การวิจัยนโยบาย คืออะไร? และทำอย่างไร? : การวิจัยนโยบาย คืออะไร? และทำอย่างไร? จงกล เลิศเธียรดำรง (jongkol@ihpp.thaigov.net) สำนักงานพัฒนานโยบายสุขภาพระหว่างประเทศ การสัมมนาวิชาการป้องกันควบคุมโรคแห่งชาติ 12 กุมภาพันธ์ 2551 ศูนย์นิทรรศการและการประชุมไบเทค บางนา


Outline of presentation:: Outline of presentation: Health research  health policy research, Definition, types, framework of policy analysis, Stages of policy analysis, Utilities of policy analysis, ART policy in Thailand, RRT policy in Thailand


Health Research: Health Research


คำจำกัดความ: คำจำกัดความ นโยบาย หมายถึง ความตั้งใจ (intention) หรือคำประกาศ (statements) หรือการกระทำหรือละเว้นไม่กระทำอย่างใดอย่างหนึ่งโดยรัฐบาลหรือ ผู้ปกครอง (Parsons 1995) นโยบายสุขภาพเป็นสิ่งสำคัญที่จะช่วยให้ความพยายามในการแก้ปัญหาสุขภาพของประชาชนโดยส่วนต่างๆของสังคมสามารถดำเนินการไปได้อย่างมีทิศทางและวิธีการที่ถูกต้อง (สมศักดิ์ ชุณหรัศมิ์ 2541)


นโยบายสุขภาพ: นโยบายสุขภาพ นโยบายที่มุ่งให้องค์กรที่มีหน้าที่ด้านการสาธารณสุขและการรักษาพยาบาลนำไปปฏิบัติเท่านั้น นโยบายใดๆที่มีผลต่อสุขภาพของประชาชน ไม่ว่าจะเป็นนโยบาย ยุทธศาสตร์ โครงการ แผนปฏิบัติการ กฎหมายระเบียบ หลักเกณฑ์ที่พัฒนาและกำหนดขึ้นโดยหน่วยงานของรัฐทั้งที่มีหน้าที่เกี่ยวข้องโดยตรงในการบำบัดรักษา ป้องกันโรคและส่งเสริมสุขภาพหรือมีภารกิจที่อาจส่งผลต่อสุขภาพในทางอ้อม


Different types of policy: Different types of policy government policy – PM statements National Economics and Social Plan National HIV/AIDS Policy National List of Essential Drugs Universal Health Coverage Scheme Drug Act Bangkok Metropolitan regulations Provincial Administrative Plan Provincial Health Plan Hospital’s criteria on drug selection/procurement Clinical Practice Guidelines Standard Operating Procedures (SOP) Laboratory manuals National policies Sub-national policies Organisational policies


Two types of policy analysis : Two types of policy analysis studies of policy content studies of the policy process media studies studies of policy consequences evaluation information for policy making process advocacy policy advocacy Analysis of policy Analysis for policy


Analysis FOR policy: Analysis FOR policy Situation Analysis Priority-setting Option appraisal Cost-Effectiveness analysis Efficiency analysis Equity analysis Survey on Acceptability Feasibility analysis Resource availability estimation Program evaluation (Andrew Green, An Introduction to Health Planning in Developing Countries)


What to be addressed in doing a policy analysis?: What to be addressed in doing a policy analysis? ‘… much health policy wrongly focuses attention on the content of reform, and neglects the actors involved in policy reform …, the processes contingent on developing and implementing change and the context within which policy is developed.’ (Walt and Gilson 1994:354) ‘Health care policy or reform is thus examined in terms of the interrelationships of context, actors, contents and process associated with policy formulation, implementation and evaluation. (Kwon 2003:530) ‘Policy context, process, content and the actors involved are all critical elements of the health policy cycle and deserve careful consideration when contemplating policy changes’ (Williams et al 2004:357)


Basic framework for policy analysis: the policy triangle: Basic framework for policy analysis: the policy triangle Content Process Context Actors Walt, G and L Gilson (1994). Reforming the health sector in developing countries: the central role of policy analysis. Health Policy and Planning 9: 353-370.


