Class notes: Debates in Public Health and Epidemiology.

First part: Conceptualizing health and diseases

PUBLIC POLICIES: OPERATIONAL ASPECTS

Rubén Darío Gómez-Arias

Executive Secretary Colombian Network of Researchon Policies and Systems of Health.
Professor of Epidemiology. National School of Public Health. University of Antioquia.
Medellín, rubengomez33@gmail.com

A version of this seminar was published in Spanish as: Gómez R. Gestión de políticas públicas:
aspectos operativos. Rev. Fac. Nac. Salud Pública 2012; 30(2): 223-236.

The group of Health Situation Analysis at worldview and social organization

the National School of Public Health, and
the Colombian Network Research on Policy
and Systems of Health have been
supporting, since 2003, the implementation
of courses on health policies management
within doctoral and master's programs of
public and private universities. Based on this
experience, multiple concepts and
discussions have emerged around
operational aspects related to the
formulation and analysis of public policies.
This article focuses on the operational
aspects involved in the formulation and
analysis of public policies, and it has been
prepared for pragmatic purposes in order to
facilitate the dialogue between academics
and decision makers.
4.1 Introduction.
As we have reviewed in previous seminars,
Public policies are power devices of social
control developed by modern states during
the mid-twentieth century. According to the
1
promoted in Europe by the Enlightenment
and Modernity, a public policy is a directive
that the State, regarded as the legitimate
authority of the social system, imposes on
the collective as the way to proceed before
a particular matter, which has been
recognized as one of public interest. Later,
as a legacy of Napoleonic Wars, this political
conception took over almost the entire
western world and was adopted by liberal
democracies that formed in Europe and the
American continent during the nineteenth
century. Since then, most countries have
been adopting these principles and have
shaped States adjusted to Law and
governed by the legal and philosophical
principles of Modernity. In the beginning of
the20th century, and to To overcome the
economic and social crisis of capitalism, the
liberal European states had to regulate the
economy through certain mandatory
mechanisms called public policies, which
had to meet the following conditions:
a) They can only be set by State
institutions as legitimate authorities;
b) They are mandatory for the whole
society, not only for the governed but
also for the rulers;
c) They must be carried out with
stakeholder involvement;
d) They must comply with legal
regulations; and
e) They should favor the common good.
Since then, the term public policy is often
used in reference to the actions of the
State, to the relations between State and
the other members of the society, and to
the ways in which government is exerted.
The concepts and analysis contained in this
chapter analize the said principles. It should
be noted, however, that since the mid
1980s there has been spread around the
world a wide controversy regarding the role
assigned to the State in neoliberal regimes. 1
23456
The course of public policy has been
described as the product of complex and
dynamic political processes that serve the
interests of social actors, involving frequent
and unpredictable events, which rarely
occur in ordinate sequence. Rather than a
technically directed process, policies are the
product of multiple social actors through
maneuvers aimed to control certain
resources. Some maneuvers are socially
acceptable according to democratic values,
but others could deem immoral and even
illegal. Practices such as bribery, blackmail,
espionage, clientelism, defamation of
opponents and rigged allocation of public
contracts are used worldwide to control the
resources of common interest, even in
countries that can boast of having
transparent democracies, as some of the
2
WikiLeaks publications have recently
highlighted it.7
Corruption, defined as the cooptation of the
State and of public goods by private groups,
has expanded its repertoire of mechanisms
of political control, and is making giant
strides in so far that the neoliberal model
has expanded, as it appears in the annual
reports published by international
organizations..8 9 Corruption has also spread
strongly in the health field, associated with
the service market expansion, insurance
practices, medicines, and other health-
related supplies. Published reports stress
the need to strengthen transparency, social
oversight committees, and citizen
participation in processes that involve
public interests, as requirements to sustain
democracy and ensure the social ends of
the State. 10 11
Despite the above, some authors
considered that where the political
conditions are favorable, the formulation
and implementation of policies
(policymaking) respond to management
strategies designed to safeguard the
rationality of decisions, reduce uncertainty
and secure the foundations of social order.
The philosophical and conceptual
perspectives of Modern States, influenced
by rationalism, proposed that governments
could not act capriciously when formulating
and implementing their policies. On the
contrary, they should be subject to the
general principles of administration, law
and public ethics. Anyway, it is
highly implausible that any administrative
technique ensures the successful
development of a policy without enough
political support. For these reasons, many
administrative techniques involved in public
policies management focus on the handling
of actors, their interests and their ability to
influence decisions in an explicit and
transparent way.
4.2 Public Policy: An Operational
Definition
Currently, there is no consensus on the
definition of public policies and on how to
manage them.12 13 14 15 In general, public
policies are power devices for social control
defined by modern political systems with
the purpose -explicit or implicit- of
regulating a matter of general interest,
particularly the use and destination of
resources. In modern societies, where the
rule of law prevails, public policies can be
defined as mandatory guidelines set by the
State for the purpose of regulating a
particular matter considered to be of public
interest, which otherwise would not be
resolved spontaneously.
In countries that have taken the form of
“Social State adjusted to Law” (but not all
are really so), public policies have the
following characteristics:
a) They belong to the exclusive power of
the State legitimately constituted. No
other actor can define them without
resorting to this instance.
b) They are mandatory for both governors
and governed.
c) They must comply with an existing legal
system.
d) They should be developed in a
democratic way, supported on the
effective participation of those involved.
e) They must favor the common good over
the interests of particular groups.
3
4.3 Normal expressions of a public policy
From a technical perspective, public policies
are complex systems of decisions that, in
practice, may be materialized in four
complementary ways:
 Legal devices
 Administrative devices
 Ideological control devices and
 Contractual mechanisms (contracts,
agreements and treaties on public
issues).
Since the 1990s, international banking has
been promoting the term "governance" as a
way of managing public affairs.This
ambiguous notion usually limits the
functions of the State to the
implementation of technical activities
related to the maintenance of social order
required for the agile operation of markets.
When evaluating and formulating a public
policy it is important to verify the
articulation of their different expressions in
a coherent and synergistic way.
4.3.1 Legal provisions
Constitutional provisions, laws, decrees, and
other regulations of state agencies act as
social control devices that contributes to
ensure the legitimacy and sustainability of
the policy and the promotion of linkages
with the rest of the legal system.
In States adjusted to Law, any public policy
should be supported on the legal
regulations in force for the country. In this
regard, when formulating a public policy, it
may be also necessary to define specific
rules, ensure its consistency with the legal
system, and support the legitimacy of the
directives. The legal basis for a policy may
be necessary in order to assure its viability
and legitimacy. However, legal basis could
be insufficient by itself to grant the
expected results. The provisions to ensure
legal consistency are even more important
in cases where policies affecting individual
rights, and when penalties for infringers are
contemplated.
4.3.2 Administrative devices
The implementation of a public policy is a
particularly complex process, which hardly
achieves its intended purpose unless it be
supported by an appropriate administrative
system.16 The administrative component of
a public policy refers to the set of
mechanisms and technical procedures
developed by the political system to
implement the directive under foreseeable
conditions that reduce the uncertainty of
the results, ensuring success. These
mechanisms are twofold: planning and
bureaucratic support.
4.3.2.1 Planning systems as tools for
policy management.
In practice, public policies are also
expressed in the plans, programs and
projects led or developed directly or
indirectly by the State, in which the content
of the directive is displayed in detailed and
systematic ways. In this respect, national
and sectoral development plans and the
government projects and programs are
particularly important mechanisms for the
implementation of public policies and are
critical success factors. From this, we must
4
recognize the importance of an appropriate
planning model that supports policy
management and define, at least, the
following core elements of the directives:
• The objectives or expected results.
• The appropriate strategies to be
implemented in order to achieve the
objectives or expected results.
• The necessary human, technical and
financial resources.
