The Health Reform Cycle
In Chapter 1 we introduced the idea that health sector reform can be viewed as a cycle.
Now we want to analyze that process in more detail. In idealized form, the process of policy change moves through a cycle of six stages—problems are defined, a causal diagnosis is made, plans are developed, a political decision is made on reform initiatives, those reforms are then implemented, and their consequences are evaluated. The cycle then begins again, as new problems arise that must be addressed by policymakers. (Figure 2.1)
Of course, in the real world, reform rarely takes place in such a simple fashion.
Instead, reform efforts may begin in different places and skip stages, or several stages may occur at the same time. For example, health reformers might begin with a diagnosis, declaring, “The cause of all our problems is that public clinics and hospitals do not have enough resources to provide good service.” Or reform advocates might start with their favorite solution—”What our country needs is a new national social insurance scheme.” Yet however the reform process unfolds, the policy cycle offers a useful way of analyzing that experience and of reminding practitioners about the tasks they need to address as part of the reform process. We have designed Figure 2.1 to highlight some major themes of this book. In particular, the “ethics” and “politics” components remind us that decision-makers confront ethical and political issues throughout the reform cycle. Questions like “What are the right priorities?” and “How can political pressures be managed?” pervade efforts at health sector reform. Our approach calls for an explicit examination of the ethical bases of health policies and rejects the notion that the values of all health systems are, or should be, the same. Because we believe that all policy positions (including our own) involve ethical dimensions, this book seeks to make our own values and goals explicit. Readers can then determine how useful our perspective is to them. We also reject the view that the health sector reform process is exclusively technical. Instead, we call for direct and extensive consideration of political factors at all stages of the reform process.
[INSERT FIGURE 2.1 HERE]
Figure 2.1: The Policy Cycle
While we identify six stages in Figure 2.1, this book focuses most on the first four: problem definition, diagnosis, policy development, and political decision. This chapter, however, presents an overview of all six stages, and shows how these relate to our approach.
The first four stages are then examined in more detail in subsequent chapters—with each of the “control knobs” that are critical to diagnosis and policy development getting a separate chapter in Part II of the book. Moreover, while we do not have a chapter on implementation, we have provided practical guidance on that point in each control knob chapter, based on experience from around the world. In our view, purely theoretical discussions of health reform options are not of much value. To move health reform forward, reformers must realistically consider the difficulties of implementing a policy idea in their particular national context. And we try to help them do that throughout the book.
Finally, the cyclical nature of Figure 2.1 emphasizes a point already made in Chapter 1.
The problems of a health care system are seldom, if ever, resolved once and for all. As countries evolve, their health care systems have to respond to new challenges. Moreover, successful reform often raises popular expectations, and thereby raises demands for further reform. But the process of reform is also imperfect. Reformers often encounter unintended consequences or discover defects in their plans that were not apparent initially. For these reasons, the cycle of reform typically occurs again and again. Let us now look at each step of the health reform cycle in more detail and at the critical tasks each requires.