Public health policy research: making the case for a political science approach

Health Promotion International, Vol. 26 No. 1 doi:10.1093/heapro/daq079 # The Author (2011). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com DEBATE Public health policy research: making the case for a political science approach NICOLE F. BERNIER * and CAROLE CLAVIER Institut de Recherche en Santé Publique, Université de Montréal, PO Box 6128, Succ. CV, Montreal, QC, Canada H3C 3J7 Chaire Approches communautaires en inégalités de santé, Université de Montréal, PO Box 6128, Succ. CV, Montreal, QC, Canada H3C 3J7 *Corresponding author. E-mail: nf.bernier@umontreal.ca SUMMARY The past few years have seen the emergence of claims that the political determinants of health do not get due consideration and a growing demand for better insights into public policy analysis in the health research field. Several public health and health promotion researchers are calling for better training and a stronger research culture in health policy. The development of these studies tends to be more advanced in health promotion than in other areas of public health research, but researchers are still commonly caught in a naïve, idealistic and narrow view of public policy. This article argues that the political science discipline has developed a specific approach to public policy analysis that can help to open up unexplored levers of influence for public health research and practice and that can contribute to a better understanding of public policy as a determinant of health. It describes and critiques the public health model of policy analysis, analyzes political science s specific approach to public policy analysis, and discusses how the politics of research provides opportunities and barriers to the integration of political science s distinctive contributions to policy analysis in health promotion. Key words: policy and implementation analysis; politics; population health; healthy public policy The past few years have seen the emergence of claims that the political determinants of health do not get due consideration and a growing demand for better insights into public policy analysis in the health research field (Raphael, 2003a; Bambra et al., 2005). This demand is fuelled by an increasing recognition that public policies both inside and outside the health domain have a significant impact on population health and health inequalities (Raphael, 2003b; Marmot and Wilkinson, 2006) and that it is necessary to be aware not only of suitable policy options but also of how politics and policy-making processes can have an impact on their possible implementation (Marmor and Freeman, 2005; Klein and Marmor, 2008 (2006); Navarro, 2008). In addition, it is argued that researchers and professionals who understand the political dimensions of health policy can conduct more realistic research and evaluation, better anticipate opportunities and constraints on governmental action and design more effective policies and programs (Oliver, 2006). In this vein, several public health and health promotion researchers are calling for better training and a stronger research culture in health policy (Walt and Gilson, 1994; Longest, 2004; Smith-Merry et al., 2007; Gilson and Raphaely, 2008; Navarro, 2008). They do this in editorials or articles that underscore the merits of policy 109

110 N. F. Bernier and C. Clavier theories for both analysis and intervention (Tarantola, 2007; Bambra, 2009; Sparks, 2009). In health promotion especially, the past few years have witnessed a growth in the number of policy-related articles (Breton and de Leeuw, 2010) and an increasing number of studies apply political science concepts and theories such as policy entrepreneurs, the social construction of public problems or the Multiple Streams Model (de Leeuw, 1999; Signal, 1998; Rütten et al., 2003; Nathanson, 2005; Mannheimer et al., 2007). For instance, Yeatman (Yeatman, 2003) uses different theories pertaining to the policy process to identify conditions that have shaped the development of food and nutrition policy at the level of local government. Using Sabatier s Advocacy Coalition Framework, Breton et al. (Breton et al., 2008) explain the process leading to the adoption of anti-tobacco policy in Québec (Canada). Generally speaking, however, the bulk of policy analysis in public health research (including health promotion) is largely concerned with measuring and evaluating policy impacts and outcomes and pays little attention to the policymaking process. A systematic review of the recent health promotion literature found that overall, policy-related articles in the field still apply few theoretical insights from political science to study the policy process (Breton and de Leeuw, 2010). Typically, researchers still have a naïve, idealistic and narrow view of public policy that is detrimental to understanding public policy as a determinant of health and to the political efficacy of health promotion. This article is premised on the idea that politically neutral interventions for better public health outcomes are fictitious and that health promotion research is inherently political. In this article, we argue that the political science discipline has developed a specific approach to public policy analysis that can help public health researchers to understand how politics and policy-making influence health and to open up unexplored levers of influence for public health research and practice. In the following sections, it (i) describes and critiques the public health model of policy analysis, (ii) analyzes political science s specific approach to public policy analysis and potential contributions to public health and (iii) discusses how the politics of research provides opportunities and barriers to the integration of political science s distinctive contributions to health policy analysis. Our discussion is based on advanced training and research experience in both political science and in public health research, an extensive literature review focused on the relationships between political science and applied health research, and an informal survey of recent policy studies published in high-impact-factor public health journals. THE PUBLIC HEALTH MODEL OF POLICY ANALYSIS Public health researchers rarely take into account the influence of macro-level changes such as political ideologies and institutions in shaping public policy choices or in selecting the knowledge input in the formulation of public policies (Navarro and Shi, 2001; Bryant, 2002). Public health researchers often examine microlevel public policies such as health in school settings as specific cases and tend to pay little attention to macro-level trends that influence these cases (e.g. the underfunding of public services or privatization of social policies). When public health research does look into public policy, it too often relies on an implicit linear model of policy-making. A linear model assumes the existence of a continuum from research to policy change: authors assume that good data are provided and that good policy decisions should follow accordingly (Tarantola, 2007; Bambra, 2009). In this view, public policies are the end product of a chain of research, evidence and recommendations and are treated as documents that give legal force to public health recommendations. As a consequence, most public health researchers strive to influence public policies through the formulation of recommendations about the course of action that public health authorities should follow. In public health journals, articles that discuss the actions of public health authorities (i.e. public policies) typically do so by identifying policy recommendations based on their research results. It is not uncommon for recommendations to claim the need for stronger regulations with regard to, for example, the use of human cells and tissues, the pricing system for drugs, or the reduction of portion sizes in the fast-food industry. Public health researchers focus largely on the current contents of health policy (Catford, 2006), as opposed to their transformation over

