Comparing public bureaucracies: problems of theory and method

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However, these differences, when the varied public and private organizational worlds are adequately segmented, will be seen not to be absolute except in the purely archetypal organisation of the public and the private. In short, these differences are located on a continuum rather than being abrupt and clearly divided. We shall then attempt to synthesize the epistemological and methodological foundations of public administration as a scientific discipline, essentially with the objective of understanding the scientific framework or paradigm in which this text is located.

The central contribution of the article is what we term the contextual model of public leadership, which is an attempt to contribute some mediating variables which permit the selection of theories of public leadership in such a way that they are sensitive to the public dimension and, at the same time, sufficiently adapted to the different contexts and levels of responsibility of public managers. Finally, we shall use this model to analyze proposals and theories of public leadership which are currently widely followed, to be able to demonstrate how it enriches the undeniable contributions of these theories.

Briefly, the text aims to contribute understanding and analytical capacity to studies of public leadership, in the hope that they will continue to empirically test some of their proposals and thereby contribute a more solid and useful theoretical framework to studies of change or modernisation in Public Administrations.

We believe an improved theory will permit a better interpretation of reality and thereby help to rediscover the importance and characteristics of public leadership. Increased information regarding leaderships of excellence will subsequently permit improved training upon the basis of successful experiences. Finally, improved training in public management will produce better managers who will contribute decisively to constructing a more democratic, effective and integrated administration. Public leadership: The state of the art. The literature on leadership is abundant in management, not so far in public management Van Wart, Yet quantity does not always mean quality, and certainly does not ensure usefulness for public managers.

Moreover, poor literature on leadership generates even more problems than it solves by leading naive public managers to follow seemingly sensible rules, which actually lead them to the edge of disaster. But the problem is that even excellent management texts can mislead public managers. As a consequence, the idea that leadership can be generally spoken of in the public sector, and be targeted at any public in that sector is, in our view, erroneous.

And what seems even more erroneous is the notion that one can write about leadership without making distinctions between the public and private sectors. When addressed to all types of audiences alike, texts with the necessary rigor and with enough of an empirical basis may uncover flanks where it becomes possible and even necessary to disqualify them. Usually, the explanations of change and continuity in the public sector have been organized around two kinds of theories: Systemic and institutional.

Governmental changes were the consequence of systemic changes, i. Or the special characteristics of the changes and the troublesome continuity of some inefficient public administrations should be understood using different institutional theories: Historical, organizational, sociological, etc. Peters, As a consequence, leadership has been fairly often neglected as a source of explanation of change in the public sector. The reason behind this omission is the idea that bureaucracies are guided by powerful forces beyond the control of administrative leaders.

For example, in the research on New Public Management it is difficult to find the "leadership factor" as an explanation of success or failure. There are exceptions i. Barzelay, but they are few. In this text we defend that leadership in the public sector is very important to explain change and continuity.

Even more, we agree with the idea that "leadership from public managers is necessary because without leadership public organizations will never mobilize themselves to accomplish their mandated purposes" Behn, , p. But public leadership should be understood in the context of the political system, not only with the conceptual and cognitive frame of management. The thousands of books and articles on leadership can be organized in six theories according to Van Wart : 1.

Great man ; this theory emphasized the idea of leadership as a special character or some mixture of qualities only possessed by extremely talented individuals, whose decisions are sometimes capable of radically changing the path of history Galton, These ideas, applied to political leaders, have been defended by very important philosophers Berlin, ; Ortega y Gasset, Trait ; this theory emphasized the importance of individual traits physical, motivational, personality and skills.

It is very similar to the previous theory but influenced by scientific methodologies -see, for example, later than the original works of this theory, McClelland and his theory of intrinsic "power motivation", which is very influential on the competency approach to human resources management, or the research by Zaccaro and his idea that leadership traits are "relatively coherent and integrated patterns of personal characteristics, reflecting a range of individual differences, that foster consistent leadership effectiveness across a variety of group and organizational situations" , p.

Contingency ; these theories emphasized the situational variables leaders must deal with, criticizing the idea of a universal set of traits associated with effective leadership. They look for effective leadership behavior. In order to find it, for example, researchers at Ohio State University administered questionnaires to thousands of employees to identify successful styles of behavior.

They identified two broad categories of leadership behavior: consideration or concern for the welfare of subordinates and initiating structure concern for the accomplishment of goals. Later, this theory was refined in different ways, such as the contingency theory Fiedler, ; Vroom and Yetton, ; Hersey and Blanchard, And more recently, research on leadership behavior has identified a third category of behavior Lindell and Rosenqvist, : Development oriented behavior concern for experimentation, innovation and organizational change , behavior which is connected with the next theory we are going to summarize.

Transformational ; this theory emphasizes the idea that leaders should have a compelling vision and must create change in the organization Bennis and Nanus, ; Kotter, , Bass, Some of the authors, however, defend a new charismatic leadership with behaviors such as Javidan and Waldman, , pp. These leaders should also have personal attributes such as self-confidence, eloquence, high energy and determination and desire for change and risk taking.

Other transformational followers emphasize cultural change as the key to effective leadership Peters and Waterman, Servant , this theory emphasizes the ethical responsibilities to followers affective leadership: Newman et al. Multifaceted or holistic ; this theory emphasizes the importance of integrating the major schools, especially the transactional trait and behavior and transformational schools, and the need of looking for cross-fertilization among them Bass, According to Van Wart , p. Administration leadership is the process of providing the results required by authorized processes in an efficient, effective and legal manner endorsed by those who defend a strict political accountability, such as Terry, , ; or Moe and Gilmour, , among others ; 2.

Administrative leadership is the process of aligning the organization with its environment, especially the necessary macro-level changes necessary, and realigning the culture as appropriate endorsed by those who defend entrepreneurial leadership such as Behn, , or Kotter, , among others ; 4. The key element of administrative leadership is its service focus or its ethical mission endorsed by those who defend ethical leadership such as Cooper and Wright, ; Ricucci, , and Frederickson, , among others ; 5.

Administrative leadership is a composite of providing technical performance, internal direction to followers, external organization direction - all with a public service orientation. We consider this last definition very close to our own idea, but it is true that it eschews the tough decision about defining the proper emphasis or focus that leaders must make.

In this paper we shall attempt to create a model for defining emphasis considering two kinds of variables: The need of legitimation and the level of institutionalization of the organization where the leader must work. In this article we follow the ideas set by Stone when he concluded that the complexity and variations in positions and public organizations produced "limitless permutations and combinations" in public leadership , p.

