Political economy analysis for health Reich, Michael R
Bulletin of the World Health Organization,
2019-Aug-01, 2019-08-01, 20190801, Volume:
97, Issue:
8
Journal Article
Peer reviewed
Open access
Achieving the health targets of the sustainable development goals (SDGs) depends on favourable political economy factors. Policy reform can be best understood, analysed and managed by recognizing how ...political economy shapes what happens in the reform process. Political economy can be broadly defined as the study ofboth politics and economics, specifically the interactions between them and their consequences for specific outcomes of interest. Political economy focuses on power and resources, how they are distributed and contested in different country and sector contexts, and the resulting implications for development outcomes. Applied political economy analysis supports policy processes in three ways. First, such analysis generates an assessment of the political landscape, including a stakeholder map, an assessment of power and position of key political actors, and an estimate of political feasibility for policy change. Second, the analysis focuses attention on how political strategies shape the feasibility of a policy reform and on the importance of politically managing the change process. Third, such analysis underlines the role of political economy factors throughout the policy cycle, including agenda-setting, policy design, adoption, implementation and evaluation.
Mexico's health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the ...2003 health reform (Seguro Popular) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico's restructuring reform. Three main ethical principles are identified as the foundation for the government's health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government's restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.
Any effort to improve health system performance must address the challenges of policy implementation. This article examines one aspect of implementation-the politics of policy implementation for the ...health sector, particularly the management of stakeholders in order to help change teams improve the chances of achieving policy objectives. Based on a literature scan of political analyses and descriptions of health policy implementation in low- and middle-income countries, we propose six major categories of stakeholder groups that are likely to influence implementation: interest group politics, bureaucratic politics, budget politics, leadership politics, beneficiary politics, and external actor politics. The categories of stakeholders can be overlapping. We examine the politics of these different stakeholder categories, and then present selected examples of published case studies that show the types of implementation challenges that arise for each category and how implementers can use political strategies to manage specific stakeholder groups and related political processes. Understanding the political dimensions of implementation can help those responsible for implementation drive policy into practice more effectively. Understanding and addressing conflict, resistance and cooperation among stakeholders are key to managing the implementation process. Systematic and continuous political analysis can help decision makers and change teams improve the chances for successful implementation.
Summary In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with ...UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls—but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.
We use policy discontinuities at state borders to identify the effects of minimum wages on earnings and employment in restaurants and other low-wage sectors. Our approach generalizes the case study ...method by considering all local differences in minimum wage policies between 1990 and 2006. We compare all contiguous county-pairs in the United States that straddle a state border and find no adverse employment effects. We show that traditional approaches that do not account for local economic conditions tend to produce spurious negative effects due to spatial heterogeneities in employment trends that are unrelated to minimum wage policies. Our findings are robust to allowing for long-term effects of minimum wage changes.
We provide the first estimates of the effects of minimum wages on employment flows in the US labor market, identifying the impact by using policy discontinuities at state borders. We find that ...minimum wages have a sizable negative effect on employment flows but not on stocks. Separations and accessions fall among affected workers, especially those with low tenure. We do not find changes in the duration of nonemployment for separations or hires. This evidence is consistent with search models with endogenous separations.
Essential medicines satisfy the priority health-care needs of the population. Essential medicines policies are crucial to promoting health and achieving sustainable development. Sustainable ...Development Goal 3.8 specifically mentions the importance of "access to safe, effective, quality and affordable essential medicines and vaccines for all" as a central component of Universal Health Coverage (UHC), and Sustainable Development Goal 3.b emphasises the need to develop medicines to address persistent treatment gaps.
Japan shows the advantages and limitations of pursuing universal health coverage by establishment of employee-based and community-based social health insurance. On the positive side, almost everyone ...came to be insured in 1961; the enforcement of the same fee schedule for all plans and almost all providers has maintained equity and contained costs; and the co-payment rate has become the same for all, except for elderly people and children. This equity has been achieved by provision of subsidies from general revenues to plans that enrol people with low incomes, and enforcement of cross-subsidisation among the plans to finance the costs of health care for elderly people. On the negative side, the fragmentation of enrolment into 3500 plans has led to a more than a three-times difference in the proportion of income paid as premiums, and the emerging issue of the uninsured population. We advocate consolidation of all plans within prefectures to maintain universal and equitable coverage in view of the ageing society and changes in employment patterns. Countries planning to achieve universal coverage by social health insurance based on employment and residential status should be aware of the limitations of such plans.
•Japan has among the world’s lowest levels of confidence in the HPV vaccine.•In 2013, public questions arose about possible side effects of the HPV vaccine.•Japan has experienced a steep and ...persistent decline in HPV vaccination uptake.•The barriers to HPV vaccine access and use in Japan occur mainly in adoption.•We recommend specific actions for multiple stakeholders to rebuild social trust.
Vaccine hesitancy is a growing concern in global public health, and illustrates serious problems arising from loss of social trust. Japan is experiencing a human papillomavirus (HPV) vaccine crisis that started with a rapid decline in the vaccination rate in 2013 from approximately 70% to less than 1% and lasting for 7 years. We analyze Japan’s case of vaccine hesitancy for HPV vaccine, using a framework for examining barriers to access and use of health technologies according to four categories: architecture, availability, affordability, and adoption. Significant problems were identified in the architecture of the decision-making body, public information availability, adoption of evidence in policy-making process, knowledge and confidence among providers, education to the public, and communication with end-users. We propose a series of actions to address these barriers. The national government should diversify the advisory committee to include broader scientific evidence and various viewpoints. Municipalities should actively distribute information cooperating with local providers. Professional associations should create an alliance to influence policy makers and deliver education to health care providers and end-users. Politicians should integrate opinions from citizens and scientists to implement an up-to-date policy. Civil society should share individual stories from cervical cancer patients and positive experiences of vaccinated girls. Mass media should use more diverse sources of information to report more comprehensive and science-based views. These actions would help build mutual trust among stakeholders, which is required to increase social trust in the HPV vaccine in Japan and thereby regain vaccine confidence and reduce preventable deaths and complications.
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