Health Policy Analysis

“Policies are many,

principles are few,
Policies will change
Principles never do”
John C. Maxwell
Learning objectives
• Discuss different dimensions of (health) policy analysis.
• Recognise different kinds of arguments one can encounter in policy
analyses - and values that can inform the way different actors analyse
policies.
• Distinguish between analysis for policy (ex-ante) and analysis of policy
(ex-post); and appreciate the methodological commonalities and
differences.
Overview
1. Policy analysis: definition; objectives/aims; scope; positive and
normative policy analysis
2. Discussion preparatory work in groups
1. Role of evidence
2. Public opinion
3. Potential dilemma’s
3. Policy analysis:
Steps (Patton, Sawicki)
Elements/dimensions; (INSP, Canada: Framework)
Stakeholder & Power analysis

4. Final considerations
Definitions
Policy: ‘Broad statement of goals, objectives and means that create the
framework for activity. Often takes the form of explicit written
documents, but may also be implicit or unwritten.’ (Buse, Mays, Walt,
2005)
Public policy: ‘whatever the governments choose to do or not to do’
(Thomas Dye, 2001)
Health policy: (Buse, Mays, Walt, 2005)
• Embrace courses of actions (and inaction) that affect the set of
institutions, organizations, services and funding arrangements of the
health system.
Definitions
Health policy: (Buse, Mays, Walt, 2005)
• May cover policies in the public (government) and in the private
sector.
• Also interested in (intended) actions of organizations external to the
health system which have an impact on health.
• Policies can be the intended or unintended result of decisions taken
over time.
• They can be expressed in practices, statements, regulations,
guidelines, allocation decisions, strategies and laws.
• They can be explicit or implicit, discretionary or statutory.
Walt & Gilson’s framework
Policy Analysis
• Health policy analysis is a multi-disciplinary approach to
public policy that aims to explain the interaction between
institutions, interests and ideas in the policy process

• It is useful, both retrospectively and prospectively, to

understand past policy failures and successes and to plan for
future policy implementation

Walt, 2008
Why policy analysis?
• Help explain why certain health issues receive political attention (Agenda
setting)
• Option appraisal (neutral or with aim of advocacy)
• Improve the prospects that technical evidence is considered during
policy formulation leading to evidence-informed policy
• Assist in identifying stakeholders which support or resist; can be used to
develop strategies, anticipate public acceptance
• Help identify and address obstacles that undermine policy
implementation: feasibility (organizational, legal, technical, human
resources)
• Evaluate: Does it work? Value for money? Distributive effects (equity)?
Demand for accountability, transparency
Two types of policy analysis
1. Analysis ‘for’ policy
Usually prospective; used for planning or formulating a new policy,
or anticipate what will happen (formative evaluation); results may
inform advocacy & lobbying, or may lead to decision to abandon it
because of lack of feasibility; ex-ante

