Table 3 The conditions under which values are used in different stages of the policy process
Category & stage | Conditions under which values are used | |
|---|---|---|
Goals | Agenda setting | Problems • The lack of achievement of goals define the principal challenges faced by health systems ◦ Goals are problematized when recognized negatively (e.g., when framed as low quality, inequity, the lack of solidarity/universality, or vulnerability to the right to health) [23, 25, 27, 28, 47,48,49,50] • The perspective underlying the goals frames the problem in a specific way ◦ Although equity, quality, solidarity, and universality are important, commonly there is not a unique definition for each them [29, 51, 52]. In the case of equity, it is possible to identify egalitarian, utilitarian and “Rawlsian” approaches to equity. In an egalitarian perspective, health services should be distributed equally for all: in the utilitarian perspective, health services should be distributed based on who gets more out of them; and in a Rawlsian perspective, inequalities in health are allowed if the status of the disadvantaged people is better than in a scenario of complete equality [23, 53] |
Policies • The perspective underlying the goals shape how some issues gain prominence in the government agenda given that this is a precursor for identifying policy options. ◦ For example, there is no consensus on the meaning and scope of universality [29, 41, 44,45,46]. For legal and human right scholars, universality equates to the right to health and implies “equal or same entitlements” to the benefits of a health system [41]. From the perspective of health economists, universality is closely related to financial protection, which leads to a focus on policy options that prioritize prepaid mechanisms such as tax revenue, contributions from social health insurance, and private health insurance in order to minimize out-of-pocket payments and prevent financial bankruptcy. In contrast, from the perspective of public health, universality is considered in relation to defining population-level priorities in health, and the package of effective interventions that is needed to comprehensively address those needs [41] | ||
Politics • The comparison of the goal against what it has achieved is an important factor in agenda setting ◦ When governments compare their indicators of what the goal has achieved with their national expectations or indicators from other countries, a bad result could be a catalyst for agenda-setting [28, 47] | ||
Policy development and implementation | Institutions • Policies that are aligned with health-system goals are more likely to be prioritized for implementation ◦ This situation is especially the case when governments have signed on to international commitments such as the MDG [16, 54,55,56] | |
Ideas • The perspective underlying the goals influence on what policy option is more likely to be chosen ◦ This determines how policies are developed and which policy options are more likely to pass [24, 32, 36, 44, 47, 57,58,59] • Policy alternatives that address intermediate goals may be preferred because they are more feasible to achieve ◦ Given that core values are very broad and imply the satisfaction of multiple dimensions, policies that focus on specific intermediate values might be preferred in policy development [60] • Goals are used as indicators for evaluating the general performance of the health system ◦ Indicators of equity, quality, solidarity, and universality are the most common ways to evaluate the global performance of health systems, even for policies that do not explicitly pursue the achievement of those goals [37] • Intermediate values are used as surrogate outcomes of evaluation of the performance of the health system ◦ Intermediate values are commonly used as dimensions or criteria to evaluate core values like equity or universality [61] | ||
Technical values | Agenda setting | Problems • Technical values are used to frame problems regarding efficiency or financial sustainability ◦ Governments usually pay attention to problems that are framed in terms of inefficiency or menaces to the fiscal sustainability of the health systems [22,23,24,25, 28, 38, 62,63,64] • Technical values influence the government agenda when a problem puts the economic stability of a health system at risk ◦ One example is the accumulation of judiciary actions in the Colombian health system [65] |
Policy development and implementation | Institutions • Technical values are used as indicators of policy effectiveness, efficiency, and financial sustainability ◦ Sometimes, policymakers use indicators of financial protection to evaluate policies focused on achieving equity or universality [66, 67] | |
Ideas • Technical values are used as pragmatic instruments to inform policy development ◦ For example, effectiveness and cost-effectiveness have been significant values to make decisions about what drugs or technologies are purchased or covered in Latin American health systems [45, 68,69,70] • Technical values are used to determine feasibility of implementing policies, and to prioritize those that are more feasible ◦ Goals such as universality are broad and complex; technical values help to find how to best achieve this goal by selecting policies that are technically possible and financially feasible [60, 71] | ||
