Using Public Policy for Social Change - Part 4

Policy Justification Framework: Understanding the Gostin Framework

The five-step Gostin framework provides a structured approach to evaluating public health policies. It focuses on problem identification, effectiveness, cost-benefit analysis, impact on rights and interests, and equity.

The Five Steps of the Gostin Framework:

1. Problem identification: Clearly defining the public health issue the policy aims to address.
2. Effectiveness: Evaluating whether the policy is likely to achieve its intended goals.
3. Cost-benefit analysis: Weighing the economic costs of the policy against its potential benefits.
4. Impact on rights and interests: Assessing the policy's implications for individual rights, freedoms, and burdens.
5. Equity: Examining how the policy affects different groups within the population and whether it distributes benefits and burdens fairly.

By systematically considering these factors, policymakers can make more informed decisions about public health interventions.

Step 1 The policy addresses a significant risk related to the problem, based on objective science (is there a problem?)

Step 2 Intervention effectiveness by showing a reasonable fit between means and ends (will it work?)

Step 3 Economic costs are reasonable when compared with probable benefits (is it worth the costs?)

Step 4 Human rights burdens are reasonable when compared with probable benefits (benefits outweigh burdens)

Step 5 Benefits, costs, and burdens from policy and its implementation are fairly distributed (benefits and costs/burdens are fairly borne by different policy target groups)

Is this policy justified? Do you support it?

The Gostin Framework is not limited to public health policy. While it was initially developed with a focus on public health issues, its core principles of problem identification, effectiveness, cost-benefit analysis, impact on rights and interests, and equity are applicable to a wide range of policy areas.

The framework's versatility stems from its focus on a systematic and comprehensive evaluation process. By applying these principles, policymakers can assess the merits and potential drawbacks of policies in sectors such as:

• Economics: taxation, trade, industrial regulations
• Environment: climate change mitigation, pollution control, resource management
• Social policy: education, housing, welfare programs
• Technology: artificial intelligence, cybersecurity, digital privacy

Essentially, any policy that impacts individuals, society, or the environment can benefit from the structured approach offered by the Gostin Framework.

The Gostin framework is designed to be applied to a single, specific policy because the details of policy matter. It doesn’t work when applied to a general or vague set of policies. For example, the framework doesn’t work when applied to something vague like education policy to address learning loss during COVID. It does not work when applied to a general policy area or a set of related policies (like immigration reform, gun control, or obesity prevention policy) because these broad areas encompass a variety of different strategies. So pick one clear, very specific policy to analyze with this framework.

The key questions that the framework helps to answer include:

1.How should public policy professionals approach designing and justifying policies that intrude upon markets and or the interests of individuals. 

2.How should public policy professionals go about making claims about what constitutes good versus bad? Public policy or policy you can support or you oppose.

This structured approach allows for a comprehensive evaluation of the policy from various angles, ensuring that all relevant aspects are considered systematically and methodically.

The framework helps you to take a moment to think systematically and methodically about the policy from multiple different angles and perspectives. The framework includes steps such as:

1. Problem Identification: Ensuring that the policy addresses a significant risk related to the problem, based on objective science.
2. Intervention Effectiveness: Evaluating whether the policy's means (integration and standardization of data) are effective in achieving its ends (improved data quality and accessibility).
3. Economic Costs: Assessing whether the economic costs of implementing the policy are reasonable compared to its probable benefits.
4. Human Rights Burdens: Ensuring that the human rights burdens associated with the policy are reasonable compared to its probable benefits.
5. Fair Distribution: Evaluating whether the benefits, costs, and burdens from the policy and its implementation are fairly distributed among different policy target groups.

The framework helps public policy professionals approach designing and justifying policies that intrude upon markets and the interests of individuals by systematically evaluating the policy's impact and implications. Here’s how the framework can be applied:

Step 1: The policy addresses a significant risk related to the problem, based on objective science (is there a problem?)

