, economic recession, droughts Structural factors (relatively unchanging elements), e.g. political system, type of economy, wealth, demographic features, technological advance Cultural factors, e.g. religious, hierarchies, social norms International or exogenous factors (Leichter 1979)