Later Terry has criticized the lack of consideration of normative issues in the leadership literature when applied directly to the public administration. For example, the blithe defense of the neo-managerial approach in public leadership can be very harmful from the perspective of democratic accountability Terry, ; Moe, ; Reich, Some others contend Javidan and Waldman, ; Dobell, that the assumption of certain ideas from the charismatic school of leadership is not very well suited for certain public environments i.

Although we tend to agree with these ideas it is important to consider the variation in positions and the differences among public organizations in order to have a more accurate vision of public leadership. The need for a more comprehensive model comes also from our experience as professors in dozens of courses for managers in the public sector in Spain and especially from the more than interviews conducted with these managers along more than ten years [3].

Many times we have explained the theory of contingency and its variants, but managers from organizations where outputs and outcomes are hard to measure have nearly always asked us the same thing, "How can I know the true degree of maturity of the employees who report to me, except in the most outstanding cases, if I am unable to establish a minimally reliable evaluation performance system?

The answer is not simple in their organizations, which Wilson identified as "coping organizations" , p. Many executive managers also ask how this theory helps to manage the political environment in which they must interact, for instance, with members of Parliament or the press. The answer could be to remind them that other leadership theorists have made interesting contributions of the analysis of power, which when added to contingency theory can set a fairly solid groundwork.

We have therefore explained to them how to define the scope of political power, what their own potential sources of power are, and how to use them Pfeffer, Once we have put this forward, we are usually asked whether that means anything goes, as long as one reaches or stays in power, or whether there are any moral constraints although the ends may be legitimate on government activity.

This leads us to remind them of the significance of normative theory as a framework for action for both the government and for public administration. Then the question we get is how to make "realism" in managing power compatible with the "idealism" of normative theory. In short, things get very messy if we chose only one theory as the way for effective leadership.

The option for a holistic approach is the best way, but it has the problem of context and position, that is: When to give priority to one theory or other considering the context of the organization or the responsibility of the manager? This is why we feel that if one wants to build a leadership theory that is useful for public managers and elected officials, much more emphasis should be placed on critical detail, and more work should be done on the differences between organizations and levels of responsibility, rather than on trying to generate universally applicable theories.

We expand on this theme in the following pages. First, it is important to clarify the distinction between public and private leadership in order to understand whether what is written about business leadership does apply to the public sector, and whether it makes sense to write about public management. Then, one must examine how one can build the "science" of public management, and how one can use that science to develop a science of leadership.

It also becomes necessary to clarify whether what is written for a President or Head of State is also useful to a member of a Senior Executive Service, to a "middle manager" to a mayor, or the reverse. We should also ask ourselves if the theories which work in a public company could work in a ministry or in the army. In short, we will attempt to clarify some concepts and define variables that allow one to properly apply different theories.

Public and private management: A controversy revisited. In order to determine what is to be managed in the public sector, we must first answer the question as to whether or not there is any difference between managing public and private organizations. We can begin by asking what the literature has to say in this regard. Traditional organization theory puts no emphasis at all on this difference. Neither Weber nor Taylor, nor McGregor were concerned with bringing out these differences.

In one of his later papers, Simon asserts that public, private and non-governmental organizations are equivalent in their critical dimensions. Research, in this field, shows, for instance, that the main factor affecting the behavior of bureaucrats is not whether the organization is publicly or privately owned, but rather size Rainey, Some authors bring out the fact that several public organizations are structured like companies: Public companies, semi-autonomous agencies, public business enterprises and the like, obtaining income from providing their services Musolf y Seidman, Others have brought out the public side of third sector organizations or the special relationship with the public sector that private sector companies working almost exclusively for the public sector as contractors have Bozeman, There are people in public and private enterprise that do essentially the same thing Mitnick, or, to put it differently, public and private management are similar in every unimportant matter Allison, Moreover, management of a host of services occurs due to the interconnection of public, private and non-governmental organizations Kettl, Although only certain public organizations can approve rules binding for all, it is equally true that without the support of NGOs and even private enterprise, in many cases, the policies or programs approved in legislation could not be implemented Rainey, There are even public organizations and administrations that act so much in their own interest, or that of lobbies , that they are not at all different from private enterprises Banfield, A continuum from private enterprise to ministries exists as Dahl and Lindblom have stated A continuum see Table 1 which includes:.

We must therefore acknowledge that the problem of ownership and control has no simple solution, although recent research stresses the differences even in the management of health services, between public and private hospitals Chubb and Moe, Based on this research Scott and Meyer, ; Rainey et al. Along these lines, Subirats , cites fourteen similar differences that should be considered also in a continuum.

But another consequence of this theory of levels of "publicness" is that we have to agree with certain authors who defended the similarities between public and private organizations. Of course, there are similarities, especially between NGOs, public enterprises, certain agencies and private companies highly regulated, and, obviously, there are more similarities in the "how to achieve ends" than in the "what are the ends".

Developing a public management science. If there are differences between public and private management, then there is reason to believe there can be independent scientific approaches with characteristics of their own. Thus, according to Bozeman , the origins of public management can be traced from different perspectives.

On the one hand is the so-called P-approach stemming from the public policy schools.

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Then there is the B-approach, with its origins in business schools. Here, the distinction between public and private becomes blurry and the focus tends to be on the management process, i. What the two have in common is a concern that goes beyond the mere internal administration of agencies, a respect for the role of policy in management, a prescriptive orientation, and an affinity for learning through experience. In a nutshell, the public management's objective is to generate a theory to give managers an indication of how to act in different environments and situations and to identify and teach the skills needed to satisfactorily put this theory into practice Perry and Kraemer, ; Perry, In this context, the leadership literature must give thought to whom it is addressing in each individual case and examine the teaching that may be useful accordingly, instead of succumbing to the tendency to put all managers in the same frame of reference.

One of the greatest concerns of both teachers and researchers of this approach is that of generating useful and directly applicable information. This raises a significant control issue since people easily abuse the knowledge of experienced managers and succumbs to profit and a lack of rigor Lynn, Knowledge in the public management literature is not always methodologically scientific, but rather a great portion is theoretical, homespun, descriptive, and personal, comprising a body of what can be called "wise" literature Bozeman, This literature is different from common sense or ordinary knowledge of public administration and is based on personal experience, stereotypes and institutionalized knowledge.