Some concepts about ‘ACTORS’Central to the political system is ‘policy actors’: Some concepts about ‘ACTORS’ Central to the political system is ‘policy actors’ Individuals, groups, organisations, the public Politicians, bureaucrats, experts/scientists, professionals, providers, clients/beneficiaries, the media Public (the state), private (the market), civil society (third sector) Sub-national, national, international actors Iron triangles, policy communities, policy networks Epistemic community – ‘think tank’ Elites, street-level bureaucrats Role, position, power, interests


How to assess ‘actors’: Stakeholder analysis: How to assess ‘actors’: Stakeholder analysis Note that actors’ roles, positions, power and interests may change over time


Slide13: How to assess actors: actors mapping POWER POSITION High Low Against Support Government party Hospitals Physicians Medical council Drug stores Drug industry Health ministry NGOs Consumers Q I Q II Q III Q IV


CONTEXT Systemic factors which may have an effect on policy: CONTEXT Systemic factors which may have an effect on policy Situational factors (transient, impermanent), e.g. war, economic recession, droughts Structural factors (relatively unchanging elements), e.g. political system, type of economy, wealth, demographic features, technological advance Cultural factors, e.g. religious, hierarchies, social norms International or exogenous factors (Leichter 1979)


Ideal ‘rational’ policy process: Ideal ‘rational’ policy process Collect scientifically valid evidence Disseminate the evidence to garner political attention Persuade stakeholders to agree with the need for policy shift Work out a new policy Implement the policy including M&E (Williams et al 2004:356, see details on pages 360-362)


Models of policy stages: stagist models: Models of policy stages: stagist models initiation information consideration decision implementation evaluation termination agenda setting formulation implementation monitoring & evaluation identify the problem diagnose the problem define the alternatives examine the consequences make the decision implementation


Key questions on policy analysis: Key questions on policy analysis Why some policies (e.g. health interventions) are adopted by policy makers, while others are neglected? How a policy is formulated? Why some activities are selected to be carried out, and others are not? How particular policies (e.g. health services) are implemented in the health sector? Why some succeed, but others fail?


Practical criteria for selection of policy options: Practical criteria for selection of policy options Perceptions of policy legitimacy (political desirability) Potential support & opposition (political desirability, social acceptability) Degree of congruence with existing values (ideologies) Perceived logistical feasibility (technical and management feasibility) Anticipated future costs/benefits (affordability & benefits to be obtained) Note: actors are not value-free. They respond to issues, problems and policies in the ways to address what they perceive and construct.


Policy formulation a process that leads to a comprehensive plan at various levels covering goals, objectives and implementation measures: Policy formulation a process that leads to a comprehensive plan at various levels covering goals, objectives and implementation measures Key question: why a public programme is designed in particular ways? What was the content (main features) of new policy? Who were key actors in the policy formulation? Who support – oppose each policy options? Who led the process? What were their roles and interests? Where did the new programme configuration come from? Was there any alternative? How the decisions were made? What were important contextual factors? How these elements affected policy decisions and outcomes?


Policy implementation: Policy implementation What happens between the establishment of policy and its impact in the world of action The connection between the expression of governmental intention and actual results actions by public and private actors that are directed at the achievement of objective set forth in prior policy decisions An understanding of how and why public policy is put into effect can be conceptualised under the heading of implementation


Policy implementation: Policy implementation Issues of focus: ‘implementation failure’ or ‘implementation deficit’ The analysis of policy implementation aims to understand the process and factors influencing the discrepancies between policy intention and action Top-down vs Bottom-up


Top-down concepts: Top-down concepts Policies set at a national or international level have to be communicated to subordinate levels which are then charged with putting them into practice (Buse et al 2005) The key to effective implementation lay in the ability to devise a system in which the causal links between setting goals and the successive actions designed to achieve them were clear and robust Implementation failure is caused by adopting the wrong strategy and using the wrong machinery


Preconditions of perfect implementation: Preconditions of perfect implementation clear, logically consistent, agreed objectives and tasks/job description causal relationships between the policy and its expected outcomes; single implementing agency: not depend upon other agencies for success; adequate time + sufficient resources including committed, skilful staff; perfect communication and coordination; those in authority can demand and obtain perfect obedience; external circumstances do not impose crippling constraints; support from interest groups and legislature (adapted from Hogwood and Gunn, 1984; Sabatier and Mazmanian 1979)


Policy implementation : Policy characteristics: Easy Implementation difficult marginal change big simple technical features complex support interest groups resist perfect communication poor short duration long clearly policy goals conflicting skilful implementers weak limit participation extensive yes legitimacy No Policy implementation : Policy characteristics see Hogwood and Gunn (1984) -10 elements of ideal implementation model


