The document discusses health policy and systems research, focusing on the capacities for health governance in low- and middle-income countries (LMICs) and the challenges encountered in implementing health regulations. It highlights issues such as the influence of medical political interests, capacity constraints, and the disconnect between policy and practice as key factors leading to governance failures. The document also emphasizes the importance of empirical research in understanding and improving health governance and the implementation of health policies.

1. https://twitter.com/KeystoneHPSR
Building the HPSR CommunityBuilding HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Researching Health Policy (POL)

2. KEYSTONE
Researching Health Policy
(POL)
Kabir Sheikh
26 Feb 2015

3. KEYSTONE
RESEARCHING DECISIONS

4. KEYSTONE
The ‘Actors’ in the System
Policies / environments
Systems
performance
and outcomes
POLITICIANS
POLICY-PLANNERS
ADMINISTRATORS
AND STEWARDS
HEALTH PROVIDERSCITIZENS
CIVIL SOCIETY
MARKET ACTORS
ADVOCATES

5. KEYSTONE
Cognition
Judgment
Behaviour
Interaction
Anatomy of Decisions
Policies / environments
Systems
performance
and outcomes
Capability of
change?

6. KEYSTONE
Rational choice approach
• Actions of decision-
makers, in response to
estimable constraints, can
be modelled and predicted
• Has predictive value and is
open to empirical testing
• Regards human beings as
being “instrumental and
not expressive” (John 1995)
• Has limited value as a
descriptive device
Predicts the behaviour of individuals, based on economic
theories of maximisation of self-interest (Sabatier 1999)

7. KEYSTONE
Bounded Rationality
• Rationality as the ideal, and
actual behaviour as divergence
from ideal
• Organizations should function
by maximising rationality in a
step-wise process: intelligence,
design and choice
• What constitutes rational
action in unjust institutions?
• What does bounded rationality
signify in the context of health,
where empathy is a core value?
INTELLECT
Reason,
rationality
AFFECT
Passion, instincts
(Simon 1957)

8. KEYSTONE
Discourse Theory
• ‘Systems of meaning’, ‘Frames’: actors’ ways of understanding the
world
• How “facts, values, theories and interests are integrated” by actors to
construct their realities, define problems, identify solutions
• “Communities of meaning”: actors belonging to the same group share
cognitive mechanisms, engage in similar acts and use similar
language to discuss policy problems
(Yanow 2000, Rein and Schön 1993, Geertz 1983)
REASONS FOR POLICY / SYSTEMS FAILURE
 Discordances in systems of meaning
 Dominance of particular systems / submission of valuable systems
 Difficulties in communicating across systems

9. KEYSTONE
Policy Learning Cycle (Vickers 1965)
Reality judgements
‘What is’
Appreciation
Value judgements`
‘What ought’
Action
judgements
‘What to do’
‘How to do it’

10. KEYSTONE
Why health regulators in India
don’t actually regulate…
• Delicate relationships with the regulated
• Lack of support from senior authorities
• Lack of regulatory capacity
• Empathy with ‘rights’ of the regulated
• ‘Development’ ethic favoured
• Disengagement with / antipathy to regulatory principles
• Focus on developmental tasks
• Neglect of regulatory tasks
(Sheikh and Porter 2010)

11. KEYSTONE
Roles and Rationales
O1
P1
P2
P3
O2 O3
 Multiple organizations
implement programmes
 Organizations participate in
several programmes
Conflicts between
organizational and
programme
rationales are
common
I must
perform
I have to
conform

12. KEYSTONE
RESEARCHING GOVERNANCE

13. KEYSTONE
Defining challenges for our time
HOW CAN WE…
• Make affordable, high quality health goods and services accessible to all?
• Get quality health services to underserved areas?
– Doctor retention or replacement?
• Best engage the private health sector?
– Government as provider, steward, purchaser?
• Effectively govern existing services, make them accountable?
– Build government capacity, efficiency, transparency
– Integrate multiple systems, sectors
• Mobilize communities for health in context of massive social inequality?

