Any policy effort to improve health system performance must address the challenges of policy implementation.1 But health policy analysis, in general, tends to emphasize issues of policy design and adoption over questions of policy implementation. Although these policy cycle phases may overlap and share common challenges, a focus on policy implementation is still needed. This article seeks to correct this gap in the literature. We build on existing knowledge about health policy implementation in low- and middle-income countries to propose a way of both identifying and addressing some of the central challenges.
Policy implementation is a complex phenomenon and cannot be adequately covered in a short paper. We, therefore, focus only on certain aspects of health policy implementation using the lens of political science. Even this focus is not easy, however, in part because few political analyses have been conducted of health policy implementation in low- and middle-income countries (LMICs).2,3 This article examines one aspect of implementation—the politics of policy implementation for the health sector—particularly the management of stakeholders in order to improve the chances of achieving policy objectives. We provide a characterization of stakeholder groupings that are relevant for all phases of policy reform, but we focus on the challenges for health policy implementation.
Throughout the article, we refer to health policy or health reform implementation with the understanding that health reform usually involves multiple policies seeking to achieve system-wide change.Health Policy Project Essay. By health policy, we mean a government decision and plan of action to make progress towards the goals of the health system: improved population health status, increased financial risk protection, and increased client satisfaction; or the intermediate outcomes for health systems, under which we include: quality, access and efficiency.1
The conceptual framework for this article draws on the theoretical literature in political science and sociology while being practice-oriented. The article is intended to assist people tasked with strategic planning for health policy implementation; these people include government policy makers and high-level implementers but may also include policy actors outside of government. They may belong to a stakeholder category themselves. We call these people “policy implementers” or “change teams,” although in practice, they may not be officially formed teams with a clear implementation mandate. Our argument, in short, is that a group of people need to plan for and manage health policy implementation for it to be successful, and they will often confront political challenges in dealing with implementation stakeholders. This article may also assist those responsible for designing health policy, in helping them anticipate implementation challenges that can be addressed in the design phase.
The Challenges of Implementing Health Policy
The implementation of a new health policy demands more than providing instructions around a policy document or designing a set of standard operating procedures.1,4 Effective health policy implementation requires “the aggregation of the separate actions of many individuals, and [an understanding of] how and why the actions in questions are consistently reproduced by the behavior of individuals.”5 One fundamental implementation challenge is that the responsibility for health policy implementation usually rests with a different set of governmental actors than the ones who designed the policy.6 Policy designers often do not understand the perspective of the implementers. The process of policy implementation thus requires working with and through a set of actors and organizations to communicate policy objectives, ensure availability of resources, achieve ownership of the policy by implementers, manage conflict and cooperation, and sustain policy changes. Health Policy Project Essay. To start a new program and maintain it, joint efforts and contributions from multiple governmental agencies or private actors are needed. This frequently results in delays, renegotiation of resources and responsibilities, and confusion among the beneficiaries.6 In short, implementation is messy.
To move health policy forward into practice, implementers must realistically consider the difficulties of implementing a policy in their particular national context.1 Policy implementers or change teams need to recognize the complexities and characteristics of the administrative context in which their policies will become operational.7 Those leading policy implementation need “persistence, discipline, and rigor” to work within their particular contexts, and they need to make difficult decisions regarding staffing, organizational structure, and relationships with stakeholders8 to make policy implementation happen. Doing all of this in real time is not easy.
Different Approaches to the Study of Policy Implementation
Given the complexity of policy implementation as a social phenomenon, it is no surprise that multiple approaches exist to study and understand it. Here we discuss a few of the different approaches and their conclusions.
Starting in the 1970s, political science as a discipline began to recognize that public policies were rarely implemented as designed and that policy outcomes were rarely achieved as desired. The seminal book by Pressman and Wildavsky9 brought the challenges of policy implementation front and center. They coined the term “implementation deficit,” referring to when the linkages get fractured between levels of government and among organizations at the local level. According to the authors, “the longer the chain of causality, the more numerous the reciprocal relationships among the links and the more complex implementation becomes.Health Policy Project Essay. ” The book’s subtitle remains striking in its length and its message: Implementation: how great expectations in Washington are dashed in Oakland: or, why it’s amazing that federal programs work at all, this being a saga of the Economic Development Administration as told by two sympathetic observers who seek to build morals on a foundation of ruined hopes. The book persists as a classic and required reading in the study of implementation.9
From this time forward, studies of implementation began to expand in political science and in the field of public administration. The term “implementation gap” appeared to refer to a judgment made after comparing what is achieved and what was expected from policy.10,11 “Implementation studies” sought to explain why policy implementation failed and to identify effective approaches for affecting “what happens.”11 These studies sometimes contrasted “top–down” approaches with “bottom–up” approaches to improving the chances of implementation. Hill and Hupe identified a key implementation challenge in the governance arrangements that occur in different policy layers, also called the “multi-layer problem.”7
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More recently, “implementation science” has appeared. In public health, these studies seek to bridge the gap between what is known to work and what can be put in practice to improve population health. This is also called the “know-do gap.” Implementation science uses multidisciplinary methods to systematically drive progress in scaling up evidence-based interventions. Implementation science has its own methods and set of tools, including stakeholder analysis, effectiveness evaluations, and mathematical modeling, all used to scale up and sustain evidence-based interventions.12
Another approach to the study of implementation is called Deliverology, “the science of delivering results,” which provides a package of methods to drive progress and deliver results in government and public policy.8 The main proponent of Deliverology is Michael Barber, who served as Chief Adviser on Delivery to the British Prime Minister Tony Blair (starting in 2001) and headed the Delivery Unit for the public policies of the Prime Minister. Barber developed these methods for many kinds of public policy, including health, education, agriculture, and other areas of public service. The methods are designed to measure and drive progress for specific public policy targets by focusing on outcomes.
As mentioned above, this article focuses on only one aspect of implementation—the politics of policy implementation for the health sector—particularly the management of stakeholders in order to improve the chances of achieving policy objectives. Attention to diverse stakeholders is a common theme in various approaches to the study of implementation. The focus on the politics of implementation shares with other approaches the common objective of seeking to make implementation more effective in delivering policy goals. Health Policy Project Essay.