Bottom-up concepts: Bottom-up concepts A process of interaction and negotiation, taking place over time, between those seeking to put policy into effect and those upon whom action depends Implementors often play an important part in policy implementation, not merely as managers of policy percolated downwards, but as active participants in an extremely complex process that inform policy upwards too (Walt 1994) Policy is mediated by actors who may be operating with different assumptive worlds from those formulating the policy and, inevitably, it undergoes interpretation and modification and, in some cases, subversion (Barrett and Fudge 1981)


Why doing ‘policy analysis’? (1): Why doing ‘policy analysis’? (1) Identifying and understanding the key influences that affect decision-making and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation (Williams et al 2004:356) Technical analysis is necessary but not sufficient to make the reform process succeed. While multilateral agencies such as the World Bank should stick to technical analysis, they could improve the quality of their technical advice and the feasibility of their policy proposals by more systematic analysis of the political factors that affect policy reform (Reich 1995:49) Public health professionals who understand the political dimensions of health policy can conduct more realistic research and evaluation, better anticipate opportunities as well as constraints on governmental action, and design more effective policies and programmes (Oliver 2006)


Why doing ‘policy analysis’? (2): Why doing ‘policy analysis’? (2) Developing political strategies for policy change Aim: to strengthen/mobilise supportive actors and undermine/demobilise the opposition What to be managed? Position – alter particular components of a policy Power – affect the distribution of political resources (money, information, image, expertise) across groups Players – recruiting and dividing Perception – address the perceptions of actors towards problems and solutions Roberts, MJ et al (2004) quoted in Buse et al (2005).


Strategy for planning and managing the policy change: Strategy for planning and managing the policy change Macro-analysis to ease the policy implementation Making values underlying the policy explicit Stakeholder analysis Analysis of financial, technical and managerial resources available and required Building strategic implementation process (Walt 1998)


What kinds of evidence needed in a policy analysis?: What kinds of evidence needed in a policy analysis? Multi-disciplinary perspectives Primary and secondary data Qualitative and quantitative Official or lay Objectivity vs Subjectivity (‘Facts’ vs ‘Views’) Context specific (Barker 1996)


Universal access to antiretroviral therapy in Thailand: an analysis of the policy process : Universal access to antiretroviral therapy in Thailand: an analysis of the policy process BACKGROUND: ART: effective treatment  reduce HIV morbidity and mortality, improve quality of life High costs of ARVs  ART coverage was 15% in poor countries Thailand: HIV epidemic started in late 1980s. Successful prevention programme  700,000 PLWHA in 2000 Public-subsidised ART programme 1992-2000 covered less than 2,000 AIDS patients a year In 2001, Thai government pledged to offer universal coverage for ART


Slide31: Thailand’s national ART programme development, 1992-2004


Slide32: “It is impossible to scale up our efforts in the ART field. With the US$6 million per year at our disposal we can treat 3,000 people. Whereas 200,000 – 300,000 need ART.” (Director of AIDS Division, 12th February 2001) Change in Thailand’s national antiretroviral therapy policy in 2001 “The government agreed in principle to include ART in Bt30 medical care program. The Ministry would double the drugs budget to 500 million baht in 2002. In the early stages, the scheme would cover 6,000 to 7,000 PLWH/A. ” (Health Minister, 30th November 2001)


Driving factors of Thailand’s universal ART policy : Driving factors of Thailand’s universal ART policy Universal ART policy New government Generic ARV production Civil society movement Domestic ART experience Global campaigns for ART extension Treatment success in other countries Drug price reduction Equity in health, human rights clinical benefits cost-saving cost-effectiveness? Affordability Well-established infrastructure Feasibility International reputation Political desirability Inspiration Source: Tantivess 2006 Number of HIV/AIDS cases


Universal access to RRT in Thailand: Universal access to RRT in Thailand Initiated by Prof. Rachit Buri in 1960, High cost care 300,000-400,000 Baht/year, A group of nephrologists and charity sought for financial support for RRT for a limited group of ESRD patients, 2001 TRT government introduced “UC policy” but excluded RRT from benefit package because of high cost issue, In 2005, NHSO set a pilot project in 3 provinces, There were series of research on various technical aspects. The economic evaluation study indicated > 3 times of GNP per capita, huge long-termed financial implication,


