A health policy is a set of objectives that are created to achieve certain goals within the health sector (Buse et al 2007). Although policies can be made at any level decisions for making a health policy is generally taken at the government level with financial or technical support from other interested organisations like the World Bank, and other Non Governmental Organisations (NGO).
The Health Policy Triangle
Buse et al (2007) explains the policy analysis using the health policy triangle which includes four interrelated factors that are significant.
This is a simple model of a complex set of intricate relationships of factors which may seem like they can be considered on their own but in reality the influence other factors (Walt and Gilson, 1994). For example the actors are influenced by the context of the environment, which in turn is affected by any of the following situational, structural or cultural factors:
Situational factors like wars, changes in governments or environmental changes.
Structural factors like demographic changes or technological advancements.
Cultural factors like diversity in language and religion.
International or external factors like NGO’s and foreign donors.
The actors also influence the policy making process using their positions, values and expectations. The content reflects some or all of these aspects, hence neglecting one could lead to inefficient policy implementation (Walt and Gilson, 1994).
The Policy Process
The process of making a policy involves various phases, for theoretical understanding of the process it is divided into stages, although it might not be exactly what occurs on practice (Buse et al 2007). The stages are:
Problem identification and issue recognition
The actors play a major role in the making of health policies, they could be either an individual, a group or an organisation interested in the policy issue. The major players in a national health policy process would include the government, which is the Ministry of Health, Ministry of Education, and Ministry of Finance, health care providers, medical professionals, national and international NGO’s like Oxfam, international organisations like World Bank and World Health Organisation and other funding agencies like Department for International Development (DfID).
A global actor is one, who has the power to influence the international health system and can be classified into public and private organisations (Damerow, 2009), examples as shown below,
United Nations Organisation (UNO)
World Trade Organisation (WTO)
World Health Organisation(WHO)
United Nations International Children Emergency Fund (UNICEF)
International Labour Organisation(ILO)
Regional International Organisations
European Union (EU)
Organisation of American States (OAS)
Non-Profit and Semi-Private International Non Governmental Organisations
For Profit International Corporations and Multi- National Corporations
Role of the Global Actors
At the national level, the main actors involved in the policy process are the elected government officials, bureaucrats and non-governmental interest groups from the commercial sector (Buse et al 2007). The role played by the international actors is gaining more importance. The general functions (Buse et al 2007) of these actors was to,
Draw the attention of the government to important issues within a country.
Provide public stimulus and support for new policies.
Assess the performance of the government, to provide accountability to the people.
Provide technical and financial support to countries in need.
IMPACT OF GLOBAL ACTORS ON NATIONAL HEALTH POLICIES
Positive or Negative??
Although generally positive, major global actors like the World Bank and WHO play significant roles in the health policy process. Since the mid 1990’s the presence of the World Bank in the health, nutrition and population (HNP) sector has given new importance to the health profiles of countries by providing financial support and focussing the government’s attention to issues neglected by policy makers (Buse and Gwin,1998). The ability to organize financial resources is the main advantage of the World Bank when compared with other organisations. It is the largest external source of funds in the low and middle income countries, and the increase in financial support for HNP is a significant role in global health (Ruger, 2005). The United States President Emergency Plan for AIDS Relief (PEPFAR) and Becton, Dickinson and Company (BD) recently declared their intention to provide support for improvement of the laboratory systems and services in HIV/AIDS affected African countries. Abbot, a multinational pharmaceutical company has sponsored state-of-the-art outpatient centres and labs at Muhimbili National Hospital in Tanzania (Yu, 2008). The Bill and Melinda Gates Foundation is perhaps the most generous organisation active in developing countries, having paid out almost $1.4 billion in grants for global development, education health programmes and financial services for the poor, by the end of 2005 (Drechsler and Zimmermann, 2006). Organisations cannot act alone to meet complex challenges, hence the World Bank is collaborating with other international organisations to strengthen its stand. For example in Brazil, Ghana and Uganda it used the sector-wide approach to gather multiple donors to fund an entire sector. Recently the World Bank has entered into a mutual agreement with WHO to provide the required technical assistance to improve the design, supervision and evaluation of its projects (Ruger, 2005).