It is based on a synthesis of studies or on systematically conveyed personal experience, validated by the scientific community itself and supervised for publication by those who revise scientific literature. Allison , Bozeman and Straussman , and Benn and Gaus are some excellent examples of this so-called "wise" literature.

Finally, there is the type of scientific knowledge that tends to arise from following up on the typical process of theory generation. Hypotheses that can be disproved are put forward, analytical tools are developed to explain them, there is an aspiration for them to be generalized, it is assumed that they can be significantly aggregated in the analysis process, a degree of separation is established between facts and values, and it is assumed that progress of the theory can be demonstrated.

This is literature that seeks to generate theory. In the view of Bozeman , both sources of knowledge are useful in public management. The problem is how to integrate them. Wise and scientific literature cannot be lumped into the same category since this would take us back to the s and those famous proverbs of administration identified by critics. Thus far, research in public management has been characterized by a series of traits Kettl, , which, to a large extent, arose as the immediate precursors of the public management approach: 1 there has been a conscious rejection of research on implementation and bureaucracy, whereas the methodological bias has been on research on the strategic approach of business schools; 2 in the face of research pessimism regarding implementation, this approach has offered an optimistic, results-oriented image; 3 high level government executives and their strategy- generating roles have served as an analysis units for research; 4 knowledge has been developed through case studies.

Four types of problems have been detected in this research strategy Kettl, First, while the tendency to focus on high-ranking executives simplifies things since one can work on similarities, it impoverishes the results. Second, not enough research has been done on types of public management that differ from traditional ministerial or agency service providers.

There is a lack of knowledge, for instance, on sub-contracted public services. Third, there is not enough knowledge on different management models according to governmental grades or areas. Fourth, knowledge is lacking on management in the middle levels of the public administration. We feel that these assertions also apply for anyone having studied the literature on leadership in the public sector. Thus, there is a lack of attention paid to middle management, advice is mixed for different levels of government executives, and there is not enough understanding of indirect management and what it represents.

Generally speaking, the methods that have been used in public management research are social science methods Perry and Kraemer, Management research has been based on varied strategies Behn, Both in private and public management, experimental design has been very hard to implement. Hawthorne experiments show that even with everything working in favor of an innovation, what was proven was exactly the contrary of what was intended Mayo, Exercising total control is virtually impossible in the public sector.

Quasi-experimental models have been more common.

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  7. Surveys have not helped much to generate knowledge, particularly when managers do not know their own work very well Mintzberg, , cited by Behn, Research based on managers' systematic exposure to their work manager-philosopher research , including highly influential examples such as Barnard , entail validity problems. Gedanke or great thinkers' research, based on logic rather than empirical research, and based on general knowledge and highly potent rationality, such as the research that gave rise to some of the most prestigious works by Weber, Simon and Lindblom, is only within the reach of the most illustrious minds.

    Research based on observation and interviews , such as the famous research done by Mintzberg on the work of executive management , raises the issue of selection, since one can choose what works and reject what does not, thereby missing out on significant information. Case studies not only intend to bring out facts, but also find the underlying principles explaining why a combination of specific activities, interacting with specific circumstances, lead to given results, and to describe these principles so that they can be applied in other situations.

    Kaufman's research on the U. Forest Service stands as an example. Other research strategies with a more interpretational approach have been developed. A very interesting current of research is what is known as "action learning" Morgan, , p. It is based on the desire to recount, through the use of metaphors that help understand reality, interventions that can produce "generalizable keys" and that are also pertinent to better understand the intervention process as well as the essential dynamics, options and problems that have been tackled.

    A different, more descriptive yet very interesting strategy aims to generate meaning through stories that organizations tell themselves Maynard-Moody and Kelly, Findings based on the analysis of these stories, based on building the entire process of generating meaning, are highly relevant both scientifically and in terms of theory Bellavita, In the final analysis, some people believe that in all public management is, particularly on a strategic level, as in political action, "art", intuition and improvisation, which no one can teach Dror, Yet from the public management standpoint, the path to take is that of discovering theories, rules, and heuristics to help managers Lynn, Although the building of leadership theories has used the different methodologies that have been put forward, one very common mistake is to overlook the fact that each theory generated pools from several specific sources for validation while forgetting other sources that probably make the theories useless under different circumstances.

    A contextual model of public leadership. Within a democratic system, administrative positions are closely bound to legitimacy, both of origin and exercise. A lack of such legitimacy would challenge the access and sustenance of power. Furthermore, to hold an administrative position is linked to a variety of special duties and limited domains. In the political theory there exist two concepts, such as auctoritas and potestas , which help to understand this fact. Auctoritas implies that those who hold power have to be legitimized by means of their capacity to meet citizens' expectations.

    That is to say, to be able to develop a legitimate political discourse, to make the right choices in strategy and to achieve results. However, potestas is more related to the power source, has to do with the space and time in which is possible to exercise power in accordance with the constitutional or legal framework.

    When analysing public leadership the ontological dimensions of space and time of rule should not be neglected. From an etymological perspective, rex King and regnum Kingdom have both of them an Indo-European origin which refer themselves to the capacity to define the limits of the civitas or space where power is exercised Marramao, Otherwise, the exercise of public leadership is done within spatial and temporal borders and, by all means, those borders are defined through a variety of implicit and explicit mandates which frame the mission, tasks, and responsibilities of those who hold managerial positions in an organisation.

    Power and freedom are concepts unavoidably linked each other. All real power is related to free individuals who voluntarily accept to obey. If so, such obedience is connected to the dimension of autoritas which explains the reasons to obey, but potestas , or the space and temporal framework in which the exercise of power takes place, is also to be included. It is not the same to be mayor in a city than to be the chief of the municipal register and it is not the same the President or the Prime Minister of a national government than a member of the senior executive service. They have different responsibilities and different potestas , they have different origin in their positions and different need of auctoritas.

    These two variables permit us to better understand public leadership. In the dimension potestas we could integrate two sub-variables: One is organizational and the other is individual. The first sub-variable is the level of "publicness" or "institutionalization" of the organization where the manager works.

    We think that the organization as the unit of analysis is critical in leadership Cook, , p. Different methods tend to illuminate different aspects of a process, and each method can be used as a check on the results obtained by other methods. To understand interdependencies in humans and the environment, it is best to promote methodological interdependence. The point can be illustrated by the historical case study of the causes of CFC use in Chapter 3. The case study identified causal connections not often noticed between the development of CFCs and fossil energy demand, operating over half a century.