• Problem Identification: Public policy professionals must identify a significant risk or problem that the policy aims to address. This could be market failures, externalities, or other issues that affect the interests of individuals.
• Objective Science: The problem must be grounded in objective science and evidence. For example, a policy to regulate the market to prevent monopolies should be based on data showing the negative impacts of monopolies on competition and consumer welfare.

Step 2: Intervention effectiveness by showing a reasonable fit between means and ends (will it work?)

• Means: The policy must have clear and effective means to address the problem. For instance, a policy to regulate the market might involve setting clear guidelines, monitoring compliance, and enforcing penalties for non-compliance.
• Ends: The policy should aim to achieve specific, measurable, and achievable ends. For example, reducing market concentration, increasing competition, and improving consumer welfare.
• Reasonable Fit: The means should be designed to achieve the ends effectively. A policy that aims to reduce market concentration through mergers and acquisitions regulations should have mechanisms in place to monitor and enforce these regulations.

Step 3: Economic costs are reasonable when compared with probable benefits (is it worth the costs?)

• Economic Costs: The policy must consider the economic costs of implementation, including any potential negative impacts on businesses or consumers.
• Probable Benefits: The benefits of the policy should outweigh the costs. For example, a policy to regulate the market to prevent monopolies might require significant investment in regulatory bodies and enforcement mechanisms, but the benefits of increased competition and consumer welfare should justify these costs.

Step 4: Human rights burdens are reasonable when compared with probable benefits (benefits outweigh burdens)

• Human Rights Burdens: The policy must consider any potential human rights burdens, such as restrictions on individual freedoms or privacy concerns.
• Probable Benefits: The benefits of the policy should outweigh any human rights burdens. For example, a policy to regulate data privacy might impose some restrictions on businesses, but these should be justified by the benefits of protecting individual privacy.

Step 5: Benefits, costs, and burdens from policy and its implementation are fairly distributed (benefits and costs/burdens are fairly borne by different policy target groups)

• Benefit Distribution: The benefits of the policy should be distributed fairly among different stakeholders. For example, a policy to regulate the market to prevent monopolies should benefit consumers and small businesses.
• Cost Distribution: The costs of the policy should be distributed fairly among different stakeholders. For example, the costs of implementing and enforcing regulations might be borne by businesses, but these costs should be proportionate to the benefits gained.
• Burden Distribution: The burdens of the policy should be distributed fairly among different stakeholders. For example, the burden of compliance with regulations should not disproportionately affect small businesses or individuals.

Conclusion

The framework helps public policy professionals design and justify policies that intrude upon markets and the interests of individuals by ensuring that:

1. The policy addresses a significant problem based on objective science.
2. The intervention is effective in achieving its ends.
3. The economic costs are reasonable compared to the probable benefits.
4. The human rights burdens are reasonable compared to the probable benefits.
5. The benefits, costs, and burdens are fairly distributed among different policy target groups.

This systematic approach ensures that policies are designed with careful consideration of their impact and implications, thereby helping to justify their implementation.

Example Applications:

For instance, if a policy aims to regulate the market to prevent monopolies, the framework would help evaluate:

1. Problem Identification: Is there a significant risk of market concentration that affects consumer welfare?
2. Intervention Effectiveness: Will the regulation effectively reduce market concentration and increase competition?
3. Economic Costs: Are the costs of implementing and enforcing the regulation reasonable compared to the probable benefits?
4. Human Rights Burdens: Are any human rights burdens associated with the regulation reasonable compared to the probable benefits?
5. Fair Distribution: Are the benefits, costs, and burdens of the regulation fairly distributed among different stakeholders?

By answering these questions systematically, public policy professionals can make informed decisions about whether to support or oppose the policy.

Another single clear policy in Indonesia related to finance is the "Financial Services Sector Master Plan 2021-2025" (MPSJKI) issued by the Otoritas Jasa Keuangan (OJK). This policy aims to enhance the resilience and competitiveness of Indonesia's financial services sector. It outlines future policy directions and strategies to achieve these goals, including improving the regulatory environment, enhancing financial inclusion, and promoting sustainable finance.