14. KEYSTONE
• Health governance in many LMIC may mirror mixed
health systems syndrome in its combination of
declining capabilities of public organizations and
infiltration and dominance of private interests (Sheikh et al
2012)
• Little research on health governance in LMIC
– Poor financial, HR and leadership capacities
– Poor organizational coherence
– Elite capture, corruption
– Little community oversight, low transparency
Health Governance in LMIC

15. KEYSTONE
What is (Health) Governance?
• How institutions, rules and systems of the state –
executive, legislature, judiciary, and military – operate at
central and local level and how the state relates to
individual citizens, civil society and the private sector
(DfID 2001)
• The exercise of economic, political and administrative
authority to manage a country's affairs at all
levels(UNDP)
• Leader selection, formulation and implementation of
policies, citizen-state interaction (World Bank)

16. KEYSTONE
WHO Views
• SYSTEMS FUNCTION: macro-level function involving guidance of
the health system through six sub-functions of policy guidance,
system design, stakeholder management and regulation and
system-level accountability (WHO health systems)
• COMPONENTS: Intelligence, policy formulation, organizational
‘fit’, implementation, partnership, accountability (WHO –
stewardship)
• POLITICAL: The exercise of authority at all levels, comprising
mechanisms, processes, relationships and institutions through
which citizens and groups articulate their interests, exercise
their rights and obligations and mediate their differences (WHO)

17. KEYSTONE
Institutions and Rules
(Brinkerhoff & Bossert)
Arena Functions
CIVIL SOCIETY Socializing, Enabling
POLITICS Aggregating, Representing, Legitimizing
POLICY Distributive, Redistributive, Regulatory, Constitutive,
Adjudicatory
PUBLIC ADMINISTRATION Implementing, Managing
Governance signifies the formal and informal rules that define roles of actors
and shape their respective interactions, within these institutional arenas…

18. KEYSTONE
Relationship with Health Systems
Health
sector
Allied
sectors
Governance of Health
Leadership
and
Governance
HR, Finance, etc
Other
Building
blocks
Health Systems Governance
Health
Sector
Food, water,
environment,
rural and urban
All other
Sectors
Governance for Health

19. KEYSTONE
What is good governance?
Governance works well if these are assured (Brinkerhoff and Bossert 2010)
• Accountability of key system actors to beneficiaries and public
• Fairness: engaging competing interest groups on equal terms
and allowing negotiation and compromise
• Capacities, power and legitimacy to manage policy making
and implementation processes effectively
• Engagement of non-state actors in policy processes, service
delivery partnerships, oversight and accountability

20. KEYSTONE
What makes governance good? (DfID 2007)
• State Capability
• Accountability
• Responsiveness
Some neglected norms that are relevant for
health governance in India and other LMIC
• Self reliance
• Equity
• Socially realized justice

21. KEYSTONE
Health governance research:
• Empirical research on decision-making at all levels of the health
system and in communities
• Investigates policy processes and systems performance as well as the
interface of health systems with citizens
• Questions focus on systems hardware (finance, HR, medicines) as well
as software (ideas, interests, values, norms, relationships, power)
• Uses a range of “HPSR” methods: policy analysis, mapping and
landscaping, ethnographies, realist evaluation

22. KEYSTONE
Mapping study: Regulatory Failure in
LMIC Mixed Systems
Regulatory failure is a pre-
eminent challenge for health
policy in LMIC; yet institutional
contexts for these failures
remain poorly explored
STUDY AIMS
Develop and field-test a research tool to:
1. Empirically map architecture of
health regulatory institutions in a
geo-political unit (state or country)
2. Identify gaps in design and
implementation of regulatory
policies
(Oxfam 2009, Nishtar 2010)

23. KEYSTONE
Steps in Research
METHODS
• In-depth interviews with
health systems officials
• Discussions with policy
elites and key informants
• Policy document review
STEP 6 Data synthesis
STEP 5 Describing regulatory activities
STEP 4 Charting putative functions
STEP 3 Listing relevant policy documents
STEP 2 Listing groups with regulatory functions
STEP 1 Detailing policy context

