Yogesh Rajkotia, PhD

Founder & CEO

ThinkWell

Disclaimer: The views expressed in this paper/presentation are the views of the
author and do not necessarily reflect the views or policies of the Asian Development
Bank (ADB), or its Board of Governors, or the governments they represent. ADB does
not guarantee the accuracy of the data included in this paper and accepts no
responsibility for any consequence of their use. Terminology used may not
necessarily be consistent with ADB official terms.

HPV Vaccination Adoption Status

Disease burden
of cervical cancer
(annually)

Public
spending on
health
(%GDP)

Political/religious
orientation

Immunization
systems
capacity (DTP3
coverage)

Adopted
HPV?

Cases: 2,258
Deaths: 1,076

2.0%

Islamic state

99%

No

Bangladesh Cases: 11,956

Deaths: 6,582

0.8%

Secular government,
Muslim majority

95%

Pilot in
progress

Indonesia

Cases: 20,928
Deaths: 9,498

1.1%

Secular government,
Muslim majority

78%

Demo
requested

Jordan

Cases: 50
Deaths: 19

5.2%

Islamic state

98%

No

Thailand

Cases: 8,184
Deaths: 4,513

5.6%

Buddhist majority

99%

No

Morocco

What influences decision-making?

Political Factors
Refers to the interaction of stakeholders with a material interest in a particular policy issue, who can affect the
direction of that policy through power and influence.

Institutional/Organizational Factors
Refers to overall health systems capacity. This includes knowledge, skills, and incentives within the system.

Socio-Cultural Factors
Refer to the values, ideas, customs and social norms of a society that influence the upraising of certain policy
reforms

Structural Factors
Refer to countries intrinsic characteristics: fiscal space, population needs, policy environment, and legal
frameworks. Explicit priority setting tools such as HTA and resource allocation formulas.
Source: Rajkotia et al. 2016 Bottlenecks to achieving UHC

Benefits package adoption: Key

defining factors
Political
Ghana
Rwanda
Indonesia
JKN
Korea
Thailand
Columbia
USA
Scale
Strong

Medium

Low

None

Institutional

Socio-cultural

Structural

The role of culture & values in UHC expansion

Country

Jordan

# of
institutional
interviews
21

Prevailing themes

Lebanon

19

Morocco

20

National solidarity and Islamic values drive support for UHC

expansion
Nationalistic values related to refugees holds back
systematic implementation of UHC policy
Sectarian preferences complicate harmonized system for
UHC
Individualist ideology also plays a role in slowing down the
process on UHC
Refugee problem further complicates harmonized
coverage
Access to health services is a constitutional and religious
value
Solidarity among Moroccans a core value supporting UHC
Out-of-pocket payments or gifts acceptable by patients
Institutional & structural factors halting progress

At what stage do the factors matter?

Fly

Walk

Crawl

Political and sociocultural factors dominate

to form policy
Offer concessions to

keep wide range of

constituents aligned

Strong political pressure to

prove policy reform was
worth it
Juggling need to keep
everyone happy with

imperative for sustainable

program
Firefighting unintended
consequences
Initial thinking on making
program more sustainable

Policy accepted as
mainstream, here-
to-stay
Emphasis shifts
towards

population need
and economic
sustainability
Implementation of
formal systems
such as HTA and
budget impact
analysis

Checks & Balances

Stable system less

vulnerable to
political winds
Long-term thinking
preferred over
short-term gains
Structural and
institutional
factors prevail,
thus greater
emphasis on data
and analytics

Institutional Capacity

Run

Key takeaways
As health systems practitioners, we must think expansively, beyond
technical issues. Policy development is an art not a science
Burgeoning of health technology assessment is a very positive
development: but it is one of many factors to consider
National intrinsic values and culture cannot be discounted, despite
our technical urges to focus on rational prioritization
Policy is politics. Keeping constituents happy, regardless of whether
the investment is cost-effective, will feature
Context is essential: strategy to influence must take into account
stage of development