• The criteria for monitoring and
evaluation.
In relation to health planning, multiple
approaches have been proposed. Some of
them emphasize the techniques and
methods;17 18 others give more importance
to the style adopted by the organization to
make their decisions, by differentiating
autocratic models from participatory and
concerted ones.19 In this regard, it should be
highlight that the success of planning does
not depend on the use of a particular
theoretical model, but on the capacity of
articulating resources and peoples’ wills,
arranging them in the best possible way
around a common goal or intention. The
best planning model will be one that allows
the group to integrate their energy and
work neatly in the intended direction with
minimal effort and maximum gain.
Technical literature reveals that no model in
itself is more successful or effective than
other, and that the outcome may depend
rather on the leadership of directives, the
capabilities of the organization, the climate
generated in the institution, and the
support received from the environment.
Among the approaches used in health
planning, there have been highlighted:
• The traditional normative approach.
This model considers planning as a
decision-making scheme based on fixed
rules and principles that all members of
the organization must comply with.
Plans are formulated by different units
of the organization, by adapting the
objectives, goals and strategies
previously defined by senior
management. Normative planning is
based on formats that the
dependencies must fill out to
consolidate the organizational plan.
Several authors have strongly critisised
not only the mechanical, conservative
and rigid nature of this approach, but
also its ignorance of the constant
changes that occur in the context.
Normative planning approaches,
however, are still widely used in several
countries to control their investment
and ensure the compliance with
minimum goals.
• Systemic approach. This holistic focus
considers reality as a whole. Each event
is integrated by different components
and elements, which should be always
defined and intervened from a whole-
view perspective. Health systems are
deemed complex and strongly
articulated systems that should be
integrally analyzed and intervened,
even where the success of
interventions depends on controlling
the interactions that occur among the
different components. The systemic
approach involves multiple qualitative
and quantitative techniques to model
and simulate situations in order to
discover the best ways to influence the
performance of the system. This could
be very useful to ground decision-
5
making processes. However, the
stringency of the techniques and
concepts developed within the systemic
approach as well as its requirements for
information gathering have limited its
application to expert groups.
 Situational strategic planning. This
approach considers that social situations
are complex, changing, uncertain and
only partially controllable. For this
reason, strategic plans are formulated
with two objectives: to anticipate a
possible vision of the future and to serve
as a map for gradually organizing actions
and transforming the situation. This
approach assumes that decisions should
be based on a situation analysis, from
which actions will arise; these options
should be intelligent, agile and creative.
The situation analysis entails deep
understanding of at least three
elements: a) the problem that will be
the focus of efforts, b) its causes, and c)
its consequences.
There are two ways to make a situational
analysis: global and specific.
The global way proposes to address the
general situation (problem or
macroproblem). Then, it must be broken
down into specific problems sorted by
priority criteria. This type of analysis, usually
applied by local governments, could be
more complex and demand more efforts
but, at long term, it could be the best option
to ensure sustainable results.
The specific way focus efforts on particular
situations (specific problems), and gradually
resolve them. This approach allows
controlling economic problems and offers
partially visible short-term results when a
carefully and intelligent priorization has
been stablished. Nonetheless, it does not
always guarantee effectiveness, efficiency
and sustainability of interventions, and its
influence on the general situation could be
limited.
In his proposed Strategic Situational
Planning, Matus developed a model for
senior management (ALTADIR Method for
Popular Planning- in Spanish Método Altadir
de Planificación Popular MAPP)20, which is
applicable to government plans and carries
with it a strong component of social
participation. This planning approach
includes three moments:21
• An explanatory moment destined to
analyze and assess a situation of
common interest; during this moment,
actors confront their own interests,
concerns and perspectives.
• A political/strategic moment intended
to define, by consensus, a target
situation in order to make decisions
about the most convenient possible
actions.
• An operating moment when
stakeholders make decisions about
resources, responsibilities and
procedures.
 The project management focus. Since
the mid-1980s, there have been
proposed some approaches and
methods aimed at solving specific
problems whose solution is given in the
form of projects. Projects are
management systems relatively simpler
than plans, as they focus on a defined
object. For practical purposes, a project
is defined as an articulated and detailed
6
set of assumptions, decisions, and
resources, interrelated and coordinated
toward a specific objective. This
approach considers that a project should
have the following characteristics: a
specific object, defined temporality
(deadline), subordinance to plans,
flexibility, creativity, singularity and
integrity (internal consistency). Several
approaches to project management,
including the Logical Framework
Approach22 (one of whose variants is
also known as Objectives-Oriented
Project Planning - in German Ziel
Orientierte Projekt Plannung ZOPP23),
are consistent with the principles of the
MAPP, particularly with regard to the
need of a good problem formulation,
and the strengthening of the
participation of those involved.24 25
Project management can be useful to
address specific aspects of a public
policy, but it does not replace planning
and, at some extent, may disperse the
efforts in absence of a good articulator
plan.
4.3.2.2 Bureaucratic support as
prerequisite for policy
implementation
Administrative arrangements refer to the
provision and implementation of
organizational and operational instances
responsible for applying the policy and
ensuring its successful development. The
development of these mechanisms implies
predicting the operational conditions of the
policy and includes, among other factors:
the institutions or agents that will be
responsible for its implementation, the
activities that should be performed, the
amount and type of human resources
involved, the technical resources that will
be required, the funds, the processes to
ensure compliance, etc. According to the
management model prevalent in each
country, the bureaucratic support of a
public policy may be exerted by State,
private agents acting for the state, or
community workers. Each of these options
leads to different management processes
whose results may result controversial. In
the case of health, the privatization of
services has led not only to the
strengthening of insurance, drugs and
medical supplies industries, but also to the
emergence of access barriers, pocket
expense raises, and increments in the
overall operating costs of the services due
to intermediation.26 27 28 29 30 31 In light of
these discussions, we should not accept a
priori that private management is better
than Statal administration (or vice versa)
without reviewing previously the available
evidence, and assessing the risks that any
decision means in terms of public interest.
Anyways, when the implementation of a
policy be undertaken by private agents,
administrative acts of delegation must
ensure that social objectives of the State
and the common good prevail over the
private interests of those who assume the
function.
To ensure that a policy be carried out
successfully, implementing laws or
administrative arrangements are not
enough. It is also necessary that the
guideline be known, accepted, and adopted
by stakeholders. These results can be
achieved through ideological control devices
and mainly two of them: education and
propaganda.
7
4.3.2.3 Education as social control device
In general, education is the process by
which a society shapes and molds the
behavior of its members, and adjusts them
to the existing social and economic order. In
this sense, education is a powerful social
control device that takes different forms
such as schooled education, divided into
"formal education" and "informal
education". Additionally, some authors
mention "non formal education" refering to
educational programs that do not lead to
academic degree but have a powerfull
normalizing effect.
For instance, "informal education" includes
a broad set of social processes incorporated
to the daily interactions, which form us
since childhood by reinforcing acceptable
behaviors of the group and punishing those
who do not meet actual values. These
processes of adaptation and change
continue throughout life thanks to various
mechanisms that may differ from those that
occur in childhood,32 and ensure that
people will adjust to social requirements.
Acknowledging people’s continuous
learning behaviors after childhood has led
to approaches and pedagogical
developments oriented to forming non-
institutionalized adults able to live in any
social setting. Theoretical and technological
advances in education have shown that
information alone is insufficient to change
the behavior of people in sustainable ways.
To change people´s behavior it is usually
necessary to apply other complementary
strategies that include environmental
changes. The three forms of education
(formal, non-formal and informal) are
essential tools for the success of a public
policy. In this regard, one will require the
support of education experts when
designing appropriate educational
strategies.
4.3.2.4 Propaganda
This device refers to the set of messages
that seek to influence people-s values
systems and change their behavior.