    These are represented schematically in Figure These connections would have not been revealed by a more standard analysis based only on the study of data on CFC use, regardless of the method used. But once revealed, the connections raise new questions best addressed by other methods. For example, the CFC case underlines the value of more detailed quantitative analysis of relationships between the spatial dispersion of an affluent population and demand for CFCs and fossil energy.

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    This sort of dialogue of methods is likely to lead to a more complete picture of the human causes of global change than a collection of unrelated discipline-based or method-centered studies. The most likely way to bring the results of different methods into contact is probably through research communities united by a common set of problems.

    Therefore, we emphasize the need to build an interdisciplinary, multimethod research community for the study of the human dimensions of global change. We discuss elements of the creation of such a community in Chapter 7. The model presented in Figure emphasizes that human systems respond to global environmental changes as a function of the way those changes affect things people value. Accordingly, the applied social science of global change focuses on assessing those effects and evaluating each available response option in terms of their direct and indirect effects on what people value.

    It is obviously difficult to make the necessary assessments and evaluations. Nevertheless, social scientists have developed techniques aimed at assessing the social effects of environmental change and of policy interventions and at placing values on effects of very different kinds, which are not readily measurable on a common scale. A set of methods, known collectively as social impact assessment SIA methodology, has been developed that could be adapted to the problem of assessing the effects of global change and the policies enacted to respond to it Finsterbusch et al.

    SIA developed out of the impact assessment provisions of the National Environmental Policy Act NEPA ; it uses some of the methods typical of technology assessment and risk assessment, but it is more focused on the effects on human systems than those activities sometimes are. The experience with SIA illuminates several important issues involved in formally assessing the consequences of global change. The goal of SIA is to predict the social effects of policies, programs, and especially projects that cause change in the physical and biotic environment and to use these predictions as an aid to decision making and public debate.

    Thus, SIAs have strong parallels to the kinds of analysis necessary for assessing the proximal effects of global environmental change on things humans value. Formal Modeling Approaches A dominant approach in the early days of SIA was to develop and apply computer simulation models for impact assessment Dietz and Dunning, ; Leistritz and Murdock, The typical model began with predictions of the labor required for the construction and operation of a project such as a prison or nuclear power plant.

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    4. The model then estimated the demand for secondary jobs, the extent to which the demand could be met locally, the subsequent in-migration, and finally the demand for government services and stresses on the local governmental budget. These models have several advantages for SIAs.

      They are based on seemingly hard and objective numbers—such as the relationship between primary and secondary jobs—that in principle can be evaluated theoretically and can be tested with empirical evidence. They produce quantitative forecasts of the types of impacts that were expected to be of great importance.

      And they can be applied quickly and easily to alternative versions of the same proposed project or to other projects with the input of a modest amount of situation-specific information. Because of these characteristics, a number of these models saw widespread use, and some are still applied today. Unfortunately, these models have several important flaws that have led to their declining importance in SIA practice.

      First, the ability of the models to make accurate predictions is very limited. Despite the use of such models for 20 years, there have been very few attempts at model validation by comparing projections with actual experience. The evidence suggests that key parameters that are assumed in the models to be constant over time, such as the ratio of secondary to primary jobs, are in fact highly variable over time and space and are quite likely to change drastically under the influence of large scale projects such as those simulated Meidinger and Schnaiberg, Thus, these models often have at their core postulated relationships that do not match social reality.

      For the practical purposes of these models, the lack of predictive validity is a serious flaw. These models handled only the impacts that could be represented with fairly simple quantification methods, such as input-output analysis or standard population projection techniques.

      As it turned out, among the most controversial impacts of large resource development projects was the prospect that they would disrupt community life, resulting in mental health problems, adverse effects on youth and the elderly, and so on. Although concern with such issues produced enough opposition in some cases to slow or block entirely the construction of large projects, these impacts were ignored in the simulation models.

      The analytical resources used for simulation had been focused on the wrong targets in terms of the political choices at hand. Finally, the projections of such models often acquire the status of facts. Modelers are usually sensitive to the conditional character of projections and the need to use them heuristically. But in practice, a few runs of the model can become fixed in the minds of those debating a proposed project, program, or policy, with other important issues pushed aside.

      People who do not find the models addressing the issues of most concern to them become skeptical of the entire analytic approach, with the result that scientific analysis becomes a lightning rod for debate rather than a way to clarify the issues. Formal models applied to the consequences of global environmental change may have analogous uses and problems. The demand for social impact assessments of the anthropogenic effects of global warming is already large and will certainly grow.

      In response to this demand, we expect to see many well-intentioned efforts to use simulation models. Such models usually take the output of physical and biological process models that are relatively well developed compared with social process models and use them to drive simple economic and demographic models.

      These simulations have great appeal because they are easy to develop from existing models of component systems and because they produce seemingly hard results. However, they have at least two serious limitations, in addition to the inherent difficulty of assessing the sorts of consequences SIAs often leave out.

      One problem is that SIA methods were developed to assess local impacts of environmental changes and human interventions, but much of the need is for global assessments. SIA methods, taking into account the limitations already mentioned, are appropriate for assessing the local social consequences of, for instance, a change in rainfall or an energy conservation incentive policy. But they have not been built to assess the global impacts of the.

      The other problem is that SIAs, which take considerable effort and expense, especially if used to assess global effects, are likely to distract attention from more important analytical and modeling questions, including fundamental questions about interactions between environmental systems and human responses. A lesson of the last two decades of SIA that might also become a lesson of applying SIA methods to global change is that simulation models of the sort described here have limited utility in advancing scientific knowledge or in aiding serious discourse on policy: their value may be illusory.

      This is not to decry all use of simulation, but to sound a warning about the potential for misuse of applied Simulations for policy purposes. Post Hoc Evaluation Approaches The SIA literature includes empirical studies of the impacts of specific projects, programs, or policies after implementation.

      These studies employ conventional and well-developed social science methods and theory to determine what actually happened in response to public or private action Finsterbusch et al. The largest body of this research addresses the effects of energy development boom towns on the community and its members Freudenburg, Such studies are very important to SIA for several reasons. First, they pointed out the importance of context in determining impacts and provided a useful caution against overgeneralizing or assuming that a specific local or regional future could be forecast with much accuracy.

