The health sector, as an area of policy determination, forms part of a bigger picture, which largely determines the decisions on health issues. The operation of the wide-ranging concepts of free markets, public management practices, and autonomy strongly influence policymaking on health through the intervention of political or socio-economic rationales that do not necessarily jive with the policies that are desirable based on the perspective of the health sector (WHO, 2009a).
In national policymaking on health, the interaction of political agents such as state government representatives, UN representatives, aid donors, development focused financial institutions, military forces, and other parties and the dynamics of these parties determine policymaking on health. In the case of international cooperation, commitments to a cooperative agenda, whether related directly on indirectly to health, would influence policymaking on health at the national level. Donors of foreign aid for allotment to a health problem would also determine national policymaking on health.
(Singh et al. , 2007) Ideally, a strong state in relation to health decision-making is one with a health department or ministry specifically taking charge of the development of policies on health issues, the allocation of resources to support the implementation of policies, and the regulation of progress. However, not all countries have a health ministry or have health departments but without sufficient autonomy to take charge of policymaking based on information derived from its experiences on health problems in the country.
In the case of Africa, many of the countries do not have functioning health departments because of the weakness of the state’s political will to exercise sovereignty. This situation leads to weak policymaking on health and other areas of social welfare. The effect is dependence on foreign aid and lending arrangements indicating policy prioritisation. This implies that health policymaking become internationalised since the decisions on the major areas of health policy are dependent on international influences instead of the national government based on its assessment of the local health context.
(Lanjouw et al. , 1999) Policymaking on health issues are often subject to political bargaining (Tenbensel, 2000). In the case of Angola, the political instability led to the assignment of the position of health minister to a representative of a rebel group as a ways of negotiating the conflict. The weakness of the government was the determinant of the state of health policymaking in Angola. While the member of the rebel group may have a clear understanding of the health issues faced by the citizens of Angola, the limited experience in governance could hamper effective policymaking on health.
In addition, health policies could become tools for political strength. Many political parties and politicians sensationalise health issues and artificially recommend solutions to win a position. (WHO, 2009b) This circumvents the necessary elements of effective policymaking and adversely affects the merit of health policies to the detriment of people requiring health services. While policymaking is in itself complex, policy development in the health sector is much more complex, especially in developing countries.
Factors in the national context determine policymaking on health. However, the weaknesses of the national government and precariousness of the domestic situation gives rise to the strong international influence on health policymaking. (Court & Maxwell, 2005; Young, 2005) In the case of Africa, much of policymaking in the health sector relies on international direction from policy-based aid donors and international bodies, particularly the United Nations through agreements on international cooperation.