Propaganda is defined as an intentional,
strategic and systematic form of persuasion
for commercial, ideological or political
purposes, which is done with the intent of
influencing opinions, emotions, attitudes
and actions of specific target groups
through controlled transmission of partial
information (which may or may not be
based on real events), mainly through direct
mass media.33 In this sense, propaganda is
also considered as a powerful mechanism of
social and political control. In the field of
public policy, propaganda entails the set of
actions implemented by political actors in
order to promote adherence to a system of
rules and ensure at short term their
approval and compliance by the population,
and at longer term their legitimacy.
Throughout history, propaganda has often
been marked by misrepresentations of
facts, by the strengthening of prejudices,
and by calls to act passionately and
recklessly. For this reason, it is usually seen
as false, misleading and malicious. However,
as any other political device, propaganda is
not good or bad in itself, because its
attributes depend on both the ends pursued
and the way it is performed. Some
approaches have proposed that the goal of
propaganda is not to inform but convince. In
this sense, it should appeal to inividual´s
interests and emotions to persuade them
8
and achieve a specific change of their
behavior. This issue is also controversial. In
the case of public policy, propaganda should
abide by the legal and ethical principles in
force within each country, including
truthfulness, timeliness, impartiality and the
respect for the rights of people.
Additionally, when designing the
propaganda system required for
implementing the policy, it would be
necessary to take into account: the ethical
aspects of the methos and expected results,
the characteristics of the target populations,
the message type deemed most
appropriate, and the best means to achieve
the results.
Unlike propaganda, which is more
interested in changing the beliefs and values
of people, publicity has been developed in
the context of markets where it is
understood as the set of actions undertaken
to inform the public about a product or
service through different media (either
mass or direct) in order to promote
consumption. However, the techniques
developed by publicity have also been
applied to changing the values and gaining
adherence of people to certain patterns of
behavior. For this reason, some authors
consider that there is no substantial
difference between propaganda and
publicity. Whatsoever, transforming
people´s behavior is difficult. This is well
known by experts in propaganda and
publicity. These areas have experienced
significant technological influence, often
highly specialized. Considering this aspect,
the participation of experts in these areas is
strongly recommended when designing
strategies to implement public policies.
4.3.3 Treaties, agreements and contracts
as instruments of public
management
The three types of devices mentioned in the
preceding paragraphs have predominated in
Keynesian and socialist countries. Currently,
and following the principles of modernity,
they are still applied by most democratic
countries. However, since 1980, a new
model of governance has been overtaking
the world, resulting in a profound
controversy. In countries that have received
neoliberal influence, the State withdraws
from public affairs and from major common
interest policy-related decisions. Issues of
general interest are now impulsed by the
most powerful economic groups worldwide
through treaties and trade agreements
imposed by private agencies on
governments and on individuals. In
countries where these influential values are
being imposed, the State loses its
prominence as head of public affairs; legal
regulations weaken (except for contractual
issues); administrative mechanisms are
limited to economic profit management;
education focuses on publicity of
commodities and services; and citizen rights
become "consumer rights", which each
person acquires with a private provider
under contractual rules. In the context of
economic and social models promoted by
neoliberal movements, public affairs
management changes dramatically. The
State is no longer considered as directly
responsible for meeting people’s needs. In
fact, people are forced to celebrate
contracts with private companies that
supply basic products and services such as
health care, education, drinking water,
energy, communications, security, garbage
collection, etc. Meanwhile, companies
9
responsible for meeting the needs of their
customers should respect them only while
payment be maintained. In this context, the
notion of citizenship rights weaken and it is
removed, to make way for what some
authors call "programmatic rights"; these
are defined as individual prerogatives
whose recognizing and legitimacy are
subject to the repayment and funding
capacities of each person.34 35
The expansion of the neoliberal model in
the field of public affairs management has
given rise to the "New Public
Management”- NPM; 36 37 38 this ideological
model proposes to solve social problems as
market issues, and its effects in the health
field have raised profound changes and
criticisms.39 40 41 42 43 44 45 46 47 48 49
Formally, the NPM proposes, among other
mainstays:
a) Adopting the principles and theories of
the market for the management of
public affairs.
b) Separating the political aspects from
administrative ones.
c) Restoring the power of the individual
over the State.
d) Decentralizing state institutions to
reorganize its authority by levels and
delegations of powers.
e) Reducing bureaucratic hierarchies.
f) Centering administration on the
generation of profits and utilities, and
g) “Straightening the State to bring it to
their optimal proportions".
Anyways, in those countries where the
management of a public service has been
delegated to the private sector, it should be
granted that contracts guarantee
 compliance with the social objectives of the
State and assure the public interests above
the private interests of economic agents. In
this respect, the extent to which public
policies involve the management of
resources by private players, it will also be
necessary to strengthen agile and effective
auditing, control and social oversight
mechanisms.
4.4 Types of public policies
According to their predominant intention,
public policies can be classified in the
following non-exclusive categories:
4.4.1 Promotional policies
Promotional policies can be defined as
guidelines that foster a specific type of
people´s behavior that is considered
appropriate to solve a particular problem of
public interest. They are very common in
public health. For instance, breastfeeding
promotion, respectful treatment at school,
waste separation since its source, programs
for adoption and use of best practices,
strengthening of health oversight
committees, and induction particular types
of consumption (rational use of medication,
physical activity, cancer screening).
Promotional policies often rely on
ideological devices (publicity, propaganda,
education and massive media). These
strategies, however, may be insufficient to
achieve or maintain the desired behavior
change since individuals are not always
completely free to make decisions. For this,
it may be necessary to implement
complementary interventions by modifying
people’s environment when modifying
effective access to resources, creating
10
incentives, and implementing other
administrative or legal measures that
enable the behavioral expected changes.50
4.4.2 Protective policies of an issue
considered as public good
Protective policies, as its name indicates,
protect a sector of society before a
previously defined and detected threat,
which may comes from nature or from
adjacent social groups. E.g. protection of
groups at risk; protection of people’s rights
to health, life, honor, liberty and property;
protection of the national industry;
consumer protection; and, the protection of
heritage assets, natural reserves, and public
goods in general, either tangible or
intangible. The success of these policies may
depend on the State's ability to characterize
and neutralize the source of threat. This
action is not always easy when the threat
comes from militarly, economically and
politically powerful groups. In this regard,
the protective policies of a public good can
be particularly controversial and conflictive.
The key to addressing these conflicts may lie
on the degree of political, legal and social
support that the group interested in
exerting changes can achieve. The policy
could also be supported on the current legal
and ethical frameworks, on constitutional
principles and international consensus. The
management of such policies involves
developing measures of legal legitimacy;
implementing strong and effective
mechanisms of surveillance and control;
applying punitive and administrative
devices; performing educational activities;
and developing studies on the nature of the
problem and on the mechanisms to control
it. Sometimes, the key to success of these
policies may lie on social mobilization for
the defense of the threatened right, action
considered legitimate and legal in most of
the world's democracies.
4.4.3 Regulatory Policies of competing
interests
Unlike previous policies where the directive
is driven in favor of an affected group,
regulatory policies face conflicts when two
or more groups have divergent interests -
though presumably legitimate - regarding a
matter of public interest; e.g.: pricing,
taxation, intellectual property, and urban
reorganization policies. In these cases,
policies must comply with principles of
justice and equity. These policies also
require careful and appropriate ethical and
legal frameworks. Their management
involves the application of different
strategies: studies of potential impact;
application of negotiation techniques;
formulation of clear and transparent rules;
wide, truthful and deep debate about the
problem and about the interests at stake;
and implementation of effective
mechanisms to monitor, control and punish
offenders.
