Effective political strategies in public health

Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.20 | No.2 | 2014 21 EFFECTIVE POLITICAL STRATEGIES IN PUBLIC HEALTH By: Scott L. Greer and Denise F. Lillvis Summary: Health in All Policies (HiAP) has the potential to improve population health by harnessing the energies of multiple sectors via intersectoral governance. We find that the difficulty of establishing intersectoral governance for HiAP breaks down into two kinds of problems: establishing coordinated actions (coordination); and ensuring that actions endure when political circumstances change (durability). We outline three categories of potential solutions to these problems: manifesting political will; changing bureaucratic procedures; and empowering allies to change policy-making. The three kinds of strategies suggest how policy-makers can, and do, create intersectoral governance that functions and endures amidst changing political winds. Keywords: Health Policy, Health in All Policies, Administration, Politics Scott L. Greer is Associate Professor, Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA and Research Associate at the European Observatory on Health Systems and Policies, Brussels, Belgium. Denise F. Lillvis is a PhD Candidate in the Departments of Political Science and Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA. Email: slgreer@umich.edu Introduction Key problems in health policy come from outside the health care system, and therefore must be addressed outside the health care system. Whether it is health promotion, health protection, population health, chronic and long-term care, early years investment, promotion of active living, or some other form of wellness, the solution most likely involves long-term collaboration between different sectors and policy tools, from private action to tax codes to physical environments to education. That has logically led to the concept of “Health in All Policies” (HiAP), a newish tag for a long-standing public health objective of promoting intersectoral coordination for better health. 1 But, promoting intersectoral cooperation towards any goal, including health, is hard. Other ministers might not appreciate the invitation to adopt the health minister’s priorities in place of their own. In recent years, public health advocates have claimed such a broad area of public policy that it’s not so difficult for health ministers to invade another minister’s policy space. 2 Or, new ministers might not care about the old ministers’ priorities. In such ubiquitous circumstances, it is not enough to have evidence. Nor is it enough to call for more leadership and implicitly blame the leaders we have. Rather, it is important to have a fuller sense of the problem and the strategies adopted to solve it. In a study we conducted, forthcoming in Health Policy, we drew on published political science and public administration literature, in health and other policy areas, to identify the challenges and the solutions that creative and effective policy-makers use in many different political systems. 3 Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.20 | No.2 | 2014 22 The problems The extensive literature on bureaucracy and politics generally can be read as identifying two different problems facing those who would try any intersectoral policy approach. Coordination: coming together to improve public health Coordination is the first problem for HiAP, and indeed policy integration of many sorts from toxins regulation to chronic care to early childhood interventions. Simply put, it is difficult to bring together different people and organisations, each with their own existing priorities, budgets, and accountabilities. They might have professionals who speak different languages, they might have different political objectives, and their leaders’ own priorities and ambitions are likely to clash. The result is that an intersectoral priority – and almost any big priority is intersectoral – will create serious coordination challenges. Durability: staying together to improve public health While coordination challenges are clear and well known, there is a second problem: the durability problem. Simply put, there is a time limit on the interests and tenure of any single minister appointee, government and party in government. It is easy for reforming energy to dissipate, reformers to move on, and plans to die. Accordingly, opponents remain quiet when they sense strength because they know they will soon sense weakness. While short-lived policies can do good, long-lived policies that become entrenched are probably most likely to produce good effects. That is particularly the case in areas of public health, such as efforts to reduce environmental pollution or promote daily physical activity, where both good and bad policies can take years of constant activity to produce their results. The solutions In other words, health policies with the potential to produce good effects face problems of both coordination and durability. It is easy to announce a sensible policy, but much harder to implement it and harder still to entrench it. We found, though, that political scientists have catalogued a variety of techniques used by politicians and other top policy-makers to solve their problems. 