National Strategies in Times of Crises: The Opportunity Cost of Failed Ones & The Aspiration For Real Change

By now it seems all too familiar to see articles starting with the phrase “Lebanon is going through an unprecedented crisis …” However, to most Lebanese, that’s old news by now. Rather, the focus of the “remaining ones” has been shifting towards investing time, efforts, and resources for driving meaningful change, each in his field. Although this seems pointless for many (based on the harsh political reality we are living), pushing against the tide has remained the choice of several; each trying to “light a corner of the dark”.

Being a healthcare professional, and living in Lebanon throughout the crisis, I have actively participated in, and thoroughly witnessed numerous public health initiatives. I have to say that although it is undeniable that the minister of health made some notable strides in leading several minor, yet crucial, reforms, the broader and more comprehensive reform attempts, needing a wider political support, struggled (and are still struggling). Particularly, several “National Policies” were launched, often led by experts in the field, with significant coverage from the media. However, these policies never translated to reality.

As a lifetime learner, I've cultivated the practice of scrutinizing comparable endeavors and extracting insights. As a result, I've distilled two principal ideas about this subject. Firstly, the crucial role politics (in its broadest sense) play in driving the policy agenda and shaping the policies, and secondly, the fact that healthcare professionals, who are frequently relied upon to formulate national strategies, lack substantial expertise in understanding, harnessing, and incorporating the political aspect in their work, falling short on the use of applied political analysis for health policy.

However, why is this a significant issue and what can be done to address it?

1-     Health system reforms don't have a one-size-fits-all solution.

Even though some general guidelines can suggest what may cause a health system to flourish or fail, every health system essentially mirrors the values of its society. Factors such as the level of government intervention, which often depends on the public sector's capabilities and the health system's path dependency, are case-specific. Therefore, national strategies, where international institutions may have a significant influence, might originate from experiences in other countries and fail to align with the local one's needs and expectations. Politicians, who are held responsible for the health system reforms, are accountable, not the advisory experts suggesting changes. Hence, to achieve a degree of political acceptance for these strategies, input on feasibility and other considerations becomes crucial.

2-     The 'ideal' reform often collides with practical realities.

National strategies are frequently based on specific frameworks and advice primarily from international and inter-governmental bodies, and usually headed by clinical and public health experts. These experts often propose “complete” and “state-of-the-art”, “academic” plans. However, the complex political scenarios, power dynamics, competing incentives, and decentralization of health system governance in developing countries might respond unfavorably to these proposals. In such situations, comprehensive policy reforms are sometimes unfeasible. Applied political analysis and health diplomacy could significantly bridge this gap, making national strategies more context-specific and implementable.

3-     National strategies often lack a concrete action plan

National strategies should be linked to a well-defined implementation plan, where the “rubber meets the road”. Such a plan should define clearly the roles and responsibilities for taking forward the projects, allocate the necessary budget, and set clear deadlines. The focus should be on executing, in order to prevent the strategy from becoming “just another piece of paper”, or what I like to call “a dead document”. It is crucial not to waste the resources dedicated to such plans, especially during crisis times. Furthermore, these strategies should be seen as evolving plans, ready for adjustments when faced with hurdles, particularly since health reform is an iterative process.

4-     Health is inherently political

Several factors make health a political issue. Firstly, it consumes a significant portion of public resources. Secondly, it's intrinsically linked to human rights. Finally, public opinion about elected officials' performance is largely shaped by health, influencing their electoral prospects. Therefore, public health should not be seen as a separate discipline but should embrace its political connections. The nature of health reforms within a country often depends on the attitudes of those in power, the political climate, and the presence or absence of a policy window. Key questions include whether the health minister is risk-averse, whether the government prioritizes healthcare, and the capacity of committed politicians to influence others' perspectives.

5- Decentralized Governance & the Legitimacy of National Strategies

It is not uncommon for many Lebanese people to look to the health minister for initiating and enforcing certain reforms. However, the reality is far more complex. The fragmented nature of health system governance, decentralized decision-making, and the diversity of stakeholders involved in implementation complicate the ability to enforce decisions with broad legitimacy unless there is sincere and substantial involvement from all relevant parties. These stakeholders can range from public entities to private ones like private hospitals, physicians, private insurance companies, and pharmaceutical companies, not to forget patients advocacy groups. Therefore, sound decisions should arise from a transparent process that ensures the participation of all significant stakeholders and provides an avenue for contestation. This approach will pave the way for legitimate strategies and policies that can be effectively enforced.

Lastly, the work of Professor Michael Reich and his team greatly influenced my thoughts on this matter. Reading "Getting Health Reform Right" and their development of tools for practical political analysis was a revelation and greatly inspired me on this topic.

Disclaimer: the views expressed in this article are mine and does not necessarily represent the views of my employer.