Dynamics of Policy Change: Lessons from Health Financing Reform in South Africa and Zambia. Major Applied Research 1, Technical Paper No. 3

摘要

This report provides an analysis of the process of health care financing reform in South Africa and Zambia during the 1990s. It is based on detailed investigations of experiences from the time of political transition in each country (1991 in Zambia and 1994 in South Africa) until 1999. The health care financing policies examined include the development and application of resource allocation formulae and a range of resource mobilisation reforms. In some respects these reforms promoted equity and system sustainability. For example, in both countries public sector budgets were reallocated in ways that promoted equity (and, in Zambia, allocative efficiency). The negative impacts included reversals over time in the South African geographical equity gains and reduced health care utilisation levels in Zambia. Important gaps in policy action were also identified in both countries. The critical factor underlying these experiences was found to be the processes of decision making surrounding the policy changes, which were bound by context and yet strongly shaped by key political and technical actors. The particular interests and concerns of these actors, and their corresponding responses to the design details of the reforms, explain the positions they took on the reforms of focus. In addition, their relative power largely explains their ability to block or mobilise support for policy change, although this was sometimes mediated by the particular strategies of policy development and implementation employed in decision making. Reflection on the varying factors explaining the pattern and impacts of policy change in the two countries generated 10 principles that could be used in any country to strengthen processes of decision making surrounding health care financing issues.