Universal access to RRT in Thailand: Universal access to RRT in Thailand In 2006 NHSO expanded the pilot sites from 3 to 13 provinces. Preliminary results from pilot sites indicated that peritoneal dialysis could be applied in rural settings, and potential cost containment is possible, In 2006, A RRT advocate group of ESRD patients was initiated, but not powerful, In June 2006, RRT advocate group submitted a proposal for financial support to Minister of Public Health with minimal response, In late 2006-2007 new Health Minister’s showed his stance to fight for access to high-cost treatment, In Sep. 2007, NHSO board accepted a plan to universally expand RRT, Health minister proposed the plan to cabinet and won approval on 30th Oct 2007, “People have been suffering, and it might still be too late to make this decision now” Surayud Chulanont


Universal access to RRT in Thailand: Universal access to RRT in Thailand วิโรจน์ ตั้งเจริญเสถียร, วิชช์ เกษมทรัพย์, ยศ ตีระวัฒนานนท์, ถนอม สุภาพร, จิตปราณี วาศวิท, ภูษิต ประคองสาย. การเข้าถึงบริการทดแทนไตอย่างถ้วนหน้าในประเทศไทย: การวิเคราะห์เชิงนโยบาย. นนทบุรี: สำนักงานพัฒนานโยบายสุขภาพระหว่างประเทศ; 2548. ภูษิต ประคองสาย, วิโรจน์ ตั้งเจริญเสถียร, วิชช์ เกษมทรัพย์, ยศ ตีระวัฒนานนท์, ถนอม สุภาพร, จิตปราณี วาศวิท. ทางเลือกเชิงนโยบายสำหรับขยายการเข้าถึงบริการทดแทนไตภายใต้ระบบหลักประกันสุขภาพถ้วนหน้า. วารสารวิชาการสาธารณสุข 2549; 15 (4): 617-31. วิชช์ เกษมทรัพย์, ยศ ตีระวัฒนานนท์, วิโรจน์ ตั้งเจริญเสถียร. อุปสงค์ของบริการทดแทนไตภายใต้ระบบหลักประกันสุขภาพถ้วนหน้า. วารสารสมาคมโรคไตแห่งประเทศไทย 2549; 12(2): 125-35. กัญจนา ติษยาธิคม และคณะ. รายงานการศึกษาเรื่องต้นทุนและประสิทธิภาพของหน่วยบริการไตเทียมภาครัฐและเอกชนในปี พ.ศ. 2544. นนทบุรี: สำนักงานพัฒนานโยบายสุขภาพระหว่างประเทศ; 2546. วิชช์ เกษมทรัพย์, ภูษิต ประคองสาย, วิโรจน์ ตั้งเจริญเสถียร. ความต้องการงบประมาณสำหรับการเข้าถึงบริการทดแทนไตอย่างถ้วนหน้า. วารสารสมาคมโรคไตแห่งประเทศไทย 2549; 12(2): 136-47. วิจิตรา กุสุมภ์, นิตยา ลาภเจริญวงศ์. คุณภาพชีวิตของผู้ป่วยไตวายเรื้อรังระยะสุดท้าย. วชิรเวชสาร 2547: 48: 107-15. ยศ ตีระวัฒนานนท์. ต้นทุนประสิทธิผลและต้นทุนอรรถประโยชน์ของการรักษาทดแทนไตในประเทศไทย. วารสารสมาคมโรคไตแห่งประเทศไทย 2549; 12(2): 50-67. ถนอม สุภาพร พจน์, เอมพันธ์, สุขฤทัย เลขยานนท์, และคณะ. บทวิเคราะห์สถานภาพผู้ให้บริการรักษาบำบัดทดแทนไตในประเทศไทยและความสามารถในการรองรับบริการเพิ่มเติมจากปี พ.ศ. 2548. วารสารสมาคมโรคไตแห่งประเทศไทย 2549; 12(2): 68-107.


References:: References: Tantivess S., Policy Analysis, 2006, Tantivess S., Health Policy analysis: fundamental concepts and research utilities, (forthcoming), Tantivess S. and Walt G. (2006), Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand, Cost Effectiveness and Resource Allocation 4:21 (http://www.resource-allocation.com/content/4/1/21) Pitayarangsarit S. (2007) Introduction to Health Policy Analysis, Kasermsab V. et al, Universal access to RRT in Thailand (forthcoming) ศ.น.พ. ณัฐ ภมรประวัติ และคณะ (2541) แผนกลยุทธ์การวิจัยสุขภาพ, คณะกรรมการวิจัยแห่งชาติสาขาวิทยาศาสตร์การแพทย์