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.