Governance values | Agenda setting | Problems • Governance values are used to frame problems in terms of corruption, failures in regulation or lack of social participation ◦ Recently, Latin American countries have come to frame problems of health systems in terms of corruption, lack of social participation or deficiencies in accountability [72] |
Policies • Governance values help to gain legitimacy in policy prioritization processes ◦ When social participation and other governance values are incorporated in the process of prioritization, governments can enhance the legitimacy of their initiatives [73] | ||
Policy development and implementation | Institutions | |
• Governance values are typically used late in the process to improve the acceptability of the policy choice ◦ Social participation is often only considered when policies have been fully developed (e.g., for informing or notifying), and accountability is only considered by the governments as a report presented at the end of the year, which is not subject to auditing and feedback [74] • Governance values are used as strategies against corruption ◦ Transparency and accountability have begun to appear as essential values for policy implementation processes in health systems [25, 27, 28, 63, 75], and they are emphasized as strategies to prevent the corruption [33, 47, 76] • Governance values are used as indicators of good governance in the health system ◦ Good governance refers to how authority in the health system is exercised. Those values are used to monitor the performance of the government, and the engagement of the citizens in the policy process [27] | ||
Situational values | Agenda setting | Problems • Situational values are used to frame problems according to specific situational influences ◦ Situational factors like the promulgation of international policies (e.g., MDGs), might influence how policymakers define problems to be consistent with the discourse of international agencies (e.g., paying attention to problems of maternal and child mortality) [30, 64, 77] • Situational values influence the government agenda when aligned international influences ◦ In the 1980s and 90s, “targeting” (i.e., establishing the basic minimum of health services by providing a subsidies with a preference to allocating them to low-income families) became prioritized as an important value to address problems of inequity, given that this value was aligned with the ideas promoted by the World Bank [21, 28, 32, 34, 51, 59]. |
Policy development and implementation | Institutions • Situational values influence the policy selection when aligned with policy legacies ◦ Countries that implemented radical health system reforms during 80s and 90s, after intense political changes within the countries have not been able to introduce important transformations in the health system since then due to the strong resource, incentive, and interpretive effects that were created from the original reforms [63] | |
Interests • Situational values influence what policy option is more likely to be chosen when aligned with interest of influential groups ◦ Policies that align with the interests or values of organized groups (e.g., doctors, patients, private sector) are more likely to be adopted [78] • Situational values are used as indicators of successful influence of specific groups or ideologies ◦ Situational values are used to evaluate the success of the government to implement their initiatives, the adoption of foreign policies (policy transfer), the power of some interest groups, and the level of progress in the implementation of a specific model of health system financing [79] | ||
Ideas • Situational values influence policy selection when aligned with the ideology of the government (e.g., left vs. right) ◦ When right-aligned governments prevail, generally health systems are influenced by values such as competitiveness, free choice, market, privatization, and targeting [19, 20, 51, 80]. In countries with left-aligned governments, values such as interculturality, public financing, prevention, and right to health prevail (e.g., Bolivia, Cuba, Ecuador, Venezuela) [26, 79, 81,82,83,84] | ||
External factors • Situational values influence the policy selection when aligned with international recommendations or requirements ◦ Latin America countries have been influenced by international agencies like the World Bank, the International Monetary Fund, WHO, PAHO, and UN. The influence of international agencies has been through a process of policy transfer, sometimes more persuasive and sometimes more coercive, which has resulted in many Latin American countries sharing a number of common characteristics [20, 25, 28, 29, 35, 45, 47, 57, 59, 81, 85,86,87] • Situational values are used to prioritize policies to be implemented when aligned with specific situational influences ◦ Perhaps the value that has had the greatest presence in the implementation of health reforms in Latin America has been decentralization, which was one of the key elements of the World Bank recommendations in the 80s and 90s [32, 47, 57, 88] | ||