4 Direct solutions: political will The simplest solutions are those involving the simple exercise of political will. Policy- makers come into office and announce new policies. These can mean specific administrative circulars, health targets, health plans, or programmatic statements such as White Papers. They attract a great deal of attention, perhaps an inordinate amount of attention, in public health circles. They show a priority and make an argument about how to achieve it, thereby providing a rallying point for advocates and enabling them to argue for the priority in meetings where it might otherwise be forgotten (e.g. if we do not keep a given sum of money in the budget, we will fail to hit our target). There are a variety of more subtle ways to show political will. Outsiders might not pay much attention to ministerial speeches, but insiders will notice which topics are mentioned, which topics recur, and which topics ministers drop. Prime ministerial or presidential speeches are even more valuable; an occasional paragraph in a speech by a head of government sends a powerful signal that the ambitious and diligent in government should continue to work on the topic. Regular briefings have the same effect. Many politicians enter office intending to seek regular briefings or meetings on a variety of topics, and insiders know to watch which briefings and meetings continue and which ones tail off. If a minister actually does demand monthly progress reports on a topic, that topic will become a priority. If a finance minister or a head of government wants the briefings, that is still more powerful. And if even a few officials or managers are rewarded or punished for supporting or impeding the policy, that communicates a powerful lesson. In each of these cases, powerful politicians are signalling that they care about an issue. That signalling will generally receive a response, whether motivated by personal ambition, or a professional commitment to service. Political will alone has limitations. It does not always address coordination challenges because those who have the will might not have the power. A well written and evidence-based health plan might propose a series of intersectoral measures that the finance, economy, transport, urban, education and other ministers and their departments can choose not to follow. Even the most powerful central actors in government, such as finance ministries, have trouble getting their way. A single spending department such as health will always have trouble coordinating other spending departments. It can seem that the health minister is simply inviting his or her colleagues to spend their budgets on solving the health minister’s problems. ‘‘ health policies face problems of coordination and durability Failure to coordinate can be bad, but political will is also extremely vulnerable to the durability problem. A health plan written in the brave early days of a new government might be a dead letter in a year when the minister is gone, let alone in five years when the entire government might be gone. Politicians frequently decline to take marching orders from their predecessors, so even amicable job changes within government can doom the initiatives of the previous minister. Bureaucratic solutions What can policy-makers do to make sure that their objectives are actually implemented and persist over time? Part of their solution is legislation – especially in countries where the legislative process is difficult. Precisely because it is difficult to legislate in Germany, or the United States, or the European Union, legislation in those systems is sticky and constraining. Once something is written in law in such systems, it is difficult to change. By contrast, in countries with more parliamentary systems, such as the United Kingdom or Spain, laws are malleable and accordingly are less able to constrain future action. In such systems, though, politicians still have ways to constrain their successors. Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.20 | No.2 | 2014 23 One of the most powerful forces in modern life is bureaucracy. A minister or official who can change the direction of a bureaucracy can change thousands if not millions of individual decisions. A minister or official who fails to change the way a bureaucracy works may be much less successful. One mechanism politicians routinely use is appointments: putting their people into key positions. Most health systems allow this, and even the Whitehall systems, which are notoriously resistant to outsiders at the top, have a variety of important executive posts in agencies whose occupants are chosen by ministers. Rewarding some people already working in the system with more power or resources achieves much the same effect. A second mechanism, also quite common, is reorganisation. Reorganisation undoubtedly has costs, but it offers the possibility of redirecting organisational priorities–for example, moving the responsibility for sports to the health ministry in Scotland made it clear that sports is to be a public health intervention, just as moving responsibility for pharmaceutical policies in the EU to DG Health and Consumer Protection made it clear that pharmaceuticals are not just another product. Reorganisation can, in fact, be a device to bring in new people with new loyalties; regulatory agencies in the new English NHS bring in people who have consulting or antitrust rather than traditional health management backgrounds. 