2. Analysis ‘of’ policy

Generally retrospective and descriptive; how did it get on the
agenda?; how was it developed and formulated?; what was its
contents?; did it achieve intended goals? (summative evaluation);
ex-post
Types of analysis – in policy analysis
Distinction between positive and normative analysis, between analysis that seeks to clarify what is
and analysis that seeks to identify what action should be taken
• Positive statements are objective statements that can be tested,
amended or rejected by referring to the available evidence.
Because positive analysis provides or predicts on questions such
as “what is” or “what happened”, it tends to be free of personal
values.
• Normative statements are subjective statements– on the
appropriateness or desirability of an economic outcome or
policy. Often, the person writing an article has a particular
argument to make and will include subjective statements about
“what ought to be” or “what should be happening”. Their
articles carry value judgements; they are trying to persuade you
of the particular merits or demerits of a policy decision.
Types of analysis: positive or normative?
• The government should increase the tax on cigarettes to prevent
people from smoking.
• A rise in average temperatures will increase the demand for sun
screen products.
• Cut-price alcohol has increased the demand for alcohol among
teenagers
• A 10 % increase in the price of cigarettes leads to a 6 % reduction
in the number of cigarettes consumed.
• The government is right to introduce a ban on smoking in public
places.
• Resources are best allocated by allowing the market mechanism
to work freely
Types of analysis: positive or normative?
• The government should enforce minimum prices for beers and
lagers sold in supermarkets and off-licences in a bid to control
alcohol consumption
• A study estimates that the average yearly cost of treating
someone with AIDS is $38,300, while the lifetime costs equal
$102,000.
• It is in our country’s best interests that the federal government
take a more active role in the prevention of AIDS.
• National health care expenditures per capita are higher in the
Country X compared to Country Y.
• To control health care expenditures, Country X should adopt a
national health insurance program similar to Country Y
Discussion of preparatory questions in groups
• Role of evidence? In analysis for/ analysis of?
• Role of public opinion? In analysis for/ analysis of?
• Potential dilemma’s- only using evidence in social/
political sensitive subject?
Types of analysis
• Science can not always decide in a public debate when issues
relate to normative statements: discussion may focus on
whether ‘good science’ or ‘bad science’ supports the
argument, while in reality it is about conflicting viewpoints
and values.
• ‘Evidence based policy’: outdated term: in social issues
within complex realities there is rarely unequivocal
‘evidence’; but science can provide solid base of knowledge
for a societal debate or at least clarify the facts and values at
stake: Evidence-informed policy
The Basic Steps in a Policy Analysis Process (Patton,
Sawicki, Clark 2013)
A Framework for analyzing public policies:
Practical guide
September, 2012
A Framework for analyzing public policies:
Practical guide
Stakeholders analysis
central to policy analysis!
• How do they define a particular issue/problem; their
perceptions?
• What are the advantages/disadvantages (‘stakes’: positive and
negative) of this particular policy for this stakeholder? How
should we understand their behaviour, intentions, agendas,
interests?
• Resources they contribute/ what is their influence?
• How do characteristics of stakeholders influence decision making
and/or processes? Who will block/support/ is neutral?
• What are interrelations and networks?
• Encompasses range of different tools.
Potential actors in the health policy space.
Final considerations: Difficult policy problems
in a complex society
• Problems often not well defined
• Seldom purely technical or purely political
• Solutions cannot usually be proven correct before
application
• Solutions not guaranteed to achieve intended result
• Solutions seldom both best and cheapest
• Adequacy of solutions difficult to measure against notions of
the public good
• Fairness of solution often impossible to measure objectively
Important Considerations: Policy Analysis
• As a policy maker, or advisor to a policy maker, you will find different kinds of
arguments in the policy analysis you encounter, related to different
stakeholders
• Important to recognize 2 forms of disagreement - disagreement in the positive
domain and disagreement in the normative domain. Arguments and
disagreements in the positive domain tend to be more related to the technical
and methodological points.
• Arguments and disagreements in the normative domain are more related to
the values and beliefs of actors. It is about decisions regarding who counts
(standing), what counts (criteria).
Important Considerations: Policy Analysis
• Arguments and disagreements in the normative domain are thus
often linked to ideologies or values of different actors.
• Conservatives value ‘tradition’.
• Classical liberals focus on ‘rights’, ‘freedom of choice’
• Pragmatic liberals focus on ‘consequences’
• Socialists appeal to ‘virtues’
• Populists, nationalists appeal to ‘intuition’, ‘sentiments
Politicians and Scientists
a systematic flaw in their interaction…
• Sticks to path and principles • Knowledge always seen as
• Doubts seen as indecisiveness or provisional
evasiveness (liability) • Professional doubters
• Language persuasive • Language descriptive
• Wish to create and change the • Wish to discover and unclose the
world world
• Premise actions on objectives • Premise actions on questions
Policy and Politics
• Policy is used in the sense of ‘course of action’. It is in fact a
‘rule of behavior’. It need not relate to politics at all times.
‘Policy’ refers to ‘the course or principle of action adopted or
proposed by a government, party, business, or an individual.
• Politics on the other hand is the art and science of
government. Politics center around the activities concerned
with the acquisition or exercise of authority or government.
• A (public) policy is the outcome of politics. The political
processes and institutions that formulate the policies make
final decisions on the contents, goals and resources for
certain policies.
Health Policy: importance
• Important part of economy: (LMIC: 4 – 8% of GDP; HIC: 8 –
17% of GDP)
• Driver of economy: bio-medical technologies,
pharmaceuticals,
• Ensuring a healthy population: CMH, 2001
• Health influenced by other domains of society: CSDOH,
2005; water, food, cigarettes, road traffic, education
Main Elements of Policy Analysis
• The context: what are the contextual factors which affect health
policy (Historical, Structural, Social, Financial, Epidemiological,
Security-related)?
• The actors: what individual, local or external groups make policy and
what are their levels of empowerment and power relationships )?
• The process: agenda-setting, formulation, implementation,
evaluation; see earlier slide.
• The trends: what are the national and international norms,
standards and directions of contemporary policy and structural
changes?
• The content: what substantive issues are on the health policy
agenda
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
1) Verify, Define, Detail the Problem.
• State the problem meaningfully:
• Determine the magnitude and extent of the problem
• Continually redefine the problem in light of what is possible; worthwhile to get
the viewpoints of as many actors / stakeholders when defining the problem.
(conduct stakeholder/actor analysis).
• Question the accepted thinking about the problem; Question initial
formulations of the problem; Eliminate irrelevant material
• Say it with data; Locate relevant sources of data
• Locate similar policy analyses
• Assess whether the problem can possibly be resolved by ‘the client’.

