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Warning: Politics with a small 'p' can seriously harm your MDGs


As Health Ministers meet at the 60thWorld Health Assembly on May 14th, they are poised to make various commitments to international health which will be both well intended and well-informed. Yet progress toward the health MDGs is off track and many recent initiatives are failing to improve service delivery. 

The reasons for lack of progress are many. Often cited problems include insufficient resources, in many contexts weak capacity, lack of operations research, and more controversially, as argued by William Easterly, inappropriate development assistance and technical support. While money, capacity and poorly spent public resources, including aid, are part of the problem, what is less often explicitly understood, acknowledged or addressed are the ways in which a wide range of actors both deliberately and unintentionally block, resist and subvert evidence-informed policy change processes. Yet, a limited amount of research confirms what most people intuitively grasp – namely, that evidence is not enough by itself to bring about policy and systems change. Wider strategies are also required to address and offset the opposition to change that is experienced at all levels of the health system.

Such opposition is based on various factors. While the benefits of pro-poor health reform are dispersed among the weak and powerless, the opportunity costs of policy change are most often concentrated on the well-organised groups that can and do block such change. These groups include commercial actors such as those in the insurance and pharmaceutical industry, cadres in the civil service who, for various reasons, might lose from reform, some medical profession groupings, and some political elites. Indeed, research reveals that some interest groups have been very successful in crafting strategies and tactics to stymie evidence-informed policy – consider the Tobacco Industry or the anti-abortion lobby in places such as Nicaragua. At the same time health care personnel, for example, often undermine policy through their everyday implementation practices, and in reaction to the pressures of their workplaces or poor management – as experience with the removal of user fees in South Africa confirms.

The good news is that careful consideration of the small ‘p’ political dimensions of introducing and sustaining evidence-informed change, can lead to reform ‘despite the odds’ as argued by M L Grindle based on case studies from Latin America. More emphasis, thus, needs to be placed on understanding the political dimensions of the proposals made at the WHA so as to identify, within different national contexts, how to address the small ‘p’ obstacles that could undermine implementation and thereby jeopardise global goals for improved health.

Sadly, little research is readily available to guide policy makers on how to address the interest group politics of evidence-informed policy change, or how to better manage processes of change. A small group of international researchers, policy-makers and donors concerned with this problem will take stock of the politics of health policy change and policy analysis research on May 21st and 22nd in London at a meeting convened by the Overseas Development Institute, London, the London School of Hygiene and Tropical Medicine, HLSP, Witswatersrand University, Johannesburg, and King's College London. Among other things, the group will review how researchers have conducted studies in the past that look at the small ‘p’  dimensions of health policy change, and how decision-makers have used this kind of research to inform their thinking and policy formulation. The workshop in London will also consider how to build national capacity and networks for further research that can assist decision-makers implement their commitments. Ultimately, these discussions will be taken forward through the existing activities of the colleagues meeting together. For example, they will inform: the planning of policy analysis research, capacity building and policy maker engagement being undertaken through the six country Consortium for Research on Equitable Health Systems; capacity development activities being implemented in Africa with the Regional Network on Equity in Southern and Eastern Africa (EQUINET) and inform technical approaches for health sector programme design, implementation and monitoring.

The workshop organisers, Lucy Gilson, Clare Dickenson, Susan F Murray and I, anticipate that these sorts of activities will be the first steps of a wider movement to acknowledge what should be obvious but often appears to be over-looked – that politics in all its guises is central to evidence-informed health policy making. As such, the international community has an obligation to support national efforts to address the politics that would otherwise undermine the sagacious recommendations of our health ministers and further imperil the international health goals.