Dr. Shahram Yazdani Political Analysis and Political Strategies

Dr. Shahram Yazdani “It is not seeing things that are wrong and asking ‘Why?’ It is seeing how things could be and asking ‘Why Not?”

Problem Definition Diagnosis Policy Evaluation Policy Development Policy Implementation Policy Legislation Ethics Politics The Policy Cycle

Dr. Shahram Yazdani Political Analysis and Policy Development Health sector reform, like all policy reform, is a profoundly political process. Policy developers should begin political analysis early in the policy cycle; They shouldn't delay political analysis until after the policy has been developed. Waiting to assess the political implications of a policy can lead to proposals that are not likely to be adopted. The technical work of policy development and the political work of feasibility assessment need to occur at the same time. The secret of success is not in predicting the future; it is creating an system that will thrive in a future that cannot be predicted”

Dr. Shahram Yazdani Agenda-Setting for Health Reform Issues come and go in political life as a matter of public attention, in what has been called the issue-attention cycle The mass media play an important role in shaping this cycle of issues for public debate, in both developed and developing countries.

Dr. Shahram Yazdani Agenda-Setting for Health Reform The issue cycle is shaped in part by economic incentives. Newspapers, magazines, radio, and television stations depend on revenues from circulation, either from direct sales or advertising. Readers, listeners and viewers consume the news in part as entertainment. As stories become worn out and boring over time, the media have an incentive to find new, interesting topics to attract viewers and readers

Dr. Shahram Yazdani Agenda-Setting for Health Reform The availability of proposed solutions also affects the definition of an issue. This is usually an active process, and depends on the existence of a committed individual or organization – international or national-working to promote the solution. In these situations, these agencies become policy entrepreneurs —actors who seek to promote a particular issue and a particular solution

Dr. Shahram Yazdani Agenda-Setting for Health Reform A crisis can provide an opportunity to place an issue on the policy agenda. The crisis can be a natural disaster, such as an earthquake, which can highlight problems in the health system that need attention, or it can be a human- caused disaster, such as an economic crisis, which can focus attention on costly imported pharmaceuticals, and provide the impetus for introducing an essential-drugs policy. In some cases, policy entrepreneurs seek for years to introduce a particular policy reform, and achieve success only when the right combination of crisis and political circumstances come together

Dr. Shahram Yazdani Agenda-Setting for Health Reform Political cycles and timing also affect which issues get on a country’s policy agenda. By focusing attention on specific issues, different groups and individuals fight for political advantage, especially during elections. Once an issue is placed on the policy agenda, it tends to push other issues off; a country is usually able to consider only a limited number of major social problems for policy reform at a time.

Dr. Shahram Yazdani Agenda-Setting for Health Reform Policy entrepreneurs not only must make their definition of the problem more attractive than alternative ones, but they have to make it more attractive than competing issues. Political timing therefore is critical, since the window of opportunity for policy change is often limited and subject to unanticipated events Policy entrepreneurs need to develop an understanding of when the window of opportunity is open, how long it is likely to remain open, and how to squeeze their policy changes through the window quickly—before it slams shut again.

Dr. Shahram Yazdani Agenda-Setting for Health Reform Changes in the policy agenda can also occur when new actors enter the political system. A new minister of health, for example, commonly seeks to define a new policy agenda shortly after entering office. Policy entrepreneurs also act on the basis of their beliefs about what would make the system better— beliefs and values that are often shaped by:  Personal experiences  Sense of moral leadership  Ideology  Professional training

Dr. Shahram Yazdani Agenda-Setting for Health Reform Sudden changes in government can provide an opportunity for health sector reform. The general culture of a society also influences the agenda-setting process, by making some topics easy to raise in public and blocking other topics as taboo

Dr. Shahram Yazdani Agenda-Setting for Health Reform Political scientist John Kingdon (1995) has argued that the best chances for successful policy change occur when three streams of events come together: 1. The objective situation—the problem stream, 2. The availability of a possible solution—the policy stream, and 3. The flow of political events—the political stream. When these three streams converge, according to Kingdon’s theory of agenda-setting, some policy response is likely to result—although the response may not resolve the problem.

Dr. Shahram Yazdani Agenda-Setting for Health Reform Health reformers therefore require the capacity to assess and manage the flow of political events (skills in which they are rarely trained) as well as the capacity to analyze the objective situation and design possible solutions (skills in which they usually do receive training). Asking if a policy is feasible is, in part, asking a question about the advocates of reform, especially their creativity, commitment, and skills—and about their opponents. Passing health care reform often means overcoming or deflecting powerful interests that will vigorously defend their positions.

Dr. Shahram Yazdani Agenda-Setting for Health Reform Health reform advocates often organize a “change team” to manage the processes of policy design and adoption They must devise an acceptable definition of the problem and a feasible proposal for the solution. The change team requires not only technical capacity for policy design but also political capacity for policy mobilization of relevant groups and individuals.

