Policy implementation

Most governments have well-constructed health policies and impressive strategy documents. But turning such high-level thinking into practical results on the ground requires systematic attention to processes and the systems to make it happen, underpinned by the in-depth analysis needed to identify and tackle barriers such as resource and skills shortages.

Delivering better health outcomes means tracking funding closely on its journey from the centre to the frontline. Public expenditure tracking surveys are an effective way of locating bottlenecks in the service delivery chain. Increased spending on health does not always translate into better outcomes; but a traditional ‘follow the dollar’ approach will not work unless scrupulously accurate records have been kept. Combining quantitative with qualitative techniques, such as focus groups and one-to-one interviews with key people, will help build a fuller picture.

Successful policy implementation depends on having people in the right places. In many developing countries, doctors and nurses are reluctant to work in rural areas. Where trained staff are scarce, governments may be reluctant to enforce policies on deployment. This has major implications for access to healthcare. So how can clinicians in developing countries be incentivised to work in rural areas? Increasing salaries is one option, but people may also be motivated by, for example, better professional development and career progression opportunities – incentives that will also benefit the health system as a whole by building expertise and raising standards.

Redesigning processes can support high-level strategic goals. Governments will sometimes make a commitment – for example, to devolve responsibility to frontline providers – but then fail to empower those providers to make essential decisions. As a result, they may find themselves paralysed: able to set performance targets, for example, but not to hire and fire staff. Organisational analysis can help highlight and address these inconsistencies, and ensure that policies are reflected in and supported by practice.

Poor people are no less deserving of quality of health care but are all too frequently faced with the choice of poor quality in the government clinic or unaffordable prices if “going private” (and often to the same doctor or nurse). Simple measures and systems are required for the licensing and accreditation of health care provider organisations and for appropriate sanctions and improvement measures for under performing individual practitioners.

The funding and provision of health care is an imperfect but pluralistic market. How can this be best exploited in the interests of the health of poor people? Attention to the detailed requirements and institutional arrangements for making contracts for health services can turn the rhetoric of public private partnerships into innovative interventions to the benefit of the health care system.