Chapter Five: Health Politics and Health Policy (by Phua Kai Lit)
. Health policy formulation, implementation and evaluation
. Interest groups
. Impact of international organisations
Although many ordinary citizens would regard healthcare and health policy
as technical matters best left to doctors and other health professionals, these
are actually areas which can be highly politicized and which concerned
citizens ought to pay attention to. In countries like the USA where healthcare
services contribute about 14% of its Gross Domestic Product (GDP), health
policy can be very contentious indeed. This is because many jobs are related
to the healthcare industry, including the organisation, financing, delivery and
regulation of healthcare services. Some sectors of the healthcare industry are
highly profitable, e.g., the transnational pharmaceutical corporations of
Japan, the USA and other Western countries with highly developed
pharmaceutical industries. Where there is money to be made (or lost) and
public policy can affect profits (the so-called “bottom line”), interest groups
which can be affected by the rules, regulations and laws of a national
government will organise and attempt to shape the direction of public policy
so as to protect or further their own interests.
Scholars who study public policy output usually divide it into stages such as
formulation, implementation and evaluation. Formulation refers to the
shaping of public policy right from its proposal stage until the last stage
when it becomes law. Implementation refers to the conversion of a law
which has just been passed by the Parliament, Congress or National
Assembly into specific rules and regulations crafted by the Ministry of
Health or other regulatory bodies to control the behaviour of healthcare
organisations, healthcare providers and healthcare consumers. Evaluation
refers to efforts made by the public regulatory bodies to determine how
successfully the law was implemented and what its effects have been
(including unintended effects). It should be emphasised that each stage can
become highly politicised depending on the specific issue at hand.
The formulation of health policy is not strictly a technical matter to be
determined by the Minister of Health with technical input from bureaucrats
within the Ministry. A good example is a public health programme to control
the spread of the HIV/AIDS virus within a particular country. Ministry of
Health personnel would probably argue that the best way to do so would be
to launch public health campaigns to warn the public about HIV/AIDS and
how it is spread. The public would be warned that it could be spread by
unprotected sex, having multiple sex partners, the sharing of contaminated
needles by drug addicts etc. However, if the public are to be provided with
specific information on how to avoid unprotected sex (e.g. by using
condoms) and how to decontaminate needles (e.g. by bleaching them), this
may offend the sensibilities of certain groups, religious as well as secular,
and may result in public uproar and controversy. In fact, this has happened
in certain countries with strong and conservative religious groups.
Sometimes, organised interest groups may attempt to place specific issues on
the public agenda so as to get the government to pass a law which will
benefit them. For example, a foreign healthcare corporation may lobby its
own government to pressure the government of another country to open up
its healthcare market to more foreign investment. A particular country may
have a strong tobacco control programme in place. However, this would be
undermined if foreign multinational tobacco companies manage to pressure
the government to allow them to enter the local market to sell cigarettes and
other tobacco products. A single issue interest group may lobby the
government to spend more of its funds to combat a particular health
problem, e.g., more spending by the government on renal dialysis to treat
patients with kidney failure. At other times, interest groups will mobilise in
order to oppose the passage of any law which would hurt their interests, e.g.,
doctors in South Korea actually went on strike when the government
introduced a law which would only allow doctors to prescribe drugs and not
to sell them to patients also. In the United States, many interest groups hire
armies of lawyers and lobbyists to actively monitor and try to influence
public policy in the healthcare field.
After a health-related law has been passed and it goes to the relevant
ministries to be converted into specific rules and regulations which are
legally-binding and backed up by sanctions, vested interest groups may also
attempt to lobby the bureaucrats in their drafting of these rules and
regulation and in the enforcement of these rules and regulations. For
example, if a law to protect the environment has been passed, the rules and
regulations can be drafted strictly and strongly enforced or it can be drafted
with low regulatory standards and poorly enforced (or with fines for
violations that are just a slap on the wrist). The passing of a law with low
regulatory standards or which is poorly enforced will have minimal impact
on a particular problem it was supposed to solve. An example would be a
law to control motor vehicle emission of pollutants which sets low standards
or which is poorly enforced.
Evaluation of health policy is supposed to enhance the formulation and
implementation of public policy through analysis of the impact or effects of
a particular law or set of laws which has been passed. However, again, this is
not a neutral exercise and it can become heavily politicised, e.g., supporters
of a particular policy may be more likely to find that the policy had had a
positive effect (or may downplay its negative effect) while critics may be
more likely to find that it has had negative effects. The tools used in policy
evaluation may also be “blunt” in that it may be difficult to determine
conclusively and to separate out the positive effects of a specific policy from
other fortuituous and fortunate factors occurring at the same time. For
example, one could argue that the rapid improvement in the health of
Singaporeans from the late 1950s onwards was due largely to housing policy
(slum residents were moved into high rise Housing and Development Board
flats with clean water supply and proper sanitation), universal basic
education and better availability of jobs rather than to higher healthcare
spending by the government per se.
We have discussed how healthcare policy formulation, implementation and
evaluation can be politicised through the participation of vested interest
groups in the policy process. What are these groups then? The most obvious
would be politicians (from the government as well as opposition parties),
bureaucrats from relevant ministries (the ministry of health, ministry of the
environment, ministry of labour etc), healthcare providers and patients and
their families. But these are not all. Less obvious interest groups include
consumer associations, senior citizen groups, religious organisations and
foreign corporations and international organisations.