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      Second, they encouraged the normal working of empirical science by stimulating debate about the theory, methods, and interpretation of past studies and allowed a variety of methods and theories to be applied to the same general problem. For example, the effects of boom town developments on youth have been studied using ethnographic methods, surveys, and statistical analysis of secondary data. New studies benefited from earlier studies, and theory, methods, and results improved. Finally, well-conceived post hoc studies borrowed from and contributed to theory and method both in evaluation research and in the traditional disciplines, often forcing the disciplines to consider problems they had not previously addressed.

      In many cases, the researchers carrying out these empirical efforts worked as part of interdisciplinary teams and learned to develop more integrated. Nevertheless, the achievements of 20 years of empirical work on social impacts have been modest. The work has often been conducted with very limited resources and tight deadlines, with resulting compromises in conceptualization and research design.

      Long-term, post hoc studies, which would be invaluable for improving prediction tools, are especially uncommon. Millions of dollars have been spent on predicting impacts, but comparatively little on measuring the actual impacts. The situation is rather like trying to understand population dynamics and develop sound population projection techniques in the absence of census data to modify the understanding and calibrate the techniques. The problem of limited resources is exacerbated by the marginal linkage of impact studies to the prestigious centers of core disciplines.

      The main streams of most social science disciplines have ignored the effects on society of the physical and biotic environment and of technology. As a result, it has been difficult to obtain support from conventional funding agencies or publication in the most prestigious journals. Many of the post hoc SIA studies have been doctoral dissertations or relatively small efforts funded from intrauniversity sources.

      Publication has often been in interdisciplinary journals that lack the circulation, prestige, and visibility of the disciplinary journals. The lack of funds and of prestige, in turn makes it difficult to attract the best young talent to these studies. Research needs : The experience with post hoc SIA studies offers several useful lessons regarding research on human dimensions of global change. Perhaps the simplest but most important is the value of ongoing studies to monitor the impacts of projects, programs, and policies.

      Although social program evaluation is a sophisticated and well-developed activity, the best methods of evaluation research have rarely been applied to environmental or resource policies or programs. A major exception to this rule is in the area of residential and commercial energy conservation. Post hoc evaluations should be viewed as an important part of the process of analyzing policy alternatives for response to global change, and resources should be provided for them. Even when the expected impacts are too far in the future to be studied directly, empirical methods should be applied to analogous programs or policies.

      As a result, the growth of research capability requires lines of support—financial and intellectual—in contact with but somewhat autonomous from the disciplines. We return to this issue in Chapter 7. For the moment, we note that agencies and foundations that support basic research should play a key role in fostering rigorous, theoretically informed, and methodologically well-designed empirical studies on human consequences of and responses to global change. In addition, mission agencies that usually fund only applied social science research, but that have some basic research programs in the natural sciences, should initiate basic research in the social sciences as well.

      To have practical importance, any assessment of the human consequences of global change, or of responses to it, must be combined with some means of placing values on the consequences. Valuation is a difficult task because consequences can be of very different kinds, so that a metric for making tradeoffs is not obvious.

      Moreover, different people often place different values on the same consequence. In the last 5 to 10 years, the problem of valuation, or commensuration of the various things humans value, has become an important theme in the SIA literature Mitchell and Carson, ; Dietz, The typical impact assessment describes a diverse list of probable impacts, for example, increased jobs, lower energy costs, loss of wildlife habitat, increased cultural diversity in the community, and increased crime and congestion.

      Often, the impact assessment makes no attempt to assign relative value to these impacts, on the assumption that relative values are and should be assigned in the political process, not by the researchers. In this model of decision making, estimates of impacts are used as inputs to the political process, to better inform the inescapable debates between conflicting values and interests.

      Although this approach has dominated most impact assessment, other forms of policy analysis in the social sciences have tried to systematize valuation. The premier technique is benefit-cost analysis BCA. In BCA, impacts are assigned market values, either directly or by imputation. Future impacts are discounted. Then, having assigned a value to all costs and benefits in current dol-. While those who produce BCAs typically caution against taking the final ratio or other measures of efficiency too seriously as decision criteria, the process does provide an explicit framework for valuing otherwise incommensurable impacts.

      It also suggests the appropriate action to be taken from among the options analyzed. Some versions of risk analysis, such as risk-risk and risk-benefit analysis, provide similar structures for making tradeoffs among impacts Dietz et al. There are many strong criticisms of BCA and risk analysis as decision-making tools for environmental policy e.

      These include methodological critiques and deeper political and ethical questions about whether it is appropriate for technical analysts to decide the relative values of outcomes instead of leaving such tradeoffs to the political system. But whatever the difficulties of particular methods and their implementation, they have the advantage of forcing careful and systematic thinking about the appropriate methods for assigning values to impacts and thus making tradeoffs among impacts.

      Recent debates in the SIA literature suggest that much more work needs to be done on the problem of valuation. Several approaches that might serve as complements to BCA, using very different theoretical underpinnings, have been offered Dietz, ; Freeman and Frey, Some of the alternatives rely on assessing people's value preferences by directly eliciting them e. None of the proposed approaches is yet widely accepted, but a dialogue has begun on the subject.

      At the heart of the dialogue is a belief that, while social science methods can never replace the political process in assigning values to impacts and making decisions about the allocations of resources, it is equally naive to believe that social science research cannot inform the valuation process.

      We believe the history of BCA has shown the value and influence of systematic thinking on value issues. Recent work on valuation in SIA is seeking to expand the domain of that thinking. This suggests a simple lesson for research on human dimensions of global change. Although the social sciences cannot resolve the value questions at the heart of individual and collective decision-making about global change, social scientists should offer their best systematic insights into methods for understanding values, value conflicts, and the implications of alternative approaches to individual and collective choice.

      Here the logical. Because of reflexivity, research on global change has the potential to seriously affect human societies. It is therefore important for researchers to be clear about the purposes of their work and to develop a context for it that is not politically naive.

      In This Article

      The problems arise most clearly in the use of formal models in policy analysis, because the connection to social choices is quite direct, but they exist as well with other methods of policy analysis. The last decade has seen increasing attention to the use of models in policy analysis and collective decision making.

      Most of that literature has been sharply critical of the effect of simulation models on the policy process Baumgartner and Midttun, ; Brewer, ; Freedman et al. The problem can be explicated by drawing the distinction between forecasting and projecting. Most modelers would argue that models project rather than predict. If the systems of structural relations incorporated into a model are a reasonable approximation of reality at present and if those structural relations do not change, the model implies that certain events would occur.

