Health Policy Actors

Dipak Mitra
Policy Actors
• Policy actors are the individuals/Groups who
discuss policy issues, persuade/bargain in
pursuit of their interest
• Give up/modify their objectives in return for
concessions from others
• Nature of actors varies by country and policy
sectors
• Institutions shape the behavior of actors by
conditioning the perceptions of their interests
Policy Actors

Policy Actors

international actors Societal actors

State actors
Classification of Actors
• Three major categories:
– State actors
– Societal actors
– International Actors
State Actors
• Understanding the state/government is crucial to the
formulation of health policies
• The state is made up of all the authoritative decision-
making bodies of the society, it is supreme and can use
coercion to achieve its ends
• Government is a narrower concept than the state and
includes public institutions (parliament, the executive,
the bureaucracy, judiciary, ministries) where collective
decisions are made into laws that affect the whole
society
State Actors
• State extends deeply into peoples’ lives and does more
than any other body to decide what policies to be
implemented
• The state’s role in economic activities expanded in both
developed and developing countries between the
Second World War and the late 1970s
• Guided by the Keynesian ideas about employment,
social welfare and industrial policy, most developed
countries assumed the government should carry out
central responsibility for most public utilities and social
services, including health
• NHS of UK was created, Universal health service of
Canada was formalized
State Actors
• During the same time the newly independent
developing countries also saw the similar trend
of strengthening of the state
• By the 1980s the concept of small state gained
popularity due to its being unresponsive,
unaccountable and inefficient
• By the end of the 1980s many governments
started to reduce their responsibilities in the
public sector-moving away from providing
services directly while retaining regulatory and
financial control
State Actors
• Despite shrinking many of its roles, in order to
increase the market forces, government continues
to affect the lives of their citizen and remains the
major actor in the society
• It continues to be a major employer of labor force,
and responsible for many services like agriculture,
health, and education
State’s role in health
• In both developed and developing countries
governments have been centrally involved in
health regulation and provision ranging from
public health measures like ensuring pure water
to border controls in order for containing the
spread of communicable diseases
• In most countries governments are intimately
involved in the provision of preventive,
promotive and curative health services
State’s role in health
• Even where government may be retreating from
mandatory controls on medical graduates, they
may still be concerned with geographical
inequities and offering financial compensation
for working in disadvantaged areas
Categories of State Actors
State actors are composed of
– 1) Elected officials
– 2) Appointed Officials
• Elected officials (2 categories):
– Members of the Executive/Cabinet (major role)
– Members of the Legislature (minor role in Parliamentary form of
government)
• Members of the Executive:
– Ultimate authority to make and implement the policy
Categories of State Actors
Source of power of the Executive
• Constitution/Law
• Control over information
• Control over fiscal resources
• Access to mass media
• Control over bureaucracy (to provide advice
and to carry out its preference)
Categories of State Actors
• Members of the Legislature
– In a parliamentary democracy, scope of influence
is minimal
– Policy functions are mainly performed in the
Committees not on the floor of the legislature
 Categories of State Actors
• Appointed Officials (Bureaucracy):
– The ‘key’ and ‘central figures’ in the policy process
• Sources of Power:
– Law
– Access to material resources
– Repository of a wide range of skills and expertise
– Access to a vast information
– Long tenure
– Close interaction with organized groups
Who makes Policy?
Bureaucrats/Politicians?
• It’s a key concern of policy making
• Policy making is not the sole responsibility of
the politicians as complexity increases,
bureaucrats have to be involved in policy
making
• Both contribute to policy making but bring to
it differing values and attitudes
Who makes Policy?
Bureaucrats/Politicians?
Bureaucrats Politicians
Technical/Factual Ideological/Idealistic

Politicians set goals and bureaucrats decides the way

of achieving them

Bureaucrats Politicians
Means/ Practical Ends/value laden
Societal Actors
• Groups are the basic units of political system
and political actions are the results of group
interaction.
• Groups are rarely ignored
• Societal Actors
– interest groups
– pressure groups
– civil society
– Research Organizations
– Mass media
Societal Actors
• Interest Groups
– Individuals of a society turn into interest group as a
result of the possession of common social
characteristics
• Pressure groups
– Interest groups turn into pressure group when they
want to obtain favorable policy decision
Why groups are important?
• Nature of pressure:
– Groups usually represent other members through
communicating their interests to the public authorities
• Two ways of pressure:
– Groups may create pressure on govt/Government may consult
groups
• Sources of Power
– Knowledge/expertise/information (They know the most about
their area of concern)
– Number ( size of membership)
– Financial (groups often finance the political parties they favor)
– Political (sometimes they campaign for the candidates who they
think would support their cause in the government)
Iron Triangle Theory
• Boyen and Johnson (2005) identified three key actors
in the policy process:
– Bureaucrats
– Politicians
– Interest Groups
• Policy is the product of the interrelationships and
interactions among these three key groups.
• If any one group becomes dominant it will cause an
imbalance/ autocracy (by trying to make policy in favor
of their interest)
• Therefore, policy process should have a power
balance among these three actors
Iron Triangle Theory

Bureaucracy

Iron
Triangle

Interest Political
Groups Executive
Iron Triangle Theory
• Interest groups make their demands to political
executives, on the other hand, political executives also
have some agenda to fulfill through interest groups.
• Both these groups opt for assistance of bureaucracy to
transform their expectations into policy decision
• Support/cooperation among these groups generate
good policies while resistance/dominance from any
single group makes the process complicated
Iron Triangle Theory
• Civil Society:
– Inner voice of the societal power, which acts as a
conscience of the society to check political power
– A voluntary association free from state control
– Addresses common problems, advance shared
interests and promote collective aspirations.
Iron Triangle Theory
• Research Organization
– Organizations engaged in multi-disciplinary
research intend to influence public policies
• Mass Media
– Crucial link between the state and society
– Media influences the preferences of govt and the
society on public problems and solutions
International Actors
• Institutions/Bodies/countries ( WTO, WHO MNCs)
• International actors influence policies through
conventions, treaties
• Nearly impossible for states to stop foreign influence
• Sovereignty of state depends:
– severity of international pressure
– nature of issue in question
– features innate to the state(economic, military and
domestic strengths)
Health Policy Actors: Theory of
Structural Interests
• Alford (1975) viewed the entire health system as a
network involving many different structural interests
• Theory of Structural interest determines which group
within the structure is powerful and to what extent
and what is the interest of particular groups within
the health service structure and how they are
interdependent on each other
• Structural interest refers to those interests which gain
or lose from the form of organization of health
services
Structural interests
• Three different types of structural interests were identified by
Alford
– Dominant Interests: Dominant structural interests are those served by
the structure of social, economic and political institutions as they exist at
a given time.
– The interests involved do no have to organize themselves to defend their
interest; other institutions do that for them.
– Physicians enjoy autonomy because of the perceived importance of their
specialized knowledge to save people-which is needed by the society, but
it is not always available
– Medical profession is this kind of interest who enjoys professional
monopoly through applying medical knowledge to treat patients without
any interference.
– Physicians do have self regulatory capacity, the profession controls their
income and career prospects
Structural interests
• Challenging interest:
– Medical profession exercises autonomy within an
institutional set-up, which in turn challenges their power
– Professionals are subject to the rules, plans of the large-scale
organizations producing health services
– Professionals are not challenged by the society, laws,
customs but they are often challenged by the persons
occupying the top position in large scale health
organizations, bureaucrats/hospital administrators.
• Repressed interests/Negative structural Interests:
– No social institutions or political mechanisms ensure that
these interests are served
– Interest of the community population falls under this
category
Thanks