RHP&EO is the electronic journal of the International
Union for Health Promotion and Education
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Five books that shaped my view of health policyde Leeuw, E. Five books that shaped my view of health policy, Reviews of Health Promotion and Education Online, 2003. URL: reviews/2003/1/index.htm. Twenty years ago I was a student of health policy and administration. It was mostly administration, and only a bit of policy (and even then taking a rather old-fashioned, rationalistic and linear approach to the policy process). For a research project on 'European health education policies' I visited the European Office of WHO for some interviews and data collection. They scheduled meetings for me - also with someone my host announced as 'a bright mind'. This bright mind turned out to be Ilona Kickbusch and she swept me off my feet, most of all by saying that health education was entering a new era. Hadn't I heard of health promotion? Healthy Public Policy? Ever since I have been on a quest. And on a mission. Policy shapes health. It is not just that political decisions shape the operations of the health care system, no, all policy (public, corporate) at all levels (local, regional, national, global) potentially affects our health and well-being, and our quality of life. I needed to understand, and then advocate, why true policies for health are so hard to produce. Nancy Milio's Promoting Health Through Public Policy (1986) was the first eye-opener. After a first reading the book left me shocked and dazed. Why in the world had no-one else before her collected and reviewed the astounding evidence that policies, aggregate decisions about our daily lives, so profoundly impact on population health and individual choice? By means of hundreds, no thousands of references from all over the world (most notably of course Norway -where Milio profoundly analysed the country's farm-food-nutrition policy- and the USA -where her roots are-), Milio demonstrated that governments in their decision-making hardly ever think about the very real health consequences of those actions. But how to do this better? To me, an important pointer was Manual Castells' The Rise of the Network Society (1996). In a volume as impressive as Milio's work he showed the powerful interconnectedness of public and private interests. Although in this book he says very little about health (apart from the observation that the health industry will be booming - an elaboration, in some way, on the notion of a medical-industrial complex put forward earlier by Navarro, Mechanic and Waitzkin) it is clear that there are huge stakes to be held by powerful actors. The most important lesson I learned from this masterpiece is that the connections between these actors are the factors that need to be understood if we really want to produce policies for health. A network is not just a set of actors; their connections determine its strength and thrust. The first book I ever read that provided me with a clear empirical perspective on how to actually study such intricate and often behind-the-scenes policy networks was Laumann & Knoke's The Organizational State (1987). Two network sociologists, Laumann and Knoke studied decision-making in the health and energy domain in the United States. They mapped the actors in the domain, and their connections. Regularly I had to put the book down and reflect on what I read. Who could have imagined that the American automobile industry had a much more powerful position in health care policy than, say, the American Public Health Association? How could that happen? What has gone wrong? Where are the indicators for powerful action from health (and thus not health care) advocates? Laumann and Knoke give a lot of prominence to 'monitoring capacity' of the actors in the network, that is, the capacity that actors have to collect information from other actors and the ability to assess the subsequent impact of others' (in)actions on their own interests. A policy network is not just a set of actors and the characteristics of their connections, but also includes the strategic factor of being able to anticipate and influence other actors and connections. OK - so you need to know the network and its components. You need to know the stakes and interests of the other actors. And then - write another book? That is what John Kingdon did, but with a new edge. In Agendas, Alternatives and Public Policies (1995) he finally managed to pull me away from a notion of policy making that says that the policy process involves a number of iterative, incremental steps from 'problem definition' to 'implementation' on a more or less linear trajectory. No, Kingdon says, policy development is a process in which problems, policies and politics continuously compete for attention of decision-makers. In that playing field you'd find many participants, visible and invisible, who have an interest in maintaining status quo, advocate a certain problem, sell a certain solution, or advance politics. And best of all, Kingdon discovered the existence of a 'policy entrepreneur' - an actor that has an interest in bringing together problems, policies and politics into a novel amalgamate: new policy. He introduced some good concepts into my vocabulary: 'softening up the system', 'windows of opportunity' or 'alternative specification'. The policy entrepreneur softens up the system by presenting to the different (visible and invisible) participants in the network alternative representations of their realities. If he succeeds, a 'window of opportunity' is opened and there is potential for a truly new policy perspective. Good. You want to be a policy entrepreneur. After reading Kingdon's book I thought we should be training health students in the art of such entrepreneurship, and quickly found that very little on the matter is available within, let's call it 'formal academia'. Policy entrepreneurship seemed a character trait, something to do with personal charisma, talent and drive. And although that may be true, there's one last book that helps even the most clumsy would-be entrepreneur comprehend the intricacies of the trade. Deborah Stone, in her Policy Paradox (1997) shows how seemingly irrational policy processes can be understood. Especially her chapter on rhetoric, metaphors and argumentation is impressive. Words, words, words: these are the tools of the effective policy maker. And for that reason, 'hors concours', a sixth publication that still holds some of the most important, empowering and innovative words in our field: the Ottawa Charter for Health Promotion. It really is worthwhile to once in a while return to the old gospel and re-read and re-appreciate its words. For me, this remains the core of health policy. References 1. Castells, M. (1996) The Rise of the Network Society. The Information Age: Economy, Society and Culture. Volume 1. Blackwell, Masden, Oxford. WWW 2. Kingdon, J.W., (1995) Agendas, Alternatives and Public Policies; second edition, Harper Collins College Publishers, New York. WWW 3. Laumann, E. & D. Knoke (1987) The Organizational State. Wisconsin: University of Wisconsin Press. WWW 4. Milio, N. (1986) Promoting Health Through Public Policy. Canadian Public Health Association, Ottawa. WWW 5. Stone, D. (1997) Policy Paradox. The art of political decision making. W.W. Norton, New York/London. WWW |
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