The determinants of policy effectiveness.

a University of Cardiff, Department of Epidemiology, Statistics and Public Health, Cardiff, Wales. Correspondence to this author (email: [email protected]). b National Public Health Service for Wales, Cardiff, Wales. Ref. No. 06-036251 There is an old military saying: “Armchair generals talk strategy, professionals talk logistics”. Much health sector policy reform is driven less by evidence than by armchair strategies shaped by ideology that frequently shows little regard for practical realities. The ideologists promote their strategies for more — or less — market involvement, user charges and devolution; but, as Siddiqi et al. demonstrate in this issue of the Bulletin, when it comes to implementation the limiting factor is the local reality.1 Armchair strategists in think tanks around the world too often assume that conditions across countries are homogeneous: that because an approach works in one country it must work in another, despite different legal and administrative systems, traditions and values, and physical and security environments. Siddiqi et al. remind us that health and its subsystems do not work in isolation. They look at the practical limitations of implementing strategy and conclude: “Careful consideration and a thorough analysis of the local context are essential before deciding in favour of outsourcing versus direct provision” (of services). Contracting needs tendering arrangements and the capacity to operate them — we might add, without external interference. They also note the importance of monitoring arrangements, and that such arrangements depend on the collection of reliable management information (including from the nongovernmental sector). Contracting also needs a system able to take action in cases of non-performance or non-compliance, again without external interference. Contracts depend on governments being willing and able to pay contractors on time. The Dahlgren & Whitehead “determinants of health” model has become axiomatic in public health policy discourse.2 Similarly, it is time we recognized that health sector policies are nested in wider systems that largely determine their effectiveness (see Fig. 1).3 What we call the “determinants of policy effectiveness” model (as it is applicable to more than just health policy) reminds us that there are limiting factors to the effectiveness of the grand plans of armchair reformers. We must consider many issues: the realities of the public administration system and its rules within which so many health policies must operate; the local training and educational systems and how they prepare professionals; and the prevailing cultural and economic values. Is information, for example, treated with respect and collected and recorded accurately and in a timely manner? Are all men and women treated equally with respect and dignity? How frequently do politicians interfere with contracts and staff appointments? We must also consider the commercial sector and the legal system and whether their practices are congruent with the proposed reforms, the general level of wealth and the governance systems that facilitate or restrict scope for corruption, and the attitude towards those who are caught. A senior Indian bureaucrat has written openly about corruption in India,4,5 and the importance of corruption in health sectors around the world has been amply described by this year’s report from Transparency International.6 None of the proposed panaceas — more government provision of health care, market involvement, involvement of nongovernmental organizations, subsidiarity, integrated primary care, “third way” approaches, etc. — will work effectively until we take cognizance of the impact of the context and environment in which they are expected to succeed. Systemic capacity building draws our attention to the need for detailed analysis of capacity shortcomings within health sectors.7 The determinants of the policy effectiveness model remind us of the need to look outwards as well. It may even be that for health-care reforms to be successful we need to give more attention to up-stream development and look for greater pace of change in the political, legal, commercial, educational and administrative systems on which successful health policy relies. O