In democratic countries with competing political parties and regular
elections, health policy can be used to win votes. Thus, an opposition
political party in a Western European nation may make all sorts of promises
regarding health policy reform as part of its election manifesto. Sometimes,
health care reform is driven by strong ideological convictions, e.g., changes
in the organisation and financing of the British National Health Service
when Margaret Thatcher was the Prime Minister. In the USA, after coming
into office as the new President in 2000, Bill Clinton (and his wife Hilary
Clinton) attempted to introduce a system of “managed competition” in the
healthcare industry. However, his ambitious programme was defeated by its
political opponents. In Malaysia, because of former Prime Minister
Mahathir’s positive view regarding privatization of public services, the
private healthcare sector (especially private hospitals) has grown
considerably since the 1980s. In Singapore, some parts of the public health
system have been corporatised and have therefore become more profit and
market-oriented.
In Malaysia, the planners of the Ministry of Health have traditionally been
most influential in shaping health policy behind the scenes. However, the
Economic Planning Unit (EPU) in the Prime Minister’s Department has also
become a significant player because of rising healthcare costs, increasing
demand and expectations of further health service quality improvements.
Other bureaucrats who are involved in healthcare policy-making include
those from the Ministry of Science, Technology and the Environment
(MOSTE) which deals with environmental problems and the Ministry of
Labour which deals with occupational health problems.
Interest groups established by providers are also active in healthcare politics
and policy-making, e.g., the Malaysian Medical Association (MMA), the
Association of Private Hospitals of Malaysia (APHM), interest groups from
other providers such as those representing the pharmaceutical industry and
so on. Medical associations may act to protect the interests of doctors
(sometimes in competition with other healthcare professionals). Thus,
medical associations may attempt to get the government to limit the power
of other competing healthcare professionals and to prevent them from
prescribing drugs and performing medical procedures. In the USA, there is
strong rivalry between psychiatrists and clinical psychologists but the former
have the upper hand in that only psychiatrists are legally allowed to
prescribe drugs. However, the clinical psychologists are able to compete in
the area of “talk therapy” and behavioural modification techniques. Again,
in the USA, there is strong enmity between the American Medical
Association (AMA) and non-mainstream healthcare providers such as
chiropractors. Sometimes, non-doctors are permitted by the authorities to
perform certain medical procedures. However, doctors have the upper hand
in that these procedures usually have to be performed “under the
supervision” of a doctor. As mentioned earlier, some countries such as South
Korea have attempted to restrict the practice of doctors selling drugs that
they have prescribed to their patients. The argument is that such a practice
gives rise to conflict of interest in that the prescribing and selling of more
drugs (or more expensive drugs) would generate more income for the doctor.
However, resistance to this attempt at ending a lucrative practice has usually
been strongly resisted by medical associations. Other professional
associations such as the pharmaceutical industry associations also attempt to
defend their interests, e.g., by strongly resisting parallel imports of cheaper
drugs from other countries and by fighting against “compulsory licensing”.
For example, multinational drug companies filed lawsuits against the
government of South Africa when the latter passed laws to promote
compulsory licensing of HIV/AIDS drugs so that local drug companies can
produce the drugs and sell them at lower rates in order to reduce the cost of
such drugs in the country.
Provider groups are usually well-organised and well-funded. However,
consumer associations are usually poorly-funded and much weaker. In
Malaysia, the strongest consumer rights association is probably the
Consumers’ Association of Penang (CAP). CAP does get involved in
healthcare and medical issues from time to time by using its publications to
raise public awareness or alarm over certain issues. The group called the
Citizens’ Health Initiative (CHI) has also been active in attempting to limit
the extent of privatization of public healthcare services in Malaysia. In the
United States, consumer groups tend to be stronger. Thus, the AARP
(American Association of Retired Persons) is quite effective in lobbying the
US Government and in protecting the Medicare scheme against cutbacks.
Foreign and international bodies such as the United States Agency for
International Development (USAID) and the various United Nations
organisations such as the World Health Organization (WHO), United
Nations Children’s Fund (UNICEF), the World Bank, the International
Monetary Fund (IMF) and the World Trade Organization (WTO) can also
shape heath policy and the organization, financing and delivery of healthcare
services in developing nations. In the past, the WHO and UNICEF were
especially influential. However, in recent years the World Bank, the IMF
and the WTO have been growing in importance as shapers of health policy.
During the first two decades after the Second World War (when many
colonies were becoming independent nations in Asia, Africa and the
Caribbean), the WHO and UNICEF were instrumental in providing the
technical advice needed by the health ministries of these new nations. The
World Bank first became involved in the funding of health-related projects
when it introduced its “basic needs” programmes in the 1970s. In recent
years, it has become an enthusiastic promoter of concepts such as “user fees”
and “privatization” as they pertain to health services provided by the
government. Cost recovery through the introduction of higher user charges
has generated controversy because critics argue that these user charges do
not result in much revenue and they also result in reduced access to public
healthcare services for poor people. The IMF has also had an impact on
healthcare services and health policy in economically-stressed developing
nations through its “structural adjustment” policies which typically push
governments to drastically cut back on spending on health and other social
services. Finally, the WTO will play a greater and greater role because of its
push for developing nations to open up their economies (including the
healthcare sector) to foreign investors and foreign companies. The WTO
agreements such as the General Agreement on Trade in Services (GATS)
and the Agreement on Trade-Related Intellectual Property Rights (TRIPS)
will also have an impact on the healthcare sectors of developing nation
economies. TRIPS will negatively affect the domestic pharmaceutical
industries of countries such as India and Brazil.