There is also a negative impact that these actors have because of the diversity of organisations which have their own set of values and goals that may not appeal to all organisations (Walt and Gilson, 1994). Another problem is when funding is increases to a particular issue other issues may be neglected, of if a donor is influential other donors may follow suit causing a bandwagon effect, where even the medical professionals could divert attention to the extensively funded issue (Buse and Gwin, 1998). Sometimes international organisations provide grants and loans only if the national governments agreed to impose economic reforms (Walt and Gilson, 1994). The World Bank has also decided to put conditions with its assistance that the government should ensure that the funds are used only for the agreed services and not outside the agenda (Buse and Gwin, 1998). The bank was also criticized for the introduction of disability adjusted life years (DALY) to the health assessments because critics felt that they lack a sound theoretical structure (Ruger, 2005).
In the recent past many countries have joined hand in the fight against HIV/AIDS and they are supported by organisations like as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the World Bank Multi-Country AIDS Program (MAP), the United States President Emergency Plan for AIDS Relief (PEPFAR), and others such as the World Health Organization (WHO), the United Nations Program on HIV/AIDS (UNAIDS), private foundations like the Gates Foundation, and nongovernmental organizations like Doctors without Borders (Yu, 2008). The extent to which the disease is prioritized varies and sometimes it could be misfinanced. For example in Ethiopia where the prevalence rate of HIV is 1.4% $130 million was donated, compared to the national health budget of $113 million, in 2003. In the Republic of Rwanda $18 million was set aside for malaria and just $1 million for child health, while $47 million for HIV/AIDS which was inconsistent for a country where the rate of infection is just 3% (Shiffmann, 2008)
To improve the shortage of health workers donors have agreed to fund their salaries. For example in Kenya the Clinton Foundation, PEPFAR and the Global Fund along with the government have agreed that the donors will fund the salaries of about 2000 workers for a limited time following which the government will take over. While in Zambia, DfID has ensured that workers are paid incentives for working in remote areas (Yu, 2008). In 2007 an estimated $640 million of PEPFAR fund was used for strengthening the health system (Yu, 2008). In China, grants from the GFATM helped shape the policy by HIV harm reduction efforts for prostitutes and drug users. Uncoordinated increase in funds can lead to disintegration of a health system in poor countries. In Tanzania for example there are around four agencies focussed on HIV/AIDS, which also shows the lack of communication between donors and recipient countries (Yu, 2008).
Ghana, is a low-income country largely dependent on external aid, within the health sector service delivery is separate from policy making. An interesting example of discord among global actors is the fight against malaria when the US funded Netmark partnership intended to set up a sustainable market for insecticide treated bed nets by eventually shifting the cost of purchase to the consumer, while on the other hand donors like UNICEF were distributing free bed nets (Drechsler and Zimmermann, 2006). It is crucial for actors to co-ordinate rather than contradict each other. It is also equally important that the donor priorities match that of the recipient countries. Studies have shown that HIV/AIDS programmes are often promoted by donors even in countries where other diseases are a priority (Drechsler and Zimmermann, 2006). This influence of donor preference finally affects the national health policy. In Ghana for example where malaria is the most imperative health concern, no other institution has been established to support the Ghana Aids Commission in its fight against the disease (Drechsler and Zimmermann, 2006).
Although not the most important, technical information does play a role in the policy process but this may not be accepted by most policy makers affecting the policy in the bargain. Take Poland for example, they used technical experts to design and implement several proposed reforms. With support from the World Bank, European Community and University experts reports were prepared, which were rejected by the policy makers. While most experts felt the need for Poland to change their current system, the major stakeholders could not find an alternative since a clear technical agreement was never made in favour on a proposed reform (Drechsler and Zimmermann, 2006).
The work of the World Bank in Bangladesh, one of the poorest of least developed countries, is commendable. With support from the bank and other donors, the government set a sector wide approach strategy which included a combination of public and private health care delivery system, promotion of primary care and cost effective service delivery. The bank also headed a group of donors to manage a co-financed project (Buse and Gwin, 1998). It can also be accredited with notifying the government on priority issues. From this example it is clear that the bank stepped up and filled the gap in leadership in the health reform and finance sector. The only shortcoming is that the bank does not have the technical expertise which is the mandate of the WHO (Buse and Gwin, 1998).
It can be seen that the global actors focus on disease specific interventions rather than supporting health systems as they claim (Marchal et at, 2009). To avoid fragmentation of a health system, the funding for health needs to be restructured. And rather than just focussing on the Millennium Development Goals the global actors should turn their attention to strengthening the health systems in developing countries.