Dr. Shahram Yazdani Agenda-Setting for Health Reform An analysis of change teams in three Latin American cases of health reform (Chile, Colombia, and Mexico) found several common traits:  Ideological cohesiveness,  High technical skills,  Work in isolation,  Use of policy networks The teams in these countries worked with several ministries and agencies, especially the Ministry of Finance, the Ministry of Planning, the Office of the President, and sometimes the military. While composed of technical people, who could formulate a new policy, they also needed to engage in bureaucratic battle with government agencies, manage the pressures from interest groups, navigate the legislative process of producing a new law, and initiate implementation of the reform.

Dr. Shahram Yazdani Politics of Health Sector Reform Four factors are of particular importance and can provide practical guidance in efforts to manage the politics of health sector reform 1. Players: the set of individuals and groups who are involved in the reform process, or who might enter the debate over the policy’s fate; 2. Power: the relative power of each player in the political game (based on the political resources available to each player); 3. Position: the position taken by each player, including whether the player supports or opposes the policy, and the intensity of commitment for or against the policy for each player (i.e., the proportion of resources that the player is willing to expend on promoting or resisting the policy); 4. Perception: the public perception of the policy, including the definition of the problem and the solution, and the material and symbolic consequences for particular players.

Dr. Shahram Yazdani Politics of Health Sector Reform Systematic characteristics of the politics of health sector reform 1. Technical complexity/difficulty 2. Concentrated costs on well-organized groups 3. Dispersed benefits on non-organized groups  The combination of concentrated costs on well-organized groups and dispersed benefits on non-organized groups constitutes what is called a collective action dilemma.  Overcoming the politics of this collective action dilemma is a major challenge for health reformers.

Dr. Shahram Yazdani Political Analysis A basic building block in designing political strategies for reform is to perform a stakeholder analysis. This consists of three stages. 1. First, identify the relevant groups and individuals. 2. Second, assess their political resources and their roles in the political structure, to determine their relative power for the policy question at hand. 3. Third, evaluate their current position on the proposed policy (including the intensity of their commitment) and their underlying interests.

Dr. Shahram Yazdani Position map for major players in health reform in the Dominican Republic in 1995 High Support Medium Support Low Support Non- mobilized Low Opposition Medium Opposition High Opposition Office of Technical Cooperati on (for Health Reform) PresidentUniversitiesNon- Government al Organization s Private Cllnicians Dominican Medical Associati on International Developm ent Banks Partido de Liberacion Domnicana ChurchDominican Institute of Social Security Employers in the Organized Sector Secretary of Health Press Secretary of Health Bureaucrac y Beneficiaries National Health Commissi on Low Power: MedHigh

Dr. Shahram Yazdani Political Analysis Stakeholder analysis combines two distinct modes of analysis. 1. One is interest group analysis. This consists of understanding those social groups that are seeking to press the government in a particular direction. 2. The second mode of analysis examines bureaucratic politics, and is focused on the competition among agencies and individuals within government For health sector reform in developing countries, one also needs to consider the activities of international agencies, such as the World Bank, UNICEF or the World Health Organization. “If you do not know who your request will affect, you are not prepared.”

Dr. Shahram Yazdani Political Analysis Health sector reform typically involves the following kinds of interest groups: 1. Producer groups: doctors, dentists, nurses, pharmacists, other health sector employees and their unions, domestic and international pharmaceutical companies, and equipment manufacturers; 2. Consumer groups: disease-based organizations, local and regional consumer groups, women’s organizations, unions representing insured workers, retirees, and military groups; 3. Economic groups: businesses with health insurance schemes, industries affected by health policies (e.g., tobacco farmers, drug sellers), and workers who gain or lose jobs; 4. Ideological groups: political parties, reform organizations, single- issue advocates (e.g., environmentalists, anti-abortion activists); 5. Health development groups: multilateral development banks, bilateral aid agencies, international health organizations, non- governmental development organizations.

Dr. Shahram Yazdani Political Analysis In addition to the ministry of health (MOH), the following government actors often play important roles in health sector reform debates and decisions: 1. Ministry of Finance: especially if the reform involves changes in the financing of health services or changes in the MOH’s budget; 2. Social Security Institute: particularly if the reform proposal involves changes in the provision of health care and a reorganization of government health facilities; 3. Economic and/or Planning Ministries: very likely if the reform proposal involves calculations about overall economic growth or decisions about debt forgiveness; 4. Local and/or Regional Governments: expected if the reform proposal involves decentralization; 5. Ministry of Education: for school health policies or for policies that affect medical schools; 6. Ministry of Agriculture, Trade, and Industry: for policies on alcohol, tobacco, pharmaceuticals, or medical equipment.

Dr. Shahram Yazdani Sources of Power and Influence TangibleIntangible MoneyInformation OrganizationAccess to leaders PeopleAccess to media VotesSymbols EquipmentLegitimacy OfficesSkills

Dr. Shahram Yazdani Position and Commitment Knowing a group’s political resources does not enable one to predict whether or how those resources will be used. Stakeholder analysis therefore needs to assess how each group views the policy issue, and what its position is. A first step is to assess the group’s interests because interests do shape policy positions. Anticipated economic consequences of a policy often determine political positions on that policy. It is also important to examine the positions that the players have taken publicly As part of this analysis, we also need to describe the intensity of each group’s current position on an issue Developing effective political strategies requires an understanding of why the key groups are taking their positions. “People do not fear change. They fear loss.”