      However, as noted above, the structural relations among the elements of social models are quite likely to change in the intermediate and long-terms. Indeed, the goal of policy modeling is to assess the effects of intentional changes in the social world. Since the models by necessity simplify the world and assume to be constant that which is not, their predictions can have only limited validity. The exact simplifications and assumptions made can never be fully validated by scientific knowledge, but always depend to a large degree on the judgment of the modeler, and that judgment reflects a modeler's world view as well as objective fact.

      While the research community understands these limits of all models, in the policy process model results often are abused. The abuse takes two related forms. First, the results of modeling are sometimes interpreted as what will happen—a forecast or prediction rather than a simple projection of the current situation Ascher, ; Brewer, ; Baumgartner and Midttun, Present actions are influenced by a.

      This limits consideration of policy responses to those options that fit within the structure of the model and precludes easy consideration of policies that might make structural alterations Meadows and Robinson, ; Robinson, In this way, the structure of a model can become a determinant of policy, rather than simply a mode of evaluating options. Technical analysis thus drives the policy process Habermas, ; Dietz, Second, the results of a modeling exercise have the aura of scientific objectivity, despite the judgments built into them. A model and its results are sometimes erroneously seen as neutral, and the selection of policy options is consequently justified as a technical activity rather than a political one.

      This perception makes models a powerful tool of advocacy Majone, Decision-making institutions claim to be responding to the forecasts in the only logical way, but in fact, ''forecasts do not reveal the future but justify the subsequent creation of the future'' Robinson, As noted in the discussion of social impact assessment, this way of using models can either limit creativity and debate or provoke skepticism. In the latter case, the models are ignored rather than being used in an informative role. The political process drives or ignores the technical analysis.

      Recently, a number of critics have suggested alternative criteria for modeling that preserve the benefits of modeling without the political problems Dietz, ; Steenbergen, ; Masini, ; Robinson, They argue that modeling should be used to increase the range of scenarios considered in the policy process, so that each scenario can be evaluated in terms of its desirability. This is essentially the approach of normative forecasting—the model is used to work backward from a desirable future into present policy options that could create that future.

      A key element in the approach is the recognition that all models build in assumptions and simplifications. To the greatest extent possible these assumptions and simplifications should be explicit to those using the model and those using information from the model. This approach places the modeling exercise within the policy process and explicitly allows interested parties to argue for their own assumptions about reality and for the inclusion of variables of critical concern to them.

      We are not opposed to the extensive use of modeling in the study of human dimensions of global change.

      What is needed is. Also needed is more clarity about the purpose for using particular models in particular analyses. The challenge of understanding global change provides a valuable opportunity to advance the state of the art in social science modeling. Social models will be most helpful, and best able to link to emerging models in the biological and physical sciences, if they take serious account of the dynamic core of human action and social structure and if they are sensitive to the ways in which models are used in the policy process. Thus we advocate research on the methodology and policy use of models, rather than simply the elaboration of existing models and modeling methods.

      Research on global change is likely to become the object of policy discussions regardless of the method used. Formal models are particularly potent influences in some circles of the policy community, but case studies, surveys, econometric analyses, and experiments can also be oversold as revealing absolute truths. Our own research was, of course, conducted among all health professionals associated with exemption, first and foremost those engaged in clinical work: nurses who are usually the front-line carers , midwives, doctors and surgeons; but we have also focussed our attention on support staff traditional birth attendants, ward assistants, carers, paramedics and managers , as well as supervisory staff district management teams, regional boards and civil servants in the health ministries.

      However, we did not favour a particular entry point nor did we target a specific profession. Naturally, we also interviewed many actors outside the health profession, such as the members of management committees and users. Various projects on public policy are concerned with the relationship between the policies and the inequalities that characterize the societies in which they are implemented, whether from a neo-Marxist perspective [ 46 ] or with a special emphasis on exclusion, inequities and vulnerability [ 47 ].

      How do public policies reproduce or exacerbate social divisions, or, on the contrary, reduce or cushion their effects? The policy of cost recovery in health facilities has been criticized for developing inequalities and excluding the most vulnerable [ 15 , 48 ]. Fee exemptions, whether in relation to specific illnesses whose costs cannot be borne by the poorest tuberculosis, HIV-AIDS or in favour of categories regarded as especially vulnerable pregnant women and children are, of course, at the centre of such questions.

      They immediately become located within 'social' strategies focused on access to healthcare by the poor, in which the challenges of the political economics of targeting come to the fore [ 49 ]. Part of our research has consisted in assessing whether visits to health clinics by vulnerable groups the bottom quintile in the classification of population based on income have been made any easier by free healthcare policies [ 50 ]. Finally, an analysis of the deliberative processes relating to public policies is another approach we have used.

      It includes public debates, discussions by experts, conferences, general assemblies, citizens' juries, media coverage, polls, etc. Boyco et al. We monitored and analysed the national conferences on free healthcare organized in Mali and Niger [ 52 ] and, in tandem with this, read through and analysed all the newspaper articles on the subject in both countries [ 53 ]. In this issue Olivier de Sardan , we describe some difficulties encountered in Mali and Niger with health officials concerning the diffusion of our results. In terms of public policies, the general situation is much the same in Burkina Faso, Mali and Niger, not only in the health sector but in other areas too.

      The same shortfall in tax revenues makes them dependent on development aid between 30 and 50 per cent of national budgets comes from foreign funding. Hence, the main public policies are shaped largely by international institutions and development agencies: as a result, they are very similar from country to country, the transfer of 'one-size-fits-all' and 'blue-print' policies becoming ever more common at the expense of their fitness for complex local realities [ 54 , 55 ]. The structural adjustment programmes of the s seriously weakened public services and administrations; corruption has become widespread and public employees are often demotivated.

      The practical norms and professional cultures [ 56 ] that govern the actual behaviour of employees are far removed from official norms. On the ground, public goods and services are co-delivered by a string of different actors and institutions, with little coordination between them, the co-delivery itself pointing to distinct local forms of governance [ 57 , 58 ].

      The State is widely regarded by the majority of citizens as untrustworthy, thus making populations sceptical about the ability of States to ensure the sustainability of any policy for which funding is not guaranteed by international donors. The capacity of the national health system to reproduce the pilot projects of NGOs concerning free healthcare have likewise met with a great deal of scepticism [ 60 , 61 ] cf. The process of setting up and implementing user fee exemptions in Burkina Faso, Mali and Niger was beset by all the major problems that generally affect public policy-making in these countries.

