The World Health Organization (“WHO”) states that “health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people.”
Implementation is the process of translating a policy into action(s) to achieve the goals and objectives of the policy. Getting the policy implementation right is vital as failure can lead to waste, frustration, anger and disruption to the intended beneficiaries of the policy.
There are numerous examples of policy failures of governments globally with evidence of failures to implement cost-effective health interventions in both high-income and low-income countries.
Models Of Policy Implementation
It is common for gaps between what was planned and what actually occurs as a result of policy implementation. According to Buse et al, there are three models of policy implementation i.e. top-down approach, bottoms-up approach and principal-agent theory (Making Health Policy. Understanding Public Health Series Open University Press. 2005).
Policy formulation and execution are distinct activities in the top-down approach. Policies are established at high levels politically and communicated to subordinate levels charged with the task of putting policy into action.
The conditions that have to be in place for the top-down approach for effective policy implementation include clearly defined, logical objectives; adequate actions that would lead to desired outcomes; implementation designed for compliance by implementers; committed officials; support from implementers; adequate time and resources; and good co-ordination and communication.
The problems with this approach include the likelihood that all pre-conditions are not present; it adopts the perspective of those in government and neglects the role of implementers; it overestimates the impact of the government action and policies may change during implementation.
The bottoms-up approach recognises that implementers at subordinate levels have an active role in implementation and may reshape policies and its implementation. Implementation is perceived as an interactive process that involves policy makers and implementers at all levels.
The policy may change during implementation. The problems with this approach are that evaluation becomes problematic and difficulty in separating the influence of implementers on policy decisions which impacts on bureaucratic accountability.
In the principal-agent theory, there is a relationship between those who define policy (“principal”) and those who implement (“agent”) which may include agreement(s) or contract(s) that the principal specific on what is to be provided and confirmation on achievement. The relationship and the agent’s discretion are affected by the nature of the policy problem; the context of the problem; and the organisation needed to implement the policy.
The Institute for Government carried out an in-depth study of case studies in areas of social justice. Their report “Doing them justice” identified lessons for how policies can have the best chance of delivery. Their recommendations were:
• “Be clear about the problem: High-level policy goals need to be matched with analysis of what problem government is trying to tackle and used to make good judgements on where to focus attention.
• Work with the wider system: Policies are never implemented onto a blank canvas; they must compete for resources and attention with other national policies and local priorities – and can draw upon some of the assets that often already exist.
• Stay close to implementers: Bringing others into policymaking is important, but once implementation begins central government also needs to keep strong links with where change is happening to understand how policies are working in the real world.
• Stay focused: Continuity is an essential ingredient of effective implementation. All of our case studies involved implementing over a period of many years and these long time-spans introduce significant risk to achieving policy goals.
• Use ministers to drive progress: While politics can add many complications to implementation, ministers play a crucial role in setting milestones and using regular stocktakes to keep up momentum.”
Readers can decide for themselves the applicability of the above recommendations to mySalam and Peka B40, both of which were top-down approaches.
Peka B40 And mySalam
The mySalam and Peka B40 schemes were launched at the beginning of 2019.
The objectives of mySalam were to provide B40 individuals aged between 18 and 55 years and their spouses, who are also recipients of Bantuan Sara Hidup (BSH) 2019, with free takaful health protection for 36 critical illnesses diagnosed on or after 1 January 2019. The administrator of the scheme is Great Eastern Takaful Bhd, a commercial insurance company, which contributed RM2 billion for takaful protection to the recipients for a 5-year period.
The objectives of Peka B40 were screening for non-communicable diseases (“NCD”), health aid, incentive for completing cancer treatment and transport incentive. NCD screening was to be done by general practitioners and the Health Ministry’s Klinik Kesihatan. The other benefits would only be available to those treated in the Health Ministry’s hospitals. Treatment for NCD was to be provided at Klinik Kesihatan. Peka B40 started with an allocation of RM100 million and was expected to be able to benefit 800,000 recipients in 2019. Applicants had to apply online.
The uptake of Peka B40 and mySalam have been unimpressive, considering that it is free.
It was reported that the Health Minister stated on 26 October 2019: “According to the latest data, we have carried out health screening of 130,000 individuals aged 50, including spouses.”
It was reported that mySalam had paid out about RM3 million as at 30 September 2019, which is paltry compared to the RM2 billion five-year funding.
There have been complaints in the media about both mySalam and Peka B40.
Complaints about mySalam included complex application procedures including bureaucracy; and exclusions from coverage because of marital status, or pre-existing medical conditions.
Complaints about Peka B40 included lengthy screening, unawareness of providers about processes; tedious, unclear processes, no feedback and inappropriate compensation for comprehensive screening with a multi-page report.
The governmental response was extension of coverage of mySalam and Peka B40 in the recently announced Budget 2020.
But will it solve the policy implementation gap?
The factors involved in mySalam and Peka B40 are:
- Content — Lack of clarity about the nature of the change and how the proposed new services fitted with existing and related services in Klinik Kesihatan, Health Ministry hospitals and general practitioner clinics.
- Context — Poor fit with local organisational priorities and organisational structures at Klinik Kesihatan, Health Ministry hospitals and general practitioner clinics; Lack of direct and indirect resources to support the change in Klinik Kesihatan, Health Ministry hospitals and general practitioner clinics.
- Process — Divergent views about responsibility for this aspect of care e.g. General practitioners screen only with treatment at Klinik Kesihatan; Interaction gaps between policymakers and implementers; Voluminous manual for implementers; B40’s access to internet; Process that is not user friendly and/or inconvenient for potential beneficiaries.
These factors do not just impact as single factors, but also act in combination and impact on each other in complex ways.
A crucial question is whether patients are at the heart of Peka B40 and mySalam.
There is an urgent need for policymakers to review and tailor their strategies to foster a genuine partnership with the implementers. This can only come about with close consultation with the implementers.
A “take it or leave it” attitude will not do. In short, policymakers have to change their approach.
Unless and until this happens, it is likely that both mySalam and PekaB40 will not achieve its targets. It will also lead to dissatisfaction and worse still, anger among potential beneficiaries.
Dr Milton Lum is a past President of the Federation of Private Medical Practitioners Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organization the writer is associated with.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.