Key Features of the Financial Services Sector Master Plan 2021-2025:

1. Regulatory Environment: Streamlining regulations to improve the ease of doing business and attract foreign investment.
2. Financial Inclusion: Increasing access to financial services for underserved populations through digital financial innovations.
3. Sustainable Finance: Promoting sustainable finance practices aligned with the United Nations' Sustainable Development Goals (SDGs).
4. Risk Management: Enhancing risk management frameworks to ensure financial stability.
5. Capacity Building: Improving the capacity of financial institutions and regulatory bodies to implement these policies effectively.

Steps to Apply the Policy Justification Framework to the Financial Services Sector Master Plan:

1. Problem Identification: The policy addresses the problem of inadequate financial inclusion and regulatory complexity in the financial sector.
2. Intervention Effectiveness: The policy's means (regulatory reforms, digital innovations, and capacity building) are designed to achieve the ends (enhanced financial inclusion and regulatory efficiency).
3. Economic Costs: The costs of implementing these reforms are reasonable compared to the probable benefits of improved financial stability and increased access to financial services.
4. Human Rights Burdens: The policy respects human rights by ensuring access to financial services, which is essential for economic empowerment.
5. Fair Distribution: The benefits of improved financial inclusion and regulatory efficiency are fairly distributed among different stakeholders, including consumers and financial institutions.

Conclusion

The Financial Services Sector Master Plan 2021-2025 is a clear policy that addresses significant risks related to financial inclusion and regulatory complexity, has a reasonable fit between means and ends, is economically reasonable, respects human rights, and distributes benefits and costs fairly. This policy serves as a model for other countries to follow in enhancing their financial sectors.

There is a single clear policy relating to public health in Indonesia. The "Health Law No. 17 of 2023" is a comprehensive policy that addresses various aspects of the health system in Indonesia. This law was enacted following the Indonesian Health Transformation Plan and encompasses six key pillars: primary health care, referral health care, health resilience, health financing, human resources, and health technology. The law merges and amends 13 existing health-related laws into a single 458-article law, aiming to formalize commitments and goals, establish the fundamental aspects of the health system architecture, and facilitate multisector cooperation to achieve health system goals.

Key Features of the Health Law No. 17 of 2023:

1. Transformation of Primary and Referral Health Care: Enhancing the quality and accessibility of primary and referral health care services.
2. Health Resilience: Strengthening the health system to respond to emerging health threats and crises.
3. Health Financing: Improving the financing mechanisms for health services, including insurance coverage and financial protection for vulnerable populations.
4. Human Resources: Ensuring adequate and skilled human resources in the health sector.
5. Health Technology: Promoting the use of technology to enhance health service delivery and management.

Steps to Apply the Policy Justification Framework to the Health Law No. 17 of 2023:

1. Problem Identification: The law addresses significant problems in the Indonesian health system, including disparities in healthcare access and workforce distribution.
2. Intervention Effectiveness: The law's provisions are designed to achieve the transformation of the health system, improve health resilience, and enhance human resources.
3. Economic Costs: The costs of implementing the law are reasonable compared to the probable benefits of improved health outcomes and system efficiency.
4. Human Rights Burdens: The law respects human rights by ensuring access to essential health services and protecting vulnerable populations.
5. Fair Distribution: The benefits of improved health services and system efficiency are fairly distributed among different stakeholders, including citizens and healthcare providers.

Conclusion

The Health Law No. 17 of 2023 is a clear policy that addresses significant risks related to the health system, has a reasonable fit between means and ends, is economically reasonable, respects human rights, and distributes benefits and costs fairly. This policy serves as a model for other countries to follow in enhancing their public health systems.

Another policy, The specific policy being analyzed is the "One Data Indonesia" policy. This policy aims to integrate and standardize data across different government agencies and levels, ensuring that the data is accurate, up-to-date, integrated, accountable, accessible, and shareable. The policy was introduced through Presidential Regulation No. 39 of 2019 and is part of Indonesia's efforts to enhance transparency and accountability in governance.