      Based on our results, they can be summed up as follows:. If anyone needs convincing that health is far from being the only sector in which these conditions prevail, we might take two examples, one from a country featuring in our study, the other from a Central African country. In Niger, decentralization came in , amid pressure from two quarters, externally, from donors, and internally, from the Tuareg rebellion. However, the State has failed to honour practically any of the promises it had made to local government for years. For many years, it has not even passed on to them the taxes raised on their behalf.

      State officials governors, prefects and technical services have sought to use the municipalities to their own advantage, at the same time impeding the delegation of authority. The powers in health matters officially handed down to the municipalities have received neither financial nor technical support, and have therefore remained a dead letter. The Democratic Republic of Congo is an extreme case, but an instructive one. An exemption policy has also been introduced there, but in the education sector, where the payment of school fees by parents had become the chief source of funding, throughout the school hierarchy.

      In contrast to the cost-recovery scheme for health, which was put in place in the s and under which user fees are retained by the health centres and used to buy medicines, pay the wages of a carer and a manager, and help with the running costs , only a small proportion of school fees are used at school level in the Congo, the rest being distributed along an ascending pathway that ends at the ministry itself.

      Under pressure from donors, the government suddenly decided to abolish these school fees without first preparing the ground, setting up the budgeting requirements or informing the teachers and parents. Accordingly, the corresponding practices did not disappear [ 62 ]. Clearly, this is not to claim that public policies are identical throughout Africa, regardless of sectors and countries. Instead, they share a 'family resemblance', in other words certain common or similar structural features, which are typical of an identical 'bureaucratic style of governance' and which no doubt relate to least two important political and institutional variables common to almost all African countries: a a colonial past, which was also the construction stage of a modern state apparatus of a very particular kind, an apparatus that remained in place after independence; b the key role later played by development aid and the rentier setting that it generates [ 63 , 64 ].

      However, beyond this 'family resemblance', public policies take on a different complexion, depending on the domains and the national contexts with which they are connected. Moreover, as we have noted, a number of significant differences exist between the exemption policies pursued in Burkina Faso, Mali and Niger, respectively. Although speeches on global health increasingly refer to health systems [ 65 ], research into health systems was relatively neglected by public health researchers for a long time, especially in French-speaking West Africa, where "The potential usefulness of research explicitly focused on health systems is under-rated" [ 66 ].

      In , a survey of the biggest database in the area of health Medline showed that only 0. For a long time, the main preoccupation was with epidemiological studies on the description of diseases, their distribution in the population and how well their etiology was understood. In Africa, this corresponded with an expansion of vertical programmes for fighting diseases. Until very recently, therefore, an exclusive reliance on statistics and a lack of awareness of qualitative methods were the norm. Whenever health systems were studied, they were not analysed from a holistic perspective; instead, studies tended to concentrate on a specific aspect, such as care delivery or funding.

      Research was focused more on health services than on health systems proper, viewed in their entirety. Anthropologists were called on to study only the so-called 'cultural' aspects of health, and economists to study only the cost-effectiveness of interventions.

      Health systems research started to gain momentum in the early years of the twenty-first century. WHO's annual report for the year is one of the cornerstones of this shift in focus followed by the report on primary healthcare. This report by WHO suggested ranking the world's health systems by performance, placing, for example, the countries covered by our research at the bottom of the table and France at the top. The use of quantitative indicators, which remains the basis for this type of comparative approach [ 67 ], and results in league tables, is often challenged [ 68 ].

      However, WHO also declared that the aims of a health system are to meet a population's expectations the concept of responsiveness and to organize a fair financial contribution hence taking into account people's ability to pay in order to improve the health of the population, although insufficient emphasis was placed on social inequality in health matters in Africa and elsewhere [ 69 ]. Finally, WHO proposed an analytical framework for the strengthening of health systems, built around six essential functions or 'building blocks' , which were initially four and sometimes become eight : 1 health service provision; 2 health personnel; 3 health information; 4 medicines and vaccines; 5 the funding of the health system; and 6 governance and leadership [ 70 ].

      In some countries, this framework has even become a dogma, which does not favour innovative, transverse or systemic analyses [ 71 ]. Various reforms of health systems also rely on this framework.

      Looking for other ways to read this?

      But there is still too little research on the changes that these multiple and endless reforms engender in relation to the overall performance of health systems, and one might be forgiven for thinking that there is a distinct tendency for them to be guided more by ideology than by scientific evidence [ 4 , 72 ]. Today, however, health policy and systems research HSPR is becoming a discipline in its own right and is increasingly tapping into other disciplines the administrative and management sciences, political sciences, anthropology, etc. The first academic organisation dedicated to health systems research Health Systems Global was established in , in the wake of two international conferences organized in Montreux and Beijing , at which our research programme was represented.

      This trend is, of course, part of the bigger picture of the work done by the Alliance for Health Policy and Systems Research over the years. However, two problems with HPSR, which our research attempted to tackle, should be mentioned here:. As a way of structuring this field, but also of increasing its visibility, field-specific journals have appeared in recent years e. BMC Health Services Research , as well as a variety of overview articles [ 73 , 74 ] and a reader presenting a selection of texts on health systems and offering a definition of the field [ 75 ]: "Health policy and systems research is defined as a field that seeks to understand and improve how societies organize themselves in achieving collective health goals and how different actors interact in the policy and implementation processes deployed to contribute to policy outcomes.

      By nature, it is interdisciplinary, a blend of economics, sociology, anthropology, political science, public health and epidemiology that together draw a comprehensive picture of how health systems respond and adapt to health policies, and how health policies can shape - and be shaped by - health systems and the broader determinants of health.

      It is interesting to note that this definition is very broad and links together - fortunately - health policy research see above and health systems research. The majority of these studies attempt to show that researchers need to move beyond traditional paradigm boundaries and marshal other theoretical concepts and approaches for example critical realism [ 76 ] or realist constructivism ' [ 77 ] to gain a better understanding of complexity of health systems and the contexts in which they are implemented, and to exploit the complementarity of quantitative and qualitative methods from a mixed methods perspective.

      In a recent publication, WHO gives every indication of wanting to play an active part in driving forward health systems research [ 78 ]. It also appears, more generally, that actors in this field are particularly concerned about the use of outcomes and about how the gap between researchers and those responsible for health systems reform can be narrowed [ 79 ].