Dr. Shahram Yazdani Political Strategies for Reform Position Strategies: Bargain to Change the Position of Players Power Strategies: Distribute Power Resources to Strengthen Friends and Weaken Enemies Player Strategies: Change the Number of Players, by Creating New Friends and Discouraging Foes Perception Strategies: Change the Perception of the Problem and the solution.

Dr. Shahram Yazdani Political Strategies for Reform Position Strategies Change a specific element of the policy’s substance Inter-issue exchanges Threats as well as promises Be flexible about “success” Perfect ain’t the point “ Either lead, follow, or get the hell out of the way!”

Dr. Shahram Yazdani Political Strategies for Reform Power Strategies Give or lend money, staff, or facilities to groups that support the reform; Provide information and education to supporters in order to increase their expertise; Give allies expanded access to lobby key decision makers; Provide allies with media time and attention in order to enhance their legitimacy; focus attention on their expertise, impartiality, national loyalty, and other positive social values.

Dr. Shahram Yazdani Political Strategies for Reform Player Strategies Mobilize players who are not yet organized and demobilize players who are already organized Change the arena of decision-making

Dr. Shahram Yazdani Political Strategies for Reform Perception Strategies In some political systems, particularly those that are open and competitive, a public appeal through the media and to specific targeted groups can change the general perception of an issue. This approach can be an effective political strategy for influencing bureaucratic and political leaders, as well as mass audiences. Political strategies directed at perceptions seek to change how people think and talk about a policy problem, how the issue is defined and framed, and which values are at stake

Dr. Shahram Yazdani Political Strategies for Reform Perception Strategies How does one alter public perception of an issue? There are various possibilities.  One can argue facts and values, reframe the issue, or seek to define key symbols associated with the issue.  Political mobilization is about emotion as well as data, and values can be used to oppose as well as promote health sector reform.  Some value-dividing conflicts may be inevitable. In such situations, one approach is to substitute specific substantive confrontation with principle- based negotiation, in which parties try to agree in advance to a set of principles that they will use to settle disagreements before they deal with the problems in detail

Dr. Shahram Yazdani Political Strategies for Reform Perception Strategies Cast the emotional tone and energy in a positive instead of a negative direction. Negotiation is a human process, filled with emotion as well as logic. Negotiators, therefore, need to manage the emotional dimensions as well as the logical content, for success “When your memory is as long as your fingernail, write it down!”

Dr. Shahram Yazdani Negotiation and Political Strategies Negotiations are often successful when the issue is constructed in win-win terms rather than win-lose terms Seek value-creating solutions, such that enough participants are willing to support the deal Respond to the real interests of other parties, not to the positions they happen to take

Dr. Shahram Yazdani Political Strategies and Ethics Politics of health reform should not be approached solely as an instrumental or Machiavellian problem. Health reformers need to consider the ethical dimensions of their political strategies, as well as how to get the policies they want. Values shape the substantive content of health reform But values also shape the processes for promoting the adoption of the health reform plan.

Dr. Shahram Yazdani Problems with Change

Dr. Shahram Yazdani Twenty Reasons Why Reforms Fail 1. Inadequate theory of implementation.  too little time for planning  too little time for practice and skill acquisition 2. Tendencies toward fads and quick fixes. 3. Lack of sustained support and follow- through. 4. Under-funding. 5. Overly centralized management. 6. Lack of technical assistance and staff development.

Dr. Shahram Yazdani Twenty Reasons Why Reforms Fail  Lack of awareness of limitations of human resources.  Turnover among actors.  Too many competing demands.  Failure to focus on the fit between the organization of the reform & the organization of the existing system.  Failure to account for local-site differences.  Failure to clarify the role relations of stake- holders.

Dr. Shahram Yazdani Twenty Reasons Why Reforms Fail 13. Not establishing a great enough sense of urgency. 14. Not creating a powerful enough guiding coalition. 15. Lacking a vision. 16. Under communicating the vision 17. Not removing obstacles to the new vision. 18. Not systematically planning for and creating short term wins. 19. Declaring victory too soon. 20. Not anchoring changes in the corporation’s culture.

Dr. Shahram Yazdani The Mighty Tenured Professors Syndrome The “Me & Mine” problem  It’s not in my job description.  It’s not in my area.  It’s not my idea.  It’s not in my plan, so it’s not in the plan. The “Us & Ours” problem  We’re too busy dancing to learn new steps.  Us, work with them? You gotta be fooling”!  They won’t let us.

Dr. Shahram Yazdani Keys to Successful Implementation (Miles, 1986) 1. Coordination 2. Shared control 3. Pressure and support 4. Ongoing technical assistance 5. Early rewards for change adaptors

Dr. Shahram Yazdani "To live is to change, to be perfect is to have changed often.”

Dr. Shahram Yazdani Thank You ! Any Question ?