CHAPTER 2 CHAPTER TWO LITERATURE REVIEW
2.3 THE POLICY DEVELOPMENT PROCESS
2.3.2 Stages of policy development
The policy process involves decisions made at a national or decentralised level, including funding decisions that impact on service delivery. Thus, consideration must be given to policies at various levels of the health system and over time to ensure sustainable scale- up (WHO, 2011). The literature presents various approaches used in the process of policy development, with the dominant view being the policy cycle. This is a sequence of interrelated stages in which policy issues and deliberations flow from “inputs” (problems) to “outputs” (policies). These include agenda-setting, policy formulation, decision- making/policy adoption, policy implementation and policy evaluation (Anderson, 2011).
2.3.2.1 Agenda-setting
The focus here is on how the problems that may become the targets of policies are identified and specified. Agenda-setting is viewed as comprising three mostly independent streams of activities, problems, proposals and politics, which occasionally link, opening a
“policy window” and enabling some matters to reach the government agenda (Kingdon, in Anderson, 2011:93).
The problem stream consists of matters on which policy players inside or outside government would like to secure action. The proposal stream comprises possible solutions for problems. Proposals are ideas that are either taken seriously or discarded. The politics stream includes items such as changes in presidential administrations. At any given time,
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many problems and issues will be competing for the attention of public officials, who will also have their own preferred ideas to promote. Agenda-building is thus a competitive process (Anderson, 2011). Nurses, who are at the coal-face, see the gaps in the healthcare system first-hand, and know where improvements are needed most, could have solutions for dealing with these challenges (ICN, 2015). Their participation at this stage is crucial for their contribution in advocating for health policy change (Harper and Vlasich, 2016).
2.3.2.2 Policy formulation
This refers to the stage of generation of options about what to do about a public problem.
Once an issue has entered the government agenda, policy-makers are expected to decide on a course of action to follow in addressing it. At this stage, the options of resolving an issue are identified, refined, appraised and formalised. Dialogues are entered into to facilitate communication between policy actors with different perspectives on the issue and potential solutions. Presenters are given a forum to debate the proposed policy options.
The dialogue is more structured, with experts being invited to speak for or against potential solutions. Proposals are drafted, which can take the form of draft legislation or regulations.
These may also identify a framework for a subsequent round of public and private policy actors’ deliberations, in order to negotiate a more specific plan of action (Anderson, 2011).
Different policy actors participate in separate aspects of policy formulation and policy design. It is imperative for nurse leaders to be engaged, so that they ensure that appropriate healthcare policies are developed. Their participation could also limit implementation difficulties, as they would have been part of the implementation plan.
According to Huber (2015), the appropriate people need to be represented at policy- decision levels to facilitate planning, implementation and monitoring, as well as to build new partnerships in order to achieve the United Nations’ new Sustainable Development Goals (SDGs) by 2030. A key component in the policy development process is an assessment of how a policy is likely to work in practice. According to the WHO (2005), policies are products of the political context within which they are developed. It is therefore useful for nurses to understand policy formulation as a social and political process. Nurse leaders are in a position to provide adequate, valuable and policy-relevant information for the policy formulation stage, as they perform their duties on a daily basis at grassroots level.
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2.3.2.3 Adoption
This is the stage when the policy is endorsed or brought into force. New or changed public policies are often adopted by means of a ruling of the cabinet, or indeed of an individual minister, without any legislative change (World Health Organization 2005).
2.3.2.4 Policy implementation
Implementation is an iterative process in which ideas, communicated as policy, are transformed into behaviour, which is expressed as social action. The aim of the social action derived from the policy is public betterment. It is most frequently manifested as programmes, procedures, regulations or practices. Input, perceptions, and the voices of different stakeholders at different tiers are thus an important part of policy implementation (Mugwagwa et al, 2015). According to the WHO (2011), a health-related policy and its implementation is complex. The flow is from health-related policy formulation to health- related policy and programme implementation and health outcomes.