time. Many articles are dedicated to discussing current health legislation choices or to evaluating policy outcomes. In this framework, the main concern for public health researchers is to provide better data about a given policy s health impacts and to make recommendations to improve it. Their main interest lies in measuring a given outcome such as the use of care services across districts, the costeffectiveness of a policy instrument, or indoor air quality before and after a decision is enacted. Viewing public policy as merely a public program or legal document that orients the contents of a government s public health program has real-world implications for public health research, practice and policy. Indeed, public policy is construed as an independent variable that impacts on a given public health issue such as air quality, physical activity or health insurance. Public policy is seen as being external to public health research and the only course of action for public health is to influence the law. Moreover, this linear model of policy-making glosses over major dimensions and implications of policies, in particular the process of actually making or implementing policies. It also views politics that is, the political activity or process of making collective decisions not as the conditions that decision-makers need to deal with, but as interference with good government, defined as efficient or ethical. The linear model of policy-making from research data to policy-making has been the subject of much criticism because it is premised on an inadequate understanding of the policy process and neglects the fact that converting scientific results into programmatic action is a complex social process (Pelto and Freake, 2003). The policy-making process is rarely characterized by rational decisions made on the basis of the best information (Young and Quinn, 2002: 218). Walt argues that expecting a direct connection between scientific results and policy reveals a misunderstanding about the nature of the policy environment. In her view, using a policy analysis approach can help us to understand the process of how research outcomes can infiltrate policy networks (Walt and Gilson, 1994). The perspective is important: if policy-making is linear, then researchers can influence public policy only from the outside ( providing data and leaving change to decision-makers) and Public health policy research 111 only with regard to the decision-making component (modifying proposed programs or legislations). But if policy-making is viewed as a dynamic process involving several actors and constant changes, researchers can become involved in and influence orientations throughout the entire policy-making process. A POLITICAL SCIENCE APPROACH There are several traditions within political science. With few exceptions, the discipline is not primarily concerned with evaluating the effects of current policies, such as health impact assessments; rather it focuses primarily on understanding how public policy-making actually works (Sabatier, 1991). Its distinct approach to studying public policy consists largely in having developed analytical tools and methods to study the policy process (Mead, 1985) [(Gormley, 2007), p. 298, 301]. Public policy and the policy process In political science, while there are many competing textbook definitions of public policy, they all have one common feature: public policy is not simply a piece of legislation or an administrative document. Among classic definitions is Thomas Dye s: Anything a government chooses to do or not to do [(Dye, 1972), p. 2], which specifies that the agent of public policymaking is a public authority, thus dissociating public policy from other kinds of policy such as private business policy. This definition also draws the analyst s attention to action and inaction as part of a policy: a government s decision to do nothing substantial about a given health problem is also public policy. For instance, political scientists view a government s decision to maintain existing spending levels as the demand for health services increases dramatically as an integral part of public policy. William Jenkins states that public policy is a set of interrelated decisions taken by a political actor or group of actors concerning the selection of goals and the means of achieving them (Jenkins, 1978). In contrast to Dye, Jenkins sees public policy not as a choice but as a political process consisting of several connected decisions ( program, legislation). He also considers the instruments (e.g. regulations, taxation, market incentives, social marketing and