Policy analysts seem to fail more often because they solve the wrong problem,
rather than getting the wrong solution to the right problem.
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
2) Establish Evaluation or Assessment criteria.
• What are the important policy goals, and how will they be measured?
• Identify criteria central to the problem and relevant to the stakeholders
• Usual criteria or common measures are: evidence of effectiveness, cost,
efficiency, legality, administrative ease and feasibility, equity, solidarity,
social & political acceptability.
• Identify desirable and undesirable outcomes
• Is there a rank order of importance among the criteria? To judge whether a
policy is effective – on its own and compared to alternative courses of
action.

In reality the choice of criteria/measures is very complex – and depends on

the stakeholders of the policy
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
3) Identify Alternatives.
• By this stage in the process, the analyst should have a clear picture of
goals, values and interests of client, and also stakeholders.
• Consider a wide range of options; examine alternatives used by
others in similar contexts.
• Consider the status quo, or no-action alternative as an option!
• Variations and combinations of alternatives should also be examined
– including unconventional alternatives, and those rejected in the
past.
• Consult with experts, do brainstorming, Delphi, scenario writing …
• Redefine the problem if necessary
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
4) Evaluate Alternative Policy Options.
• Select appropriate methods and apply them correctly, often a mix of
qualitative and quantitative analysis is required; ideally the problem
defines the methods..., no tool-box approach, combine methods.
• Estimate expected outcomes, effects, and impacts of each policy
alternative; look at technical, economic, and political feasibility of
each alternative.
• Do the predicted outcomes meet the desired goals?
• Can some alternatives be quickly discarded?
• Continue in-depth analysis of alternatives that make the first cut: this
step is at the heart of the policy analysis process.
• This is also the stage to check the definition of the ‘problem’
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
5) Present/Display Alternative Policy Options.
• Choose a format for display; use matrices, reports, lists, charts, scenarios,
arguments
• Show strengths and weaknesses of each alternative, using the evaluation
criteria
• Describe the best and worst case scenario for each alternative
• Remember the difference between a technically superior alternative, and a
politically viable one! Again, important to remember that rarely will there be
only ONE acceptable or appropriate alternative!
• The presentation of options must also include reflections on the possible side
effects and risks associated with a particular course of action – and possible
ways to mitigate these.

Trade-offs are central to the policy process – if solutions were easy or obvious,
the problem would not be around for ‘analysis’.
Steps in policy analysis (Patton, Sawicki, Clark, 2013)
6) Implement, monitor and evaluate the policy
• Draw up a plan for implementation
• Design monitoring system
• Suggest design for policy evaluation
• Was the policy properly implemented?
• Did the policy have the intended effect(s)?
Practical principles for policy analysts
(Patton, Sawicki, Clark, 2013)
• Policy analysis vs policy research: inform public decision makers well
enough to avoid major errors;
• Cost of policy study should not exceed benefits of a more precise solution
• Best technical alternative may not have politically best chances of getting
adopted
• Interplay: analytical tools, process of interaction with stakeholders,
communication to convey results of analysis
• Maintain trust of many: public, policy-makers, media, science community…
• Learn to deal with uncertainty
• Say it with numbers; and check the facts! (what sources?; single source?;
Were methods clear?; Check critical definitions)
Practical principles for policy analysts
(Patton, Sawicki, Clark, 2013)
• Make analysis simple and transparent: will your client understand it
and make better decisions as a consequence?
• Learn to advocate for position of others, develop case from different
perspectives: “be a broker, not an advocate”.
• Give analysis, arguments, assumptions, uncertainties, values, NOT
decisions: “inform policy, don’t make it”.
• Push boundaries of analysis beyond the specified problem: problems
and their alternative solutions sometimes presented in a narrow way.
• Be aware that there is no such thing as an absolutely correct, rational
and complete analysis: “perfect is the enemy of the good” and
eventually: “what goes inside the black box of decision making is not
a rational, logical process in which information and research
determine policy outcomes”.