Key Features of the One Data Indonesia Policy:

1. Data Integration: Harmonizing data obtained by each ministry and agency to ensure consistency and accuracy.
2. Data Governance: Establishing a regulatory framework for data management, including data standards, metadata, and interoperability.
3. Data Security: Ensuring the security of data to prevent misuse and unauthorized access.
4. Public Access: Making data accessible to the public to promote transparency and accountability.
5. Implementation: The policy involves the preparation of local action plans at the sub-national level, involving civil society organizations and regional governments.

Steps to Apply the Policy Justification Framework to the One Data Indonesia Policy:

1. Problem Identification: The policy addresses the problem of fragmented and inconsistent data across government agencies, which hinders effective governance and development programs.
2. Intervention Effectiveness: The policy aims to achieve effective data integration and governance, which is essential for targeted policy-making and public participation.
3. Economic Costs: The costs of implementing the policy include investments in digital infrastructure and training personnel, which are reasonable compared to the benefits of improved data management.
4. Human Rights Burdens: The policy respects human rights by ensuring access to information and protecting privacy through robust data security measures.
5. Fair Distribution: The benefits of improved data management and governance are distributed fairly among different stakeholders, including citizens and government agencies.

Conclusion

The One Data Indonesia policy is a clear and comprehensive initiative that addresses significant risks related to data fragmentation, has a reasonable fit between means and ends, is economically reasonable, respects human rights, and distributes benefits and costs fairly. This policy supports open government values, enhances transparency and accountability, and aligns with Indonesia's Medium-Term National Development Plan (RPJMN) and Sustainable Development Goals (SDGs).

Last but not least, JKN (Jaminan Kesehatan Nasional) is a clear single policy aimed at achieving universal health coverage in Indonesia. It is managed by the Social Security Administering Body for Health (BPJS-K) and is designed to provide comprehensive health insurance coverage to the majority of the population. The policy includes a wide range of health services such as curative care, prescribed medicines, accommodation for inpatient care, and ambulance services, while excluding services like cosmetics, accidents caused by hobbies, and traditional medicines. JKN has been instrumental in reducing out-of-pocket payments and increasing the utilization of healthcare services, particularly among the poor and vulnerable populations

Policy Justification Framework: Steps

Step 1: The policy addresses a significant risk related to the problem, based on objective science (is there a problem?)

Problem Identification:

• Healthcare Access: Indonesia's healthcare system faced significant challenges in providing universal access to healthcare, particularly for the poor and vulnerable.
• Healthcare Quality: The quality of healthcare services was inconsistent, with a high reliance on hospital care rather than primary healthcare.
• Financial Sustainability: The JKN scheme incurred increasing deficits each year, posing a financial sustainability risk.

Step 2: Intervention effectiveness by showing a reasonable fit between means and ends (will it work?)

Policy Intervention:

• Universal Health Coverage: JKN aims to provide universal health insurance coverage, ensuring that the majority of the population has access to healthcare.
• Primary Healthcare Strengthening: Strategies include increasing capitation rates, reallocating patients more equitably, and implementing performance-based measures to enhance primary healthcare utilization.
• Deficit Management: Annual deficit funding projections and robust financial planning are implemented to manage future deficits.

Step 3: Economic costs are reasonable when compared with probable benefits (is it worth the costs?)

Economic Analysis:

• Costs: Implementing and maintaining JKN involves significant financial investments, including annual deficit funding.
• Benefits: The benefits include improved healthcare access, reduced out-of-pocket expenses for the population, and enhanced health outcomes.
• Cost-Benefit Analysis: The economic costs are reasonable when compared to the probable benefits of improved health outcomes and increased access to healthcare.

Step 4: Human rights burdens are reasonable when compared with probable benefits (benefits outweigh burdens)

Human Rights Consideration:

• Health as a Right: Ensuring universal access to healthcare is a fundamental human right, and JKN's implementation aligns with this principle.
• Burden Distribution: The benefits of JKN are distributed fairly across the population, with a focus on the most vulnerable groups.