112 N. F. Bernier and C. Clavier propaganda) used to implement government decisions as an integral part of public policy. James Anderson s definition brings a problem-solving dimension. He describes public policy as a purposive course of action followed by an actor or a set of actors in dealing with a problem or a matter of concern [(Anderson, 1984), p. 3]. In this light, public policy is not tied to a specific actor (e.g. department, presidency) but involves all the actors and solutions assembled by public authorities (comprising several departments and administrative levels) to deal with a given problem. From a political science perspective, public policy analysis thus includes, but is not limited to examining specific laws, regulations and programs. Rather, public policy analysis embraces the whole set of solutions initiated by public authorities. This detailed attention gives a more realistic image of public policies as well as a richer perspective on the conditions and constraints governing policy-making. This approach can be very useful for public health research. Indeed, it points to elements of the policy process that shape the actions of public authorities in health, whether the ideology of the party in government, budget allocation mechanisms or the rules of public consultation. Besides, all these elements of the policy process correspond to levers of influence for public health research, practice and policy. Let us examine these in greater detail. Levers of influence Applying a political science lens draws attention to the policy environment in which decisionmakers make decisions and to how this environment offers constraints and opportunities to promote the different actors interests and their capacity to influence policy outcomes. Better awareness of the whole policy process implies that the influence one seeks to exert over public policy does not need to be limited to making decisions about the enactment of a given piece of legislation. The sequential approach to public policy, which includes agenda setting and problem definition, formulation, implementation, evaluation and revision, is a useful tool in this respect. Although it is not a description of real-world policy-making, this model highlights the many points of influence on policy orientations. Levers of influence can also be identified through the study of three components of a public policy: determinants, contents and impacts (such as health outcomes, market exclusion and efficiency). Political scientists tend to concentrate on determinants and content [(Pal, 1989), pp. 22 23], which we explore below. Policy determinants Just as public health researchers study the determinants of health, political scientists study the determinants of public policy. The changing constellation of actors, public opinion, media exposure, decision-making behaviour, administrative arrangements, budget allocation mechanisms or the rules of public consultation, pre-existing programs and legislation and political institutions (e.g. the Senate or federalism) all contribute to shaping public policy. All these elements correspond to levers of influence for public health research, practice and policy. Political scientists study how choices and decisions made by policy-makers are the results of complex interactions with various stakeholders constrained by historical, political and social forces and legacies. Nathanson s (Nathanson, 2005) study of policy orientations for tobacco control showed the relevance of policy determinants for public health research. Because of prevailing individualism and distrust of government intervention (macro-level characteristics of the American political system), judicial action against tobacco manufacturers was a preferred course of action in the USA. In contrast, European countries favoured tax-increases, advertising bans and smoking bans because smoking was framed as a responsibility of the State. Nathanson showed what type of health promotion interventions were more likely to succeed and how political cultures and structures as well as militant grassroots antismoking movements shaped national policy orientations. Policy content As mentioned earlier, a political science approach to studying policy content is not focused exclusively on formal public programs or legislations as released by government authorities. It tends to look at policy orientations over a period of time. Policy content includes stated or unstated goals and intentions and the

redefinition of the problem to which the policy is addressed. It also includes the governing instruments (e.g. legislation, administrative programs and by-laws) and delivery mechanisms (e.g. fiscal or profit incentives or disincentives, regulation and budgets). Surprisingly perhaps, the analysis of policy content may extend to actors responsible for policy implementation outside of government whenever they are also part of policy, such as professional associations, non-governmental organizations or private enterprises involved in and relied upon for a public policy s implementation and governance. As an example of policy content analysis, Bernier (2006) studied how public health policy unfolded over a 20-year period in Québec (a Canadian province) taking into account the ensemble of conditions that supported the goal of addressing social inequalities in health over time. Bernier for instance identified several policy documents, the contribution of different policy actors (ministries, health councils, etc.) and administrative structures or instruments supporting Québec s policy (for instance the creation of a Public Health National Institute). Distinctions between issues regarding agenda setting, the role of interest groups, the strategies of political parties with regard to a specific issue, the policy networks or the contents of a policy program make it possible for us to understand how public policies are made and what they are made of. They also enable to identify levers of influence on health policy. For example, identifying two coalitions of actors involved with a specific health problem and their respective stance about the issue is necessary to devising an efficient advocacy strategy. Similarly, understanding how a policy evolves over time even when there is no formal reform, highlights problems that would otherwise remain unnoticed. If, for example, governments fail to adapt public services to population ageing, the quality or accessibility of public services for the elderly will likely diminish and impact this group s health negatively. Also, government documents are not always representative of a government s activities. As Hacker (Hacker, 2004) showed in his study of health reforms in several countries, some governments enact health reforms that lead to no change (reforms without change) while others undertake a series of small but cumulative changes over the years without enacting major legislation (change without Public health policy research 113 reform). Above and beyond considering the passage of a new piece of legislation or the reformulation of a government program, a political science approach typically focuses on the temporal and wider dimensions of public policy to understand the evolving content of a given policy in its social environment. MAKING THE CONNECTION? SOME ISSUES AHEAD Integrating political science into health promotion and public health research requires more than a greater knowledge of political science s approach. It calls for dealing with the politics of research. Making the connection is a highly political issue in itself. The politics of research in both fields have played against such a connection, with both political science and public health seeking scientific objectivity over political engagement. Political science s relationship with decisionmaking and applied research has been tortuous. Following the Second World War, the policy sciences emerged in the USA and in Europe as a subfield of political science and were initially concerned with increasing the rationality of decision-making. However, in the 1960s, government authorities increasingly used political science research to legitimate their decisions while sociologists shattered the myth of rational decision-making. Political scientists then became increasingly concerned with suppressing normative concerns from public policy analysis, advancing the scientific status of their discipline and, especially in Europe, refining abstract conceptualizations of public policy-making (Parsons, 1995; Portis and Levy, 1988; Smith, 2002; Donovan and Larkin, 2006; Hassenteufel, 2008). Economists stepped in the field of action-oriented policy analysis and still wield more influence than political scientists in public debates (Rothman and Poole, 1985; Raphael, 2003b; Farr et al., 2006; Oliver, 2006; Gormley, 2007). This being said, political science is equipped to contribute more to practical politics than has thus far been the case (Donovan and Larkin, 2006), and some authors believe it should take up issues such as abortion, gun control and stem-cell research and provide research outputs that are of value to practitioners (Hardin, 2002; Gormley, 2007; Prewitt, 2009).