4.4.4 Reparative policies
These policies aim to reverse the effects of a
damage that has been considered of public
interest. For instance, refugee inclusion
strategies; displaced communities inclusion;
and reparation and compensation to victims
of violence. The management of such
policies can demand several complementary
strategies: developing legal regulations to
legitimize reparation; forecasting
administrative mechanisms to generate and
apply resources directed to rehabilitation,
compensation and resocialization; and
11
defining control instances. In addition, these
policies should include measures to avoid
further occurrences of damage, and devices
to prevent and punish those actions
considered potentially harmful to the
common good, among them: economic
sanctions, advertising aimed at making
damages visible, police measures, and other
mechanisms of social sanction. These
policies also require the development of a
proper legal foundations, educational
activities and surveillance systems to detect
and promptly manage further threats.
4.4.5 Sanctioning policies
These policies aim to discourage a certain
type of behavior or practice considered
contrary to public interests, and correct the
imbalance caused by the violation of the
rule. Eg: anti-corruption policies, sanctions
for the control of driving under the effects
of liquor, or measures against domestic
violence. The sanction can be considered a
necessary but undesired act, in the sense
that it is applied to ensure the rule when it
has not been possible to avoid the infraction
by other means. The policy may include
legal sanctioning mechanisms for the
offense such as imprisonment or fine.
However, there are also mechanisms of
social sanction that play an important role
in the prevention and control of infractions.
The term social sanction refers to
expressions of rejection manifested by
people as a reaction to certain behaviors
considered contrary to current values.
Social sanctions can help prevent violations
of the norm; however, it is usually the result
of other mechanisms of social control, and
not only the expression of the group's scale
of values. Due to the influence of education,
propaganda and the media, people adapt
their values to the current ideology and act
based on stereotypes and prejudices. In this
sense, the social sanction may be weak
against infractions and even become a
mechanism of injustice or exclusion. From
the above we conclude the importance of
carefully managing this type of practice,
foreseeing its impact on the rest of the
current values.
4.5 Public policy analysis
A public policy is a complex and dynamic
power device that involves multiple decision
schemes as shown in Figure 1. In such a
sense, analyzing and evaluating a policy
must account for at least the following
elements:51
a) Content. Content analysis of a public
policy aims to describe and delimit the
directive, its object (problem definition),
its principles, its objective and its
strategies. It focuses on the formal
aspects and often relies on discourse
analysis techniques highlighting the
most relevant aspects of the guideline,
its inconsistencies and its omissions. A
limitation of formal policy analysis is
that the explicit content of the directive
does not always coincide with the actual
situation; in this regard, analysts must
have an external standard to which the
12
reviewed contens be assessed and
contrasted.
b) Actors involved. When analyzing this
component, it is important to identify
and assess the roles of the different
people, groups and institutions involved
in both the problem and the solution. Of
particular interest is the analysis of
actors involved in the formulation and
implementation of the policy.
Stakeholders analysis includes a
characterization of those involved, their
needs, their interests, their
organizational patterns, their
interactions, their ideological affilitation,
and their ability to control resources and
to influence political decisions.
c) Context. The analysis of this component
aims to explain the social, economic,
cultural and administrative conditions in
which the problem appears and the
policy is formulated.
d) Process. This analysis focuses on how
the policy has unfolded, from the
construction of the problem to the
evaluation of its effects. Usually center
its interest in issues such as
participation; transparency; conflict
resolution strategies used by those
involved to impose their own interests;
and roles played by actors (academia,
trade unions, business groups,
politicians, public servants, and media).
 Figure 1. Public policy analysis: Points to take into account
e) Results. This analysis focuses on the
effects, favorable and unfavorable, of
the policy on the issue addressed (direct
results) and on other sectors (indirect
results). Impact analysis seeks to
demonstrate that certain observed
changes result from the policy and not
from other condition; this is not always
possible, because the problems that are
the subject of a policy often respond to
complex dynamics.
4.6 Formulation of a public policy
Social problems approach the political
agenda through different routes, which are
rarely predictable or controllable.
Sometimes a situation becomes a public
issue by a cumulative process of pressures,
tensions and historical dissatisfactions that
affect the stability of the political system
57
and require solution by the groups in
power. Usually, the problem is the result of
conjunctural issues that capture the public
interest. It may also occur that a public
policy already exists, but new conditions
affect the groups in power demanding the
adjustment of the guidelines. In every case,
for engaging in policy formulation, the
situation must be also well known by
politicians and decision makers as a
situation that menace their own interests.52
Getting these actors to take the problem as
their own and decide to solve it by means of
an explicit public policy is not always a
simple task. Figure 2 shows, in an idealize
scenario, some of the major processes
involved in the formulation of a public
policy. The figure looks simple; however, we
must take into account that political
processes are seldom linear, sequential, not
adjusted to ideal conditions.
Figure 2. Processes involved in the formulation of a public policy

11
From a technical perspective, the
formulation of a public policy may
involve the following, closely related
processes:
4.6.1 Formulation and visibility of the
problem as a matter of public
interest
This is one of the most complex
components of the process, because it
involves multiple situations, actors and
interests that relate to one another in
uncertain ways. Among the conditions
that influence positioning an issue on the
public agenda, the following are
particularly important: a) the interests of
governors, b) the interests of the
different economic, political and social
groups capable of exerting pressure on
governments, c) the pressures of
international organizations on the
political system, and d) the role of
media.53 Throughout the process of
recognition, definition and assessment of
a problem as a priority issue, each of
these groups uses the resources at their
disposal to impose their own interests on
the decision by applying systematic
pressure strategies that are neither
always known by the actors under
pressure, nor subject to technical
management. One of the most important
resources has to do with access and
control of the mass media.54 Because of
this complex conflict of interests, the
more powerful group will not only decide
which issues are included in the agenda,
but also how to interpret and present
them publicly. During this phase,
subordinate groups interested in the
issue can also affect the decision through
their own strategies: advocacy, lobbying,
12
dissemination of evidence, propaganda,
legal actions, and social mobilization.
The positioning of a problem on the
agenda seldom occurs unintentionally,
passively or at random. In practice,
positioning is usually the product of an
interest group that gets to influence
decision makers, and whose success
idepends on its organizational capacity,
its availability of resources, and its links
to the political apparatus. Moreover and
notably, it is necessary recognize that
governments do not always represent a
homogeneous interest, and sometimes
they become the space of confluence of
different power groups, often inspired by
competition or common interest. The
legitimacy of governments can be highly
variable, as much as their ability to
control the political agenda. Additionally,
due to the growing influence of
neoliberal ideologies, sovereignty of
States is increasingly limited and
constrained to certain action fields
imposed by international banking
superpowers and by trade agreements.
To sum up, the centers of power and the
actual decision makers are not always in
the Government, and this should be clear
to other stakeholders when designing
their strategies.
According to this, the ability of an
interest group to control the political
agenda and influence any decisions may
depend on the following actions:
4.6.1.1 Grounding the arguments
This action implies collecting and
systematizing information on the
situation which we want to regulate, by
specifying: a) its definition in operational
terms that be amenable to intervention,
b) its causes, c) its consequences, d) its
tendency, e) its social, political and
economic impact, and f) its meaning to
the public.