24. KEYSTONE
Design Gaps
Delhi
• RSBY and government subsidies to
private hospitals both aimed at
reducing costs of private care for EWS,
do not address the high incident costs
in public facilities, or financial
protection of non-EWS. No direct
control of care costs, no regulation of
competition.
• No credible regulatory mechanism to
limit practice by unqualified providers.
For both quality of care and conduct of
providers, absence of credible
community-based forum for grievance
redress.
• Accessibility of care not addressed
through act or policy
Madhya Pradesh
• No known laws or regulatory policies
for the curtailment of costs for users of
health care, other than recently
introduced Janani Sahayogi Yojana
(Scheme)
• For quality of care and conduct of
providers: absence of credible
community-based forum for grievance
redress
• Variable accessibility of care (workforce
distribution): only mandatory rural
service, no incentive based policies

25. KEYSTONE
Implementation Gaps
Delhi
• Cost of Care: Information asymmetries impede
uptake of social insurance scheme, also lack of
stringent regulatory component. Reduced
investment in regulatory capacity of relevant
departments impedes enforcement of EWS free-
bed condition for hospital subsidy
• Quality of care: multiple contestations of NHRA
have diluted content. Partial implementation due
to personnel constraints and organizational
inertia, active resistance of medical fraternity
• Provider conduct: Councils role transformation to
less of disciplinary function, more on protecting
professionals’ rights, medical sanctity
• Accessibility of care: health authority
subordinated to urban development authority in
determining location of new hospitals
Madhya Pradesh
• Quality of care Clinical Establishments Act,
PNDT, MTP: Implementation is partial due to
personnel constraints problems of inter-
departmental coordination, affects
relationships with hospital owners
• Provider conduct: self-regulatory council’s
commitment to disciplinary functions, made
problematic by closeness to associations who
oppose regulation. Engagement with
additional tasks such as reducing quackery
greater than performance of disciplinary
roles.
• Accessibility of care: implementation of rural
medical bonds hampered by extensive
contestation by doctors’ groups, problems in
coordination between government
departments involved in placements

26. KEYSTONE
Key factors underlying governance failure
1. Influence of medical political interests (regulatory agencies
are largely constituted of medical professionals, or reliant on
their cooperation)
2. Discordance in inter-departmental relationships and
coordination within the State regulatory machinery
3. Severe constraints in numbers and capacities of personnel
for regulation

27. KEYSTONE
IMPLEMENTATION ANALYSIS

28. KEYSTONE
How it helps…
 Provides multi-layered explanations and solutions for
problems of implementation: often a pre-eminent concern
in LMIC health policy
 Helps in systematically investigating the functioning of
complex and poorly understood systems and institutions

29. KEYSTONE
Uses of implementation analysis
• Diagnostic: explaining why a policy is ineffective or
partially effective
• Strategic: identifying factors which influence the viability
and effectiveness of a policy or policy process
• Prospective: generating knowledge to inform the future
trajectory of policy processes

30. KEYSTONE
Implementation: the classical view
Policy
Execution
Implementation
on front-lines
• A managerial function,
succeeding and separate
from policy-making
• Not integral to an
understanding of policy
“a series of mundane
decisions and interactions”
(Van Meter and Van Horn 1975)
ExternalFactors
(Hogwood and Gunn 1984)

31. KEYSTONE
Action-centred approaches
• Implementation central to understanding of policy
• Seek to understand what “actually happens or gets done,
how and why?” (Barrett and Fudge 1981)
• Investigating actors (as individuals and as members of
groups), processes and contexts (Walt and Gilson 1994)

32. KEYSTONE
Written and living constitutions
“confronting the manifestations of the living constitution with
the prescriptions of the written” (Hjern and Hull 1982)
• Written constitutions: policy problems as defined and
addressed by the ‘political system’
• Living constitution: policy problems as defined and addressed
by relevant actors (engaged in implementation)

33. KEYSTONE
Methods commonly used…
• Interviews
– With representatives of implementing groups
– With stakeholders and users
– With policy elites and key informants
• Review of documentation
– Public: constitutions, reports, outputs
– Internal: circulars, memos
• Thematic case studies (Yin 2003)
• Units of analysis: individuals, organizations, “groups”, “networks”