      Our own work in French-speaking Africa belongs to this perspective [ 1 , 80 ]. Although there has been a steady fall in mortality rates over the years in the three countries under consideration, especially as far as children are concerned, quantitative indicators for health remain very unsatisfactory and will not enable the Millennium Development Goals MDG to be attained by cf. Ridde, this issue. This situation reflects a combination of four sets of converging factors. Health centres are still far too few in number problem of geographical accessibility and remain poorly attended by patients; there are not enough skilled staff in rural areas, especially outlying areas; and the health system suffers from a chronic shortage of financial and material resources: the health budget is small and falls well short of international commitments Abuja Declaration , the health centres are under-equipped, and small items of equipment, medicines and inputs are often in short supply.

      The quality of care provided leaves much to be desired: contempt for the anonymous user, the extortion of money from patients, a lack of professional conscience, absenteeism, mismanagement of human resources, numerous shortcomings in managing inputs and stocks. These problems are regularly reported by users [ 23 ] and the press, but NGOs, international institutions and local politicians remain obstinately silent on the matter in the local arena.

      In the absence of any social security or meaningful commitment to the worst-off the official mechanisms for helping the destitute do not work very well, if they work at all , the low standard of living of the vast majority of the population soon transforms any spending on health such as obstetric care into 'catastrophic expenditure' putting the economic viability of households at risk.

      In all three countries, the public health system currently faces growing competition from two very distinctive types of modern private healthcare channels apart from 'traditional' or, more often, 'neo-traditional' healthcare, either in the form of self-treatment or of the services of a variety of specialist 'healers', who are not necessarily any cheaper.

      For most people, both in the countryside and in towns, it is the 'informal pharmacies' ' pharmacies par terre ' , in other words, informal vendors peddlers or market stalls , who supply consumers with the majority of modern medicines. These are usually sold individually, without any kind of quality control and often smuggled into the country [ 81 , 82 ]. In urban areas and among the better-off, private clinics attract the more affluent clients.

      Session 1. Organizational theories

      In response to this situation, reforms of the health systems have become a regular phenomenon in Africa over the last 30 years. These have consisted of the promotion of primary healthcare, cost recovery, community participation a resurgence of which is in evidence today , the establishment of districts and the health pyramid, hospital reform, the creation of mutual insurance companies, user fee exemptions, and, more recently, performance-based financing.

      To these should be added the innumerable and unending sector-based and vertical mini-reforms that constantly modify the organization of work: for example, there has been an explosion of healthcare programmes in the last 15 years in the area of mother-and-child health alone: emergency obstetric and neonatal care, essential newborn care, active management of the third stage of labour, refocused antenatal consultations, prevention of mother-to-child transmission of HIV-AIDS, clinic- and community-based integrated management of childhood illness, key family practices programme, rapid diagnostic tests for malaria, etc.

      All of these mini-reforms are, in reality, mini-public-policies, on various scales. They correspond to what Hardee et al. Indeed, every new public policy is presented as a reform of the policies in place. All of them are aimed at improving the current health system, at making it more effective and more efficient, and at providing a better service. Most of them are designed by experts from the North in the form of standard procedures to be implemented in many African countries.

      And yet, ironically, most of them do not start from a thorough diagnosis of the health system as it really is and actually works: the daily interactions between health workers and the population and the routine functioning of health services, which is often far removed from official norms and organizational charts.

      In other words, most reforms and mini-reforms are based on the fiction that the health system in place in Burkina Faso, Mali and Niger is the official one and that health workers comply routinely to professional rules. The same thing happened in the case of fee exemptions. Sadly, however, the reality is completely different. Users all complain about the way they are treated by health staff, about the corruption that is rife in health centres and about the fact that the care they receive is rushed and of poor quality.

      Low-level staff, who do the bulk of the work, bemoan the lack of equipment and shortages of supplies, the appropriation of bonuses and other benefits by those above them in the hierarchy, absenteeism among doctors, and even wheeling and dealing by some of them. Doctors fail to discipline staff who are found to be at fault, they fail to get midwives posted to outlying areas or to carry out checks on the quality of care, and are even more remiss in monitoring the application of the innumerable micro-reforms. Each of these micro-reforms is usually preceded by a short period of 'training': the health staff who attend are supposed to practise what they have learnt and disseminate it to their work colleagues.

      This rarely happens in reality. Hence, the epidemiological studies and public health analyses undertaken in African countries have various 'blind spots'. In other words, apart from a few exceptions, a number of serious 'problems' in the day-to-day workings of health systems are hardly debated or 'brought out into the open', either because they are not picked up by the usual investigation protocols or because they have become firmly entrenched routines, or even because they challenge vested interests. And yet, many of the failures that bedevil health programmes are attributable precisely to these factors, which generally relate to the 'real practices' of health staff which often diverge from official norms , the ways in which care is actually organized with all their contradictions, inadequacies and inconsistencies , how health policies often inconsistent themselves are implemented on the ground with significant discrepancies between intention and execution, and the use of extensive scope for manoeuvre by frontline workers.

      New field research needs to be done on these 'neglected problems', which concern the actual governance of health systems, the implicit rationales of the actors involved, and the quality real or perceived of healthcare provision. Posting and transfer which are in reality very far removed from official regulations and optimal use of workforce is an example of such "challenges that are all but ignored in the health literature" [ 86 ].

      All these topics only appear in official documents in the form of slogans or instructions, and very rarely as complex issues needing to be documented. However, only finely tuned qualitative investigations are able to capture these neglected problems: these are a necessary complement to the work of a quantitative nature if the intention is to research into health systems in terms of their daily operations on the ground cf.

      It is precisely for this reason that we combined both types of investigation. The first step towards indispensable reforms is to highlight the neglected problems faced by health systems and to document them. The fact is that, unless these problems are diagnosed - and most of the time they are not even mentioned publicly in national and international decision-making circles or in the field of epidemiology and public health - the implementation of health policies will continue to miss their intended targets by a wide margin, with a multitude of unintended and undesirable consequences.

      All authors read and approved the final manuscript. Thanks to Susan Cox for the translation of this article. Olivier de Sardan and V. Mises en forme et mises en oeuvre des politiques d'exemptions de paiements au Sahel by J. Ridde eds , , Karthala, Paris, with the permission of the publisher.

      National Center for Biotechnology Information , U. Published online Nov 6. Author information Article notes Copyright and License information Disclaimer. Corresponding author.

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