During this phase, it is particularly
important to seek, review, evaluate, and
interpret the evidence, understood as
the best information obtained from the
available sources.55
Concerning to public health policies,
literature has coined the concept of
"evidence-based public health", defined
as the development, implementation and
evaluation of interventions to promote
and protect health applying the
principles of scientific reasoning.56 57
Technicians propose arrange the
evidence in an orderly and
comprehensive manner, including not
only published scientific information but
also the lore and the knowledge acquired
by the group based on their
experiences.58 59 To substantiate the
arguments, one should bear in mind that
the data itself does not explain the
situation if it has not been properly
valued from technical perspectives
(validity, reliability, applicability, and
practicality) and from moral criteria (such
as the ethical, legal, and cultural codes in
force). The approaches that propose
"evidence-based policies" have been
object of a heated debate. Critics have
questioned the inconvenience of
extrapolating to the field of social
sciences a notion of evidence that has
presented difficulties even in natural
sciences. Moreover, the gap between
knowledge management and
policymaking has been also widely
13
studied. Reports suggest that knowledge
management can optimize policy
decisions; however, this process does not
happen mechanically, and it may be
associated with multiple conditions,
including the political contexts, the
characteristics and stereotypes of actors,
and the degree of interactions between
academics and politicians.60 61 62 63
4.6.1.2 Stakeholder Analysis
The term "stakeholder analysis" (also
called by some technicians "stakeholder
mapping") refers to the characterization
of social agents currently and potentially
affected by the situation, and interested
in the results of the policy. Those social
agents involved constitute a
heterogeneous and dynamic group that
includes: individuals and institutions
either negatively or positively affected by
the problem: those interested in
maintaining or changing the situation;
and those who could influence the
decision such as specific sectors of the
population, guilds, economic groups,
academics, international organizations,
political parties, public officials,
governors and, especially, the media.
Each of those involved may have their
own view of the problem, derived from
their particular interests. The stakeholder
analysis refers to the early, systematic
and continuous identification of the
interests that intersect in relation to the
problem and its possible solutions, and to
the evaluation of the forces resulting
from this interaction.64 To do this, it is
essential to take into account each of the
persons and agencies interested in both
the problem and the possible solutions,
thus characterizing the function or
activity that assumes such actor, his
interests, his potential and his
limitations. Lastly, it is important also to
value the implications of actors’ roles in
the process. From a technical
perspective, stakeholder analysis
requires three groups of complementary
actions: a) identification and
characterization of those involved, b) an
assessment of the stakeholders’ ability to
influence the process, and c) definition of
strategies to incorporate them to the
solution.65 An optimal stakeholder
analysis should provide sufficient and
useful information to develop specific
lobbying strategies targeted to each
audience according to its characteristics.
A superficial analysis of those involved
can lead to ignore the strength of actors
who might eventually impose their
interests in politics. Literature describes
many techniques to facilitate stakeholder
analysis; anyways, the idea is not just to
document the analysis but to use this
information to define the most
appropriate lobbying strategies in each
situation.
4.6.1.3 Design of advocacy and
lobbying strategies
In previous sections, we have stressed
that public policies are the result of social
interaction processes where the groups
with greatest power frequently impose
their will upon others. Since the
Renaissance, Machiavelli's work
highlighted the wide range of strategies
used by politicians and governors to get
and retain power, among which there are
manipulation, lying, cheating, deceit,
betrayal, blackmail, intimidation, and
murder. The media have shown that, at
present, different regions worlwide apply
14
many of these practices, and that they
are part of secret and hidden agendas of
governments, even in those countries
that boast of their democratic
foundations. Faced with these practices,
other actors brandish the ethical and
legal principles that have given rise to
Modern States subjeted to Law, and that
are defended by international agencies
and agreements. Such principles are set
assuming that the participation of
citizens and interest groups is
transparent and comply strictly with the
legal and ethical principles that govern
the Democratic States of Right.
Among the forms of participation in
public policy, two stand out: advocacy
and lobbying.
Advocacy is defined as the process aimed
at influencing social actors in general, to
get their support for a political decision.
The term lobbying usually refers to a
form of pression made directly over the
rulers and legislators by a group
specifically responsible for this activity. It
can be defined as the systematic activity
of persuasion performed on some
individuals or institutions with the
capacity to modify a decition in a field of
social life, in order to ensure their
support on certain types of arguments or
viewpoints about a controversial issue.
Some forms of advocacy consistent with
the ethical guidelines of international
agencies and with the principles of the
State of Law, are the follow:
 Media strategies: formal
communications with the public,
press conferences, radio and
 television programs, informational
programs, social networks on the
Internet, and advertising and
propaganda campaigns.
 Social mobilization strategies:
marches, public manifestations and
social networks.
 Activities of academic debate,
analysis and dissemination of
arguments and evidence.
 Establishment of partnerships
according to the results of the
stakeholder analysis.
 Direct lobbying.
Lobbying has grown considerably since
the end of 1970 thanks to activist groups,
nonprofit organizations, and private
companies in defense of their own
economic interests. Since the mid 1990s,
lobbying has been configuring a
specialized vocational area and, in some
cases, a very profitable intermediation
industry.66
Both processes, advocacy and lobbying,
are particularly sensitive to public ethics,
and their methods and scope are the
subject of international debate and
concern, mainly in relation to the ability
some groups have to impose their will to
coopt the State by any means in defense
of minority interests, and also to restrict
the public interest.67 68 69
Advocacy and lobbying are not exempt
from political risk. Their success could be
related to the clarity of the objective
pursued, the strength and legitimacy of
their underlying principles, their internal
coherence and consistency with other
public actions, and the intelligence of
their methods. These conditions can
ensure the success of advocacy and
15
lobbying, but in any case, this will depend
on their commitment degree, their image
in the eye of public opinion and the
leadership of the interest groups.
Some authors have highlighted the
mediation as a particular form of political
influence. Unlike advocacy and lobbying
that pursue the self-interest of actors,
mediation assumes itself as neutral
against a decision that is in dispute
between two or more opposing sides. To
the extent that the mediator is not
polarized, they rapprochement between
the actors (in conflict) may be facilitated.
In any case, "neutrality" does not imply
absence of criteria by the mediators, who
must act according to their principles and
values. On the contrary, clarity,
legitimacy, and strength of principles
constitute the keys to successful
mediation.
4.6.2 Defining the Policy Object
In theory, public policies must be aimed
at solving problems of public interest.
The object of a policy must be a specific
situation perceived as a problem, that
will be modify by a directive. Formulating
the object of the directive involves
defining and characterizing a situation
from the perspective of the common
good, expressing it as the problem of a
group that simultaneously affects the
interests of others. In this sense, it will be
considered a matter of public interest.
Formally, the object of the policy may be
expressed as an existing unfavorable
situation or as an unresolved need.
Specifying the problem is not always
easy. The difficulty with this analysis is
that problems do not exist by
themselves, but only when people value
a situation as contrary to their interests,
and then they qualify it as a problem.
Throughout life, human beings shape
different intentions or interests arising
from their biological conditions, their
personal history and their social
interactions. In everyday life, people are
valuing their experiences in the light of
these interests, and the experiences that
collide with them are qualified as
problems. In this sense, a problem is just
the gap between how people experience
a given situation and how they expect it,
want it or require it to happen. The key
to judging a situation as a problem lies in
the interests of those who value it. We
value something as a problem when it
does not fit our intentions. The
importance given to a problem is directly
proportional to the magnitude of our
interests. The diversity of experiences
and interests lead people to different
conceptions when evaluating problems.
Therefore, characterizing and assessing
problems have a very important and
essentially subjective component that
inevitably arises during the formulation
of any policy.
In the case of public policies, defining the
"object" entails precising the problem
that originates and justifies the
intervention; this element will articulate
the remaining components of the
directive. In other words, a public policy
has sense insofar as it contributes to
solving problems of public interest. For
this reason, we cannot expect much from
a policy without an adequate definition
of its object. This happen in several
countries, where policy makers often
implement "solutions", even before
16
understanding the situation they intend
to regulate.
It is not always easy to converge
interests, needs and requirements of the
total population on a uniform
proposition. Administrative trends have
proposed different models and tools to
analyze and formulate problems in
technical ways,70 several of which could
be especially important when defining
the public issue subject to intervention.
In Latin America, the Logical Framework
Approach is one of the most widespread
methods for managing projects. It
proposes several relatively simple
techniques to develop and feature a
problem in a handy way. It is clear that a
public policy is more than a project;
however, when the political context
allows it, the formulation of a policy
could be administered as such. In this
sense, traditional management
techniques may be very useful.