Step 5: Benefits, costs, and burdens from policy and its implementation are fairly distributed (benefits and costs/burdens are fairly borne by different policy target groups)

Distribution of Benefits and Costs:

• Population Coverage: JKN covers approximately 83% of the population, ensuring that the benefits of improved healthcare access are widely distributed.
• Financial Burden: The financial burden of implementing and maintaining JKN is shared among the government, healthcare providers, and the insured population.
• Fair Distribution: The policy ensures that the costs and benefits are fairly distributed among different policy target groups, including the poor and vulnerable.

Conclusion

The JKN policy addresses significant risks in Indonesia's healthcare system, including limited access to healthcare, inconsistent quality, and financial sustainability issues. The intervention is effective in strengthening primary healthcare, managing deficits, and ensuring universal coverage. The economic costs are reasonable compared to the benefits of improved health outcomes and increased access. The policy respects human rights by ensuring access to healthcare as a fundamental right and distributes the costs and benefits fairly among the population.

Summary of Rationale

The JKN policy is justified and supported based on a comprehensive analysis using the Gostin framework. Firstly, the policy addresses significant risks in Indonesia’s healthcare system, including limited access to healthcare, inconsistent quality, and financial sustainability issues. Secondly, the intervention is effective in strengthening primary healthcare, managing deficits, and ensuring universal coverage. Thirdly, the economic costs are reasonable when compared to the probable benefits of improved health outcomes and increased access to healthcare. Fourthly, the policy respects human rights by ensuring access to healthcare as a fundamental right and distributes the costs and benefits fairly among the population. Lastly, the benefits, costs, and burdens are fairly distributed among different policy target groups, including the poor and vulnerable. These points collectively demonstrate that the JKN policy is a well-justified and effective intervention aimed at improving Indonesia’s healthcare system, thereby enhancing the well-being of its citizens.

Is JKN justified? Do you support it? From a public health perspective, JKN is a step in the right direction towards achieving universal health coverage and improving population health. However, the program requires ongoing evaluation and improvement to address its challenges and ensure that the benefits outweigh the burdens.

Some factors to consider when forming opinion about JKN:

Factors supporting JKN:

• Increased access to healthcare: JKN has the potential to expand healthcare coverage to a significant portion of the population, reducing disparities.
• Financial protection: It can protect individuals from catastrophic healthcare costs.
• Potential for improved health outcomes: With increased access to care, preventive services, and treatment, overall population health can improve.

Factors opposing JKN:

• Financial sustainability: JKN faces challenges in maintaining financial viability due to rising healthcare costs.
• Quality of care: Ensuring consistent and high-quality care for all beneficiaries is a complex issue.
• Administrative burden: The program involves significant administrative complexities.

Ultimately, whether or not to support JKN is a complex decision that depends on individual values and priorities. It's essential to weigh the potential benefits against the challenges and consider the long-term implications of the policy.

Overall, while JKN has potential, its success depends on effective implementation, adequate funding, and continuous monitoring of its impact.

The ability to consider multiple perspectives, including policy framing, effectiveness, economic efficiency, ethics, and fairness, is essential for crafting sound and equitable policies.

By incorporating these elements into the decision-making process, policymakers can:

• Enhance policy clarity and coherence: A well-framed policy is more likely to resonate with the public and garner support.
• Optimize resource allocation: Considering economic efficiency helps maximize the benefits of a policy while minimizing costs.
• Ensure ethical considerations: Upholding values of fairness and justice is crucial for public trust and legitimacy.

In essence, the Gostin framework offers a robust approach to policy analysis that can help you move beyond reactionary responses and develop well-supported positions. The Gostin framework is an excellent tool for conducting a comprehensive and structured analysis for to a single, specific policy. By applying its principles to justify, oppose, or support a policy, you can arrive at a clear, well-reasoned position.

Source: cousera