Pass or fail – ensuring successful transfer of health policy between countries
ID21
2004-03-19
How do health policies spread from one country to the next? Transfer without ownership may make implementation difficult. Researchers from the London School of Hygiene and Tropical Medicine look at the development of international policy on tuberculosis (TB) control over the last two decades.
How do health policies spread from one country to the next? Transfer without ownership may make implementation difficult. Researchers from the London School of Hygiene and Tropical Medicine look at the development of international policy on tuberculosis (TB) control over the last two decades.
Do policy-makers adopt and adapt health policies voluntarily, after learning about experiences in other countries, or do international organisations or donors more often impose policies? The researchers posed these and other questions during interviews with 40 key players in TB policy development. They identified several stages in the history of the policy response:
The emergence of HIV in the early 1980s lead to increasing numbers of TB cases and alarming rises in multi-drug resistant disease in some industrialised country cities. This re-established the recognition of TB as a public health problem in the North.
From the early 1980s researchers tried to develop short courses of treatment (six months) that would be feasible and effective in developing countries. But these studies were slow to be absorbed.
The World Health Organisation (WHO) recommended short-course treatment for developing countries for the first time in July 1990. But the Global TB Programme was still criticised for moving too slowly. In 1993 WHO shifted from a purely technical focus to intensive advocacy, declaring the disease a ‘global emergency’. It also branded a new TB policy – Direct Observation of Treatment, Short-course chemotherapy (DOTS). The marketing of DOTS was hugely successful, in terms of attracting attention and resources for TB.
But this success masks considerable controversies:
* TB control is a vertical approach, but international health policy in the 1970s and 1980s tended to encourage broader approaches, such as integrated primary healthcare.
* WHO were reactive rather than proactive in responding to TB. Studies of cost-effectiveness by the World Bank and the Ad Hoc Commission on Health Research were more influential in setting the agenda.
* The scientific community feared that DOTS would be operationally difficult and that its branding over-simplified a very complex problem. Policy-makers argued that they needed simple messages for their advocacy effort to raise funds for TB.
The chosen acronym for the policy brand (DOTS) created confusion. Many believed that WHO was only promoting directly-observed therapy (DOT) – a controversial approach. By 2000, however,
Global TB Programme members were denying that DOT was ever the primary focus of DOTS and claimed that they used the catchy acronym to sell the policy to donors and policy-makers.
The Global TB Programme effectively exploited a key opportunity to come up with a branded solution to TB control. The researchers conclude that policy transfer in this case was facilitated by:
* handover of advocacy roles from the academic or medical community to policy entrepreneurs
* branding and marketing, with a media campaign exploiting external focusing events
* simplification of policy to sell the concepts to politicians.
However, they also point out that this approach carries inherent risks. Successful branding does not always lead to successful policy implementation. Over-simplified policies, while useful for fund-raising, can become rigid blueprints, thus undermining locally appropriate adaptation. And when these policies emerge despite significant disagreement between stakeholders, it is not clear that the best approaches for public health win the day.
(Source: Jessica Ogden, Gill Walt and Louisiana Lush , id21 Research Highlight: 3 March 2004
Reference:
‘The politics of ‘branding’ in policy transfer: the case of DOTS for tuberculosis control’, in Social Science and Medicine 57: 179-188, by J. Ogden, G. Walt and L. Lush, 2003
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