The technical formulation of a situation
as a problem of public interest involves
several complementary actions:
a) The description, characterization
and assessment of the general
situation in which the problem is
framed. A good analysis must account
for the behavior that the problem has
had in the region over recent years
and for its different manifestations.
The analysis of a problem also
involves disassambling it into specific
problems that could be analyzed and
evaluated more easily.
b) The selection and definition of the
specific issues that will be the object
of regulation. Even if resources
abound, a policy cannot disperse its
 efforts. In this respect, it may be
necessary to apply prioritization
procedures for concentrating efforts
on those aspects rated as most
important.
c) The causal analysis of the
problem. It is a set of activities to
explain why the problem selected
exists. This includes identification,
characterization and assessment of
the causes that produce the problem
and its consequences for those
involved.
The activities implicated in a technical
formulation of the problem must be
based on a good review and critical
evaluation of the best available
information, either in published
literature or in experiences of social
agents.
4.6.3 Definition of the principles and
foundations of the intervention
Public policies must be legitimate. The
term legitimacy refers to the degree of
social support that a guideline has. The
legitimacy of a public policy is related to
the ability of the power to gain
obedience without resorting to physical
intimidation or coercion. From a modern
conception, policies should not be based
on violence and arbitrariness, but on
arguments to substantiate and make
sense of the guideline while making it
viable. In States of Law, the legitimacy of
a policy is based on its consistency with
the legal as well as ethical platforms, and
with the endogenous values of the social
organization.
17
The formulation of a public policy must
guarantee its legitimacy. This pourpose
will require defining the "principles” of
the intervention. The “principles” are
explicit statements of different types
(technical, legal, and moral) that cover
the directive with legitimacy, and give it
the character of mandatory standard.
Defining the set of principles that
support the decision is particularly
important when solving complex and
controversial problems.
In relation to health, international
agencies have proposed some goals that
act as general pillars of any public policy:
71 72
 Reducing health inequalities.
 Improving the health status of
people.
 Improve the response of health
systems towards the legitimate
expectations of the population.
 Protecting people in an equitable way
from the derived financial
implications of health care.
4.6.4 Formulation of policy objectives
Public policies must have explicit and
well-defined objectives. Objectives are
the anticipated expression of the
expected results and are formulated as
favorable descriptors of an observable
future situation, wherein negative charge
related to the problem has been
removed. In Spanish the objectives that
may be quantified along time are often
called "goals" (metas).
There are different approaches to
formulating objectives.73. Technically, the
objective should clearly define and
precize the expected result, describing it
as an observable and achievable
situation. A common mistake in
formulating objectives is to confuse the
expected result (the what) with the
means to achieve it (the how). This
confusion tends to affect the
effectiveness of interventions, diverting
attention towards the means instead of
the results. For example, the objetctive
of a health policy should be to improve a
condition or health indicator, rather than
the increase in insurance coverage and
consumption of medical services. These
latter may be important as means but
not as an end, and their implementation
does not guarantee by itself an
improvement in the health of people.
4.6.5 Formulation of strategies
After having established the objectives,
the policy should also define how to
achieve them. To achieve an objective,
there can be multiple ways. Some of
them are more effective, simpler, safer,
and less expensive. When examining the
different alternatives that could lead to
the objective, it is possible to identify
how many of them seem comparatively
more advantageous, as it guarantees the
best results with minimal losses. A
strategy is such option (or principle of
action) that provides the maximum
advantage in relation to the intended
objective. The selection of strategies
should not be a mechanical act, but the
product of a thoughtful and intelligent
analysis. In general, one should
systematically review and compare
several alternative actions before
selecting the strategic choice; this can be
done by weighing the results, efforts, and
18
potential damages. In this regard, it may
be important to review how, when, and
who has applied the analyzed strategies
previously, and what results were
obtained with them.
Therefore, strategies are means, not
ends. They would lose their value if they
were separated from the objective.
Therefore, it is meaningless to design
strategies and rules without firstly
defining objectives. Formally, strategies
can be expressed as general action
frameworks aimed at achieving a specific
result. Additionally, strategies must be
feasible, applicable, assessable, and
legitimate. Besides, strategies must be
incorporated clearly and explicitly in the
public policy. Some authors propose to
express strategies as gerunds in order to
emphasize their character of means,74 for
instance “strengthening research
capacity of universities...”, “developing
an information system... ”,
“redistributing the tax system... ”,
“removing administrative barriers to
services... ”. As general lines of action, it
is not expected that strategies were
described in detail; this will be done later
on, during the planning phase, when they
will be broken down into simpler units of
action as processes, procedures and
activities.
Objectives and strategies are at the core
of every policy.
4.6.1 Definition of formal and
operational aspects
After defining the objectives and
strategies of the policy, it will be
necessary to establish the required legal
and administrative mechanisms to
implement it. These mechanisms vary for
each case and depend on the
characteristics of the policy and its
components, including the follow:
 Juridical and legal projects. These
instruments involve formulating and
managing draft laws, decrees, or
other statal regulations. Not all policy
provisions should take the form of a
legal rule. However, this forma may
be necessary: a) if the directive
affects previous standards,
particularly in terms of resources
with specific destination, or rights
and privileges of any actors; b)
whenever competing interests
emerge among social actors; c) or,
when an incumbent government
desires to turn their programs and
guidelines (government policies) into
permanent policies (State policies).
 Plans, programs, and projects.
Development plans are an excellent
way to implement public policies,
with the advantage that they can
coordinate efforts and synergistically
solve problems isolated in previous
phases. Public policies and each of
their strategies should be adequately
supported by a plan. Rather than
duplicating processes or generating
isolated or parallel plans that
fragment the management, agents
responsible for public policy could
build on and strengthen existing
planning systems. Within plans, one
may define programs and projects
that develop the operational
contents of the policy, by specifying
activities, goals, resources,
competences and responsibilities,
19
application areas, periodicity,
monitoring, and evaluation systems.
 Monitoring and control devices.
Insofar as different actors participate
in the implementation of the policy
and assume functions and
responsibilities, monitoring and
control systems will be required to
ensure the fulfillment of the
guidelines and the protection of
public interest, in contexts that
involve the social purposes of the
State. In each country, there may be
different mechanisms to ensure
compliance with policies; in any case,
citizen oversight and accountability
systems are appropriate tools of
(participatory) democracy that should
be strengthened.75 Additionally,
stakeholders involved in policimaking
must put in practice effective anti-
corruption measures to ensure the
transparency and legality of the
policy. This will include institutional
and administrative strengthening of
State control agencies: prosecution
offices, comptrollerships and
ombudsmen.
REFERENCES
1 Start D, Hovland I. Herramientas para el Impacto
en las Políticas Públicas: Manual para
Investigadores. Investigación y Política para
Programas de Desarrollo. Londres, 2004.
http://www.odi.org.uk/resources/download/2667
.pdf
2
Matland RE. Synthesizing the Implementation
Literature: The Ambiguity-Conflict Model of
Policy Implementation. J Public Adm Res Theory
(1995) 5 (2): 145-174.
http://jpart.oxfordjournals.org/content/5/2/145.f
ull.pdf+html
3 O'Toole LJ Research on Policy Implementation:
Assessment and Prospects J Public Adm Res
Theory (2000) 10(2): 263-288
4 Smith T. The policy implementation process. Nacionales de Salud. Borrador 3 de junio 2010.
Policy Sciences Volume 4, Number 2, 197-209 Documento de consulta.