34. KEYSTONE
CASE STUDY: IMPLEMENTING PUBLIC
HEALTH GUIDELINES IN INDIA

35. KEYSTONE
Implementing national guidelines
• Problem: non implementation of national public health policy
guidelines (HIV, TB, diarrhoea, RI, etc.) by medical providers in
India
• Objective: diagnosing the problem of policy-practice gaps
• Methods: in-depth interviews with implementers and other
key actors, ‘framework’ analysis

36. KEYSTONE
Orienting Framework
Policymakers
Frontline
Implementers
(Practitioners)
Other Influential
Group(s)
Designated
Implementers
Group A
Designated
Implementers
Group B
Formal implementation channels
Direction of
research

37. KEYSTONE
Diverging from putative roles
• Frontline practitioners don’t follow guidelines
• Administrators don’t enforce implementation
• Health programmes don’t enforce guidelines
• Professional regulatory bodies demonstrate no role in the
enforcement of guidelines

38. KEYSTONE
Diagnosis: resources, capacity
• Human resource capacity
– E.g. not enough inspectors to regulate the private medical
sector
• Material resources
– E.g. shortage of protective equipment, to protect health workers
from cross-infection
• Access to, and utilization of finances at different levels

39. KEYSTONE
Diagnosis: inter-organizational relations
Employment
(contractual)
and answerabilityAnswerability
for HIV tasks
Employment,
answerability for
other tasks
Poor
communication
GOVT.
HOSPITAL
State health
department
State AIDS
Control Society
Hospital practitioners
Programme staff
(technicians,
counsellors)
Hospital administrators
GENERAL HEALTH SERVICES & HIV/AIDS PROGRAMME
PERFORMANCE VS. CONFORMANCE
(Sheikh ‘08)
‘PERFORMANCE LOGIC’ ‘CONFORMANCE LOGIC’
Some shared
posts

40. KEYSTONE
Diagnosis: uncertainties of affiliation,
legitimacy, role
Affiliation Formal affiliation to Ministry of Science and Technology,
not Ministry of Health
Multiple authorities 26 states , “each with its own authority, its own setup…
each with their own rules…”
Defining legal basis for
work
“there is no licensing mechanism for medical labs... We
had to ask lawyers what we should accept as a proof of
legal identity.”
Defending “non-profit”
identity
“We had to fight with the Revenue department; they
wanted us to pay service tax. We convinced them that
accreditation is like an educational service ...”
NATIONAL ACCREDITATION BOARD FOR LABORATORIES:
PROMOTING RATIONAL PRACTICES
(Sheikh ‘08)

41. KEYSTONE
STATE MEDICAL COUNCILS: UPHOLDING
PROFESSIONAL STANDARDS
Diagnosis: distortion, subversion of
institutional functions
‘Written constitution’
• Enforcing code of ethics
• Regulating practitioners’
professional conduct (including
adherence to prescribed practice
norms)
‘Living constitution’
• Role perceptions focused on
sanctity of profession
• Negation of disciplinary functions
• Instances of provision of legal
protection for doctors in
negligence cases
(Sheikh ‘08)

42. KEYSTONE
http://delhimedicalcouncil.nic.in/

43. KEYSTONE
Implementing national guidelines
State Medical
Councils
Administration /
Management
Departmental
Authorities
Staff (Medical
Practitioners)
Clients
Courts and
Consumer
Forums
Medical
Council of India
State health
programme
National Health
programme
Civil Society
Organizations
Medical
Associations
Accreditation
agencies
International
Organizations
Facilitation
LitigationProfessional
Regulation
EducationSupervisionSupervision* EducationInstituting
VCTCs*
HOSPITALS
Education
Supervision
Legislature
Technical and
Financial
Support
Attempted
Legal Reform
(HIV Laws)
Supervision
Grievance Redress
Supervision
Grievances
Grievances
Government
Health
Authorities*
Implementing relevant laws
FORMAL IMPLEMENTATION CHANNELS
* Not applicable in the case of
private and charitable hospitals
Putative Roles of Various Groups and Institutions in Implementation (Sheikh ‘08)

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