114 N. F. Bernier and C. Clavier As far as public health research is concerned, politics is and will remain a very sensitive issue. Tensions will continue to manifest themselves in the output of influential public health journals for the years to come, inasmuch as the politics of research in public health interfere with the development of health policy analysis. The professional values of many scientists hold that politics and science should remain distinct (Rothman and Poole, 1985), and politics tends to remain a forbidden topic for anyone wishing to climb the academic ladder. More importantly, funding from public sources hampers the inclusion of themes related to politics in interdisciplinary public health research teams (Navarro, 2008). As well, there is a profound disagreement among population health researchers and health advocates as to what constitutes appropriate areas for health promotion action and policy activity. Many public health researchers are reluctant to actively engage with policy and politics (Navarro, 2008). However, whether researchers are actively engaged or not, research on issues such as tobacco control, obesity reduction, low birth weights in disadvantaged groups and health inequalities is far from being politically neutral. The recent controversy surrounding the political role of the World Health Organization s Commission on the Social Determinants is but one illustration of the political nature of health promotion research (Green, 2010; Lee, 2010). We agree with authors who claim that the quest for evidence that is so central to epidemiology (the main discipline in public health research) should not prevent action and that public health practitioners should engage socially and politically to promote solutions to public health issues (Catford, 2006; Bambra, 2009; Sparks, 2009). In our view, the inherently political nature of health policy means that conceiving politically neutral policy improvements for better public health outcomes and reduced social health inequalities is a fiction we need to come to terms with. Health promotion research is political by nature and political science tools can make it more influential. In summary, public health researchers call for better insights into policy research and some political scientists are ready to open up to different, more practical challenges. Although public policy is a significant topic in the public health literature, it is rarely an object of analytical focus as such. Bringing the two worlds together is both a challenge for existing politics of research and a unique opportunity for health promotion and public health research to strengthen their policy analysis capacity and influence. Political science has developed conceptual, theoretical and methodological tools to study the policy process in a rigorous, systematic and comprehensive manner that goes well beyond the review of government documents and legislation. As such, it can contribute significantly in a variety of areas, such as health inequalities, public nutrition, tobacco control and environmental health. A better knowledge of policy processes would focus attention on many points of possible influence on public policy. Public health researchers with a basic literacy in politics, policy content and policy processes would be more likely to question idealistic assumptions about politics and policy-making and be better equipped to get involved in the policy process and enhance their relevance for practitioners and decision-makers dealing with realworld problems. Researchers who are reluctant to become politically involved could complement existing studies by contributing to understanding the political forces, processes and aspects of public policy that shape and influence the population s health. If public health research is to develop its policy analysis capacity and encourage political scientists to bring new insights into public policy, the field s ambivalence towards political engagement must be questioned. ACKNOWLEDGEMENT The authors would like to thank Michael Eshimokhai for research assistance. FUNDING The work was supported by a grant (no. 5795) from the Fonds de recherche en santé du Québec (FRSQ). REFERENCES Anderson, J. E. (1984) Public Policy-Making: An Introduction, 3rd edn. Holt, Rinehart and Wlinston, Boston.

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