5 O'Toole JR, Montjoy R. Interorganizational http://new.paho.org/hq/index.php?option=com_
Policy Implementation: A Theoretical Perspective docman&task=doc_view&gid=7891&Itemid=
17
Public Administration Review Vol. 44, No. 6 (Nov. Green, Andrew. An Introduction to Health
- Dec., 1984), pp. 491-503 Planning in Developing Countries. Oxford
6 Howlett M. Policy Instruments, Policy Styles, University Press 1999 2nd Ed 338pp
18
and Policy Implementation. National Approaches Eagar K, Garrett P, Lin V, editor. Health
to Theories of Instrument Choice. Policy Studies Planning: Australian Perspectives. Melbourne,
Journal Volume 19, Issue 2, pages 1–21, March Allen and Unwin; 2001
19
1991 Matus C. Método Altadir de Planificación
7
WikiLeaks. http://213.251.145.96/ Popular. Buenos Aires, Lugar Editorial; 2007.
8
Transparencia Internacional. Informes 2001- Colección Salud Colectiva
20
2009. Matus C. Método Altadir de Planificación
http://www.transparency.org/publications/gcr Popular. Buenos Aires, Lugar Editorial; 2007.
9
World Audit. England. Colección Salud Colectiva
21
http://www.worldaudit.org/corruption.htm Jefatura de Gabinete de Ministros, Secretaría
10
Tanzi, Vito Corruption Around the World: para la Modernización del Estado. Documentos
Causes, Consequences, Scope, and Cures. conceptuales: Planificación Estratégica
International Monetary Fund (December 1998) Situacional. Este documento sigue el desarrollo
Vol. 45, No. 4 1998 presentado por Sotelo Maciel, Aníbal Jorge en:
http://www.imf.org/external/pubs/ft/staffp/1998 Análisis PROBES. Un método para el análisis
/12-98/pdf/tanzi.pdf situacional y la formulación de estrategias, ESTS-
11 Nussbaum D. Corruption in health: what every UNLP, La Plata, 1997.
22
policymaker should know. Transparency USAID. The Logical Framework. Washington,
International org. D.C. 2006
http://tistats.transparency.org/index.php/content http://pdf.usaid.gov/pdf_docs/PNABI452.pdf
23
/download/6729/40507/file/CMRB- EuropeAid Cooperation Office. Project Cycle
Nussbaum.pdf Management Guidelines, European Commission,
12
Organización Mundial de la Salud (OMS) Un Bruselas, 2004
Marco Para Políticas, Estrategias y Planes http://ec.europa.eu/europeaid/multimedia/public
Nacionales de Salud. Borrador 3 de junio 2010. ations/documents/tools/europeaid_adm_pcm_gu
Documento de consulta. idelines_2004_en.pdf
http://new.paho.org/hq/index.php?option=com_ 24 Camacho H, Cámara L, Cascante R, Sainz H. El
docman&task=doc_view&gid=7891&Itemid= Enfoque del marco lógico: 10 casos prácticos.
13
Ramio-Mata C. Teoría de la Organización y Cuaderno para la identificación y diseño de
Administración Pública. 2002, Editorial Tecnos, proyectos de desarrollo. Fundación Cideal-
Madrid 302p Acciones de Desarrollo y Cooperación A.D.C.
14
Walt G, Shiffman J, Schneider H, Murray SF, Madrid, 2001 http://preval.org/files/00423.pdf
25
Brugha R, Gilson L. Doing’ health policy analysis: GTZ. Gestión del Ciclo del Proyecto (PCM) y
methodological and conceptual reflections and Planificación de Proyectos Orientada a Objetivos
challenges Health Policy and Planning (ZOPP): Guía. GTZ-P-FORM2 Deutsche
2008;23:308–317 Gesellschaft für Technische Zusammenarbeit
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2 (GTZ) GmbH. 1996.
515406/pdf/czn024.pdf http://www.scribd.com/doc/6997962/GTZGestio
15
Policy Toolkit for Strengthening Health Sector nCiclodeProyecto-y-Zopp-en-Espanol
Reform, Latin American and Caribbean Regional 26 Waitzkin H, Iriart C, Jasso-Aguilar R.
Sector Reform Initiative. Privatization of Health Services in Less Developed
http://info.worldbank.org/etools/docs/library/48 Countries: An Empirical Response to the
545/RD1.PDF.pdf Proposals of the World Bank and Wharton
16
Organización Mundial de la Salud (OMS). Un School. International Journal of Health Services,
Marco Para Políticas, Estrategias y Planes 2007,3 7(2):205-227

20

27 Daskalova N, Tomev L, Ivanova V, Nikolova A,
Naydenova Z, Trakieva D, Health care reforms
and privatization – Social and economic
consequences: case of Bulgaria. Institute for
social and trade union research. 2005
http://www.gpn.org/research/privatization/priv_
bulgaria_engl.pdf
28
Rachlis A. Privatized Health Care Won’t Deliver.
Commissioned Policy Research. Wellesley
Institute. Advancing Urban Health, 2007
http://wellesleyinstitute.com/files/privatizedhealt
hcarewontdeliver.pdf
29
Podgorsak EB Privatization is not an answer to
health care access problems, increased public
funding is. Curr Oncol. 2009 March; 16(2): 2–3.
30
Homedes N, Ugalde A. Privatización de los
servicios de salud: las experiencias de Chile y
Costa Rica. Gac Sanit 2002;16(1):54-62
31
Angell, M. Privatizing health care is not the
answer: lessons from the United States. CMAJ
2008;179:916-9
http://www.cmaj.ca/cgi/reprint/179/9/916?ijkey
=28985360723a870f4639d850b967362e27f1df42
32
van Duijvenvoorde ACK, Zanolie K, Rombouts S,
Raijmakers M, Crone EA. Evaluating the Negative
or Valuing the Positive? Neural Mechanisms
Supporting Feedback-Based Learning across
Development. The Journal of
Neuroscience, September 17, 2008, 28(38):9495-
9503
33 Nelson RA A Chronology and Glossary of
Propaganda in the United States. Greenwood
Press. Westport, CT. 1996
http://www.questia.com/PM.qst?a=o&d=141434
61
34
Haque MS. Global Rise Of Neoliberal State And
Its Impact On Citizenship: Experiences In
Developing Nations. Asian Journal of Social
Science 36 (2008) 11–34
http://profile.nus.edu.sg/fass/polhaque/Haque.p
df
35
The World Bank and the State: A recipe for
change? The Bretton Woods project. 2000.
http://www.brettonwoodsproject.org/art-16242
36
Paul J. Andrisani, Simon Hakim, and E. S. Savas,
The New Public Management: Lessons from
Innovating Governors and Mayors (Norwell, MA:
Kluwer, 2002), chapter 1.
37
E. S. Savas, Privatization and Public-Private
Partnerships (Chatham House Publishers: New
York 2000).
21
38
David Osborne and Ted Gaebler, Reinventing
Government (New York: Addison-Wesley
Publishing, 1992), chapter 9.
39
Arbeláez M, Gaviria M, Franco A, Restrepo R,
Hincapié D, Blas E. Tuberculosis control and
managed competition in Colombia. Int J Health
Plann Mgmt 2004; 2004(19):S25-S43.
40
Kroeger A, Ordoñez-Gonzalez J, Aviña A.
Malaria control reinvented: health sector reform
and strategy development in Colombia. Tropical
Medicine and International Health 2002;
7(5):450-458.
41
Stuckler D, King LP, Basu S International
Monetary Fund Programs and Tuberculosis
Outcomes in Post-Communist Countries PLoS
Medicine Vol. 5, No. 7, e143
doi:10.1371/journal.pmed.0050143
42
Kim JY, Millen J, Irwin A, Gershman J (2000)
Dying for growth: global inequality and the health
of the poor Monroe (Maine): Common Courage
Press.
43
Goldsborough D (2007) Does the IMF constrain
health spending in poor countries? Evidence and
an agenda for action. Report of the Working
Group on IMF Programs and Health Spending.