The conventional wisdom is that South Africa has good policies, but lacks delivery capability, due to a gap that is always evident between policy development and implementation (de Satgé, 2009). Clay and Shaffer (1984), in de Satgé (2009), observe that policy-makers sometimes avoid responsibility for the policies they make. The authors refer to this dichotomy between policy and implementation as an “escape hatch”. “Policy- makers who see implementation as a disconnected process to policy-making, may blame a poor policy outcome on inadequate political will or lack of sufficient resources in the implementation phase, rather than poor policy-making” (de Satgé, 2009:2).
The distinction between policy development and implementation could be ended by the development of a more interactive policy process. While implementation is largely perceived as an administrative function, policy makers often view policy-making as a political process. However, implementation always makes or changes policy to some extent (de Satgé, 2009). This suggests the importance of participation by implementers as part of the policy development process: “How a policy is to be implemented should be an integral part of the policy design” (Government of United Kingdom, 2001, in (de Satgé, 2009:9).
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2.3.2.4.1 Theoretical frameworks for implementation
There are three major theoretical models of policy implementation, namely:
The top-down approach: According to Buse et al (2012), this approach considers policy formation and policy implementation as divergent activities. Policies are developed at higher levels in a political process. They are then cascaded to lower levels, which are held responsible for the technical, managerial and administrative tasks of putting policy into practice. Since this approach adopts the perspective of those in higher levels of government only, the role of other actors is neglected in the process.
The bottom-up approach: This approach recognises the active role that is likely to be played by individuals at operational levels. The way a policy is implemented could then be changed by using discretion to review the objectives. The bottom-up approach sees policy implementation as a cooperative process involving policy-makers, implementers from various levels of government and other actors. In evaluating the impact of a policy, it becomes difficult to separate the influence of individuals and different levels of government on policy decisions and consequences (Buse et al., 2012).
Principal–agent theory: Another way of understanding policy implementation beyond the top-down and the bottom-up approaches is through the principal–agent theory, mainly developed by political scientists and sociologists. In this approach, a relationship exists between the principals (those who define policy) and agents (those who implement policy).
This relationship may include contracts or agreements that enable the principal to stipulate what is provided and check that this has been accomplished. The complexity of the relationship is influenced by the context or circumstances surrounding the problem. For example, the political and economic climate or technological change (Buse et al, 2012).
2.3.2.4.2 Implementation guidelines
Preparation for implementation should occur throughout the policy development process.
If the guidelines are based on evidence that is known to health professionals, linked with performance indicators and implementation strategies, they can lead to an improved quality of care and health outcomes. Guidelines can contribute to cost-containment, and when used in auditing at a local level, they can improve quality assurance. The guideline development process needs to be integrated at all levels of the health system, from national policy through to public health programmes. This process needs to include hospital and primary care implementation, financing, auditing and health professional
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education, with all professional groups accepting and applying the principles and practice of the approach. The health outcomes of a country could be improved through evidence- informed policy and guideline development (Young and Quinn, 2014).
The process of guideline development requires time, energy and resources. This process is crucial to ensuring universal ownership by health professionals who will provide support to effective implementation and improved quality of care. If a policy direction links guideline development to improved health outcomes, the process needs embedding in the system at all levels, from national policy through to public health programmes, hospital and primary care implementation (Garner et al, 2015).
2.3.2.5 Evaluation
This is the final stage in the policy-making process. It includes monitoring, analysis, reviews and consideration of existing or proposed policies. A policy should be evaluated independently for some time (months or years), depending on the magnitude of changes it brings about after it has been implemented, in order to measure the success of policy outputs and programme outcomes, identify surfacing issues and problems, provide feedback and aid improvement or corrective action. Reviews are decided upon at the time or during the policy development stage to accommodate progress and developments (Young and Quinn, 2014). At this stage, the policy has already been implemented. The nurse leaders are continuously faced with the ripple effects of implementation, as well as those of the policy itself. Therefore, their unique position not only enables them to identify limitations and constraints in policy, but also to initiate effective procedures to rectify them.
The nurse leaders could use this window to enter and advocate for an evaluation of the outcomes of the policy.