Politics and policy

Ever since the onset of the Covid-19 pandemic, health sector reform has attracted a great deal of attention. However, what has been missing in the debate on policy making for health care is the core political component. We often use the word ‘politics’ in a negative sense where self-interest predominates and one uses a situation to one’s own advantage. Another term one frequently comes across in political discourse is ‘political will’ or more commonly ‘lack of political will’, implying lack of action.

I am referring to the political skills required to bring about policy change. Political will alone is not sufficient, it must be backed up by the skills necessary to translate the will into policy and policy into action. In 2001, the FAO published a report on Fostering the Political Will to Fight Hunger and concluded that the problem was ‘political determination’. It further observed: “To the extent that the means exist to eradicate hunger… its continued existence on a vast scale is a consequence of either deliberate choice… or incompetence in applying possible solutions”. Political will consists in the willingness to make a choice and political skill in the competence to find the solution and the means to apply it.

In the pre-pandemic period, it may be argued that sufficient political will was not forthcoming to accord the necessary priority to public health; on the other hand, after the outbreak of the pandemic, it became the topmost priority. A crisis can of course radically alter priorities. There is again a noticeable difference in the government’s approach to the problem during the first and second phases of the pandemic. In the case of the former, there was a strong political will in dealing with the situation and taking decisions to combat the disease. During the latter, elections became the priority and action on the pandemic went into the background with all the consequences that followed. In other words, the political will was located in winning the polls rather than in taking considered decisions about how to contain Covid.

The time is ripe for evolving a sound healthcare policy with a long-term perspective. And this is where political skills become important. According to American political scientist Michael R. Reach who is a specialist in political analysis of health reform and is a Research Professor of International Health Policy at the Harvard School of Public Health, political leaders engaged in policy reform need political skills in two key areas: political analysis and political strategies. Analysis relates to assessing the political intentions and actions of stakeholders who could include individuals, groups and organisations who have an interest in a policy and the potential to influence related decisions. Strategies are concerned with making causal predictions -- what happens if a particular approach is adopted. Decisions taken after a careful analysis of the issue and choosing the right strategy can result in a successful policy change.

In dealing with a complex situation like the current pandemic, the issues to be tackled such as testing, tracing, hospital admissions, use of masks, enforcement of the lockdown, the success of the entire operation called for adequate resources, technical competence and political skills in taking decisions on crucial matters, convincing stakeholders and ensuring accountability. How did the political leadership respond to the challenge?

Take just one issue, viz, dealing with stakeholders who included health professionals, hospital authorities, pharma industries, the media and of course, the people. Contracting the services of private hospitals had become essential in view of the severe shortage of public resources. The approach of the state governments was to use the coercive power of the state for reservation of beds in private hospitals and pricing of their services. Failure to comply with government instructions involved penalties. Ministers, legislators and senior officers started inspecting hospitals and showing their might against the errant ones. This led to a feeling of alienation and resentment amongst private hospitals, a key stakeholder in the programme. Could there have been a better strategy to secure voluntary cooperation instead of subjecting them to submission?

There were other issues like the confusion in organising the supply of vaccines -- the vacillation in deciding whether the central or state governments should deal with it, resulting in delays and precious loss of time, the timing of elections and allowing crowded gatherings during the pandemic. Could these have been better managed?

The case of Health Care Reform in the US offers illuminating lessons. When Bill Clinton wanted to reform the healthcare system, he faced enormous pressure from interest groups, mainly from the American Medical Association and medical insurance and other business groups. The Centre for Public Integrity noted that the debate over health reform was “the most heavily lobbied legislative initiative in recent US history” involving hundreds of organisations and over $100 million. Political analysts have argued that Clinton’s strategies failed on account of three factors: a) appointing a technocrat with limited experience to head the health reform task force, b) giving the overall responsibility to Hillary Clinton and c) starting the process of political bargaining over the reform package after presenting it to the Congress.

In contrast, Barack Obama made his plan for health care reform a part of his presidential campaign. Once in office as President, he initiated a discussion on what he termed Health Care for America Plan. This pushed the Congress to study the proposal and interstingly, the Senate and the House of Representatives came up with their own plans. Efforts were made to reconcile the two and finally the Patient Protection and the Affordable Care Act were passed in 2010.There were several obstacles, but what helped Obama’s success was his strategy to involve the Congressional leaders, a transparent process and his own championing the cause of reform and effectively communicating it to the people.

The key issues to be addressed in healthcare reform in India are: a) making a clear distinction between public health or preventive care and curative services, b) market failures in the private health sector, especially in insurance coverage, c) state capacity and d) areas of state intervention. Political analysis of the challenges involved in such matters and evolving appropriate political strategies are crucial in deciding policy changes. Reforming a policy also requires the ability to manage the politics of change. Government would do well to engage professional policy analysts just as they employ economic advisors.

It’s not just ‘the economy, stupid’ of Clinton, but ‘it’s the politics, stupid’ that is important for success.

(The writer is former Chief Secretary, Government of Karnataka)