Washington (D.C.): Center for Global
Development.
http://www.cgdev.org/doc/IMF/IMF_Report.pdf
44
Friedman EA (2004) An action plan to prevent
brain drain: building equitable health systems in
Afric Boston: Physicians for Human Rights.
Available:
http://physiciansforhumanrights.org/library/docu
ments/reports/report-2004-july.pdf. Accessed 31
March 2008.
45
(6) Murray M, King G (2008) The Effects of
International Monetary Fund Loans on Health
Outcomes. PLoS Med 5(7): e162.
doi:10.1371/journal.pmed.0050162
46
UNICEF, (1987) Adjustment with a human face.
Volume 1: protecting the vulnerable and
promoting growth Cornia GA, Jolly R, Stewart F
Oxford: Clarendon Press.
47
Banerji D (1999) A fundamental shift in the
approach to international health by WHO,
UNICEF, and the World Bank. Int J Health Serv 29:
227–259.
48
Navarro V. What we mean by social
determinants of health. International Journal of
Health Services, 39(3):423–441, 2009
49
Navarro V (2004) The world situation and
WHO. Lancet 363: 1321–1323
50
Parsons Wayne. Políticas Públicas: Una
introducción a la teoría y la práctica del análisis
de políticas públicas. FLACSO, México 2007
http://books.google.com.co/books?id=4j_3k3eCw
HUC&pg=PA230&lpg=PA230&dq=politicas+prom
otoras&source=bl&ots=cbI7Wcubdc&sig=k0GCHE
mrSfwLGWx66ek53rCkuRU&hl=es&ei=K9_yTPfSE
YGdlge3y5mtCg&sa=X&oi=book_result&ct=result
&resnum=10&ved=0CDQQ6AEwCQ#v=onepage&
q&f=false
51
Roth Deubel, Andre-Noel Políticas Publicas:
Formulación, implementación y evaluación
Ediciones Aurora. 2007 Bogotá.232p
52
Walt G. Health policy: An introduction to
process and power. Witwatersrand University
Press. Johanesburg. Zed Books, London and New
Jersey; 1994.
53
Lewis Jenny M, Considine Mark Medicine,
economics and agenda-setting. Social Science &
Medicine 48 (1999) 393±405
54
James W. Dearing and Everett M. Rogers
Agenda-Setting. Thousand Oaks, CA: Sage
Publications, Inc, 1996, 139p
55
Rychetnik L, Hawe P, Waters E, Barratt A,
Frommer M. A glossary for evidence based public
health. J Epidemiol Community Health
2004;58:538–545. doi: 10.1136/jech.2003.011585
56
Brownson, Ross C., Elizabeth A. Baker, Terry L.
Leet, and Kathleen N. Gillespie, Editors. Evidence-
Based Public Health. New York: Oxford University
Press, 2003.
57
Sutcliffe S, Court J. A Toolkit for Progressive
Policymakers in Developing Countries. Research
and Policy in Development. Overseas
Development Institute’s Research and Policy in
Development, London, 2006
http://www.odi.org.uk/resources/download/154.
pdf
58 Rychetnik L, Frommer M, Hawe P, Shiell A.
Criteria for evaluating evidence on public health
interventions J Epidemiol Community Health
2002;56:119–127
59
Fafard P. Evidence and Healthy Public Policy:
Insights from Health and Political Sciences,
National Collaborating Centre for Healthy Public
Policy. Canadian Policy research projects. May
2008.
http://www.cprn.org/documents/50036_EN.pdf
60
Bronfman M, Langer A; Trostle J. De la investi-
gación en salud a la política. La difícil traducción.
México: Manual Moderno; 2000.
22
61
Davis P, Howden-Chapman P. Translating re-
search findings into health policy. Soc Sci Med
1996;43(5):865-872
62
Gómez-Arias RD, Orozco-García DA, Rodríguez-
Ospina FL, Velásquez-Vélez W. Políticas públicas y
salud: relación entre investigación y decisión.
Revista Facultad Nacional de Salud Pública 2006
24(2):105-118
63
Walt G. Health policy: an introduction to
process and power. Johannesburgo:
Witwatersrand University Press; 1994.
64
Schmeer K. Section 2: Stakeholder Analysis
Guidelines. In: Policy Toolkit for Strengthening
Health Sector Reform, Latin American and
Caribbean Regional Sector Reform Initiative
http://www.eestum.eu/voorbeelden/Stakeholder
s_analysis_guidelines.pdf
65 Gómez-Arias RD, Yepes-Delgado CE,
Rodríguez-Ospina FL, Roldán-Jaramillo P,
Velásquez-Vélez W. Martínez-Ruiz O, Lopera-Villa
J, Vargas-Peña G. Manual de gestión de
Proyectos. Facultad Nacional de Salud Pública.
Editorial Universidad de Antioquia. 2009. 380 PP
ISBN: 978-958-714-281-
66 Bonilla-Gutiérrez C. Las Tres Fases del
Cabildeo. Mi Espacio. Grupo InfoSol, México
2003.
http://www.miespacio.org/cont/invest/tresfa.ht
m
67
OECD. Principles for managing ethics in the
public service. Organization for Economic Co-
operation and Development OECD
Recommendation. PUMA Policy Brief No. 4 1998
http://www.oecd.org/dataoecd/60/13/1899138.
pdf
68
Saint-Martin D, Thompson F Public ethics and
governance: standards and practices in
comparative perspective. Emerald Group
Publishing, 2006
http://books.google.com.co/books?id=u7XG9H2l
OWwC&printsec=frontcover&dq=public+ethics&s
ource=bl&ots=L5BqJ4MvqB&sig=AaGhj-
gDCK_2t1qg8rXa9-
R1tM4&hl=es&ei=kuocTeHSNcGclgeH-
LSyDA&sa=X&oi=book_result&ct=result&resnum=
8&ved=0CEwQ6AEwBw#v=onepage&q&f=false
69
Habermas J Historia y crítica de la opinión
pública, Barcelona, Gustavo Gili, 1981.
70
Marco para Iniciativas de Políticas Públicas
Propuestas de Jóvenes a favor de la Juventud
Hondureña. Documento Preliminar. Tegucigalpa.
2000.
http://www.bvs.hn/bva/fulltext/Politicaspublicas.
pdf
71
OMS. Subsanar las desigualdades en una
generación. Comisión sobre los determinantes
sociales de la Salud: Informe final. Organización
Mundial de la Salud. Ginebra. 2009.
http://whqlibdoc.who.int/publications/2009/978
9243563701_spa.pdf
72
WHO. Reducing health inequities through
action on the social determinants of health.
Document A62/9. Sixty-Second World Health
Assembly. 2009.
http://apps.who.int/gb/ebwha/pdf_files/A62/A6
2_R14-en.pdf
73
GTZ. Gestión del Ciclo del Proyecto (PCM) y
Planificación de Proyectos Orientada a Objetivos
(ZOPP): Guía. GTZ-P-FORM2 Deutsche
Gesellschaft für Technische Zusammenarbeit
(GTZ) GmbH. 1996.
http://www.scribd.com/doc/6997962/GTZGestio
nCiclodeProyecto-y-Zopp-en-Espanol
74 Gómez-Arias RD, Yepes-Delgado CE,
Rodríguez-Ospina FL, Roldán-Jaramillo P,
Velásquez-Vélez W. Martínez-Ruiz O, Lopera-Villa
J, Vargas-Peña G. Manual de gestión de
Proyectos. Facultad Nacional de Salud Pública.
Editorial Universidad de Antioquia. 2009. 380 PP
ISBN: 978-958-714-281-5
75
Center for Democracy and Governance.
Promoting transparency and accountability:
USAID.s Anti-corruption experience. Bureau for
Global Programs, Field Support, and Research.
U.S. Agency for International Development
Washington, DC January 2000
http://www.usaid.gov/our_work/democracy_and
_governance/publications/pdfs/pnacf740.pdf

23