5 Likewise, the creation of French Regional Health Agencies was an opportunity for the government to insert people committed to its agenda (e.g. inequalities reduction) into powerful new positions. A third mechanism politicians use to entrench their preferences in the bureaucracy is to change procedures. Mandatory impact analysis, for example, is a technique to encourage bureaucracies to make some decisions and not others. Obliging government agencies to conduct business impact or regulatory impact analysis creates opportunities for affected business interests to influence, protest and slow the decision; 6 mandatory environmental impact analysis has the same benefit for environmentalists. Mandatory health impact analysis, therefore, would be a way to oblige bureaucracies to slow down, inform those concerned with health of decisions, and explain themselves. Another key procedural change is the creation and manipulation of interdepartmental committees and consultations. These can be important forums for government decision-making (including decision-preventing) and representation on them is important. So, for example, making sure that the health ministry is represented on key committees making intersectoral decisions is a way to make sure that the health ministry is informed and able to participate in decision-making within the committee or in broader government. Equally, keeping other ministries out of key committees is an important way to keep them from blocking decisions. Indirect solutions If sheer force of political will is frequently insufficient for coordination and never sufficient for durability; and if bureaucratic change still faces the challenge that it is hard and might be undone by your successor; there is still a third kind of option, one little explored by public health scholars but one well known to political scientists and politicians. That is the indirect approach – changing the political context so it is friendlier in the future when there is a different minister, different direction, and different government. One way to change the context of future politics in your favour is data – the establishment of regular data releases that highlight issues and that advocates, the press and opposition parties can use to force progress. Data on health care waiting times, or food insecurity, or obesity, or many other topics can put those issues on the agenda regardless of whether the minister wants it. International comparative data can be particularly useful because it can be used to argue that the country is failing in relation to its peers. In some cases, governments have been known to support international organisations’ data collection projects in order to have an excuse to collect and release some kind of data at home. A second indirect solution is to support outsiders – advocates and experts who can generate ideas, highlight problems and press for actions no matter who is in office. This can mean support to civil society organisations, the establishment of independent agencies that can catalogue issues, and support to researchers (such as training journalists in public health, or public health workers in advocacy). In these cases, the idea is to solve the durability problem by creating outside supporters who can press for government action and keep issues on the agenda. Even if (when) such inconvenient agencies are tamed or eliminated, and the non- governmental organisations (NGOs) defunded, the human capital remains; allies have new skills in advocacy and government relations. A third solution is to make it easier for future allies to challenge decisions by future governments. Ombudsman procedures, for example, can be expanded to allow challenges on health grounds to a variety of public agency decisions. But the most dramatic indirect strategy is to introduce some aspect of judicial review. The much-heralded United States National Environmental Policy Act (NEPA), for example, is best known for mandating environmental impact assessment and inspiring health impact assessment. But its real force lies in the opportunities that it creates for environmentalists to challenge actions in the courts on the grounds of noncompliance with the law. ‘‘ Indirect solutions are frequently uncomfortableIndirect solutions are frequently uncomfortable. They involve, essentially, solving the durability problem by making ones’ successors’ lives, and frequently one’s own life, more difficult. Introducing more NGO critics, let alone the possibility of legal challenge, means creating stress. But it is a key part of the toolkit of ministers who want to make sure that their agenda continues after they are Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.20 | No.2 | 2014 24 gone, regardless of their agenda. Making it easier for outsiders to influence the government, and making sure there are more of the right kind of outsiders, is a political approach policy-makers often use for a variety of reasons, and there is no reason why it should not be used for public health. Anyway, most of the discomfort will be borne by one’s successors. Conclusion Policy-makers and politicians are more strategic and farsighted than public health writers typically acknowledge. Political scientists have spent decades cataloguing the ways they go “beyond leadership”, making direct and indirect bureaucratic and political changes to entrench their policies, allies, and favoured procedures so that future bureaucratic inertia and political arguments promote their goals. Recognising the variety of techniques available, and developing a wider range of public health interventions, might pay off in both our ability to engage with the political system and help formulate creative solutions to the problems of coordination and durability. References 1 Leppo K, Ollila E, Pena S, Wismar M, Cook S (eds.) Health in All Policies: Seizing Opportunities, Implementing Policies. Brussels: European Observatory on Health Systems and Policies, 2013. 2 Fox DM. Populations and the law: the changing scope of health policy. Journal of Law, Medicine and Ethics 2003;31(4)607 – 14. 3 Greer SL, Lillvis DF. Beyond leadership: political strategies for coordination in health policies. Health Policy 2014;116:12–7. Available at: http://dx.doi. org/10.1016/j.healthpol.2014.01.019 4 McQueen D, Wismar M, Lin V, Jones CM, Davies M. Intersectoral Governance for Health in All Policies: Structures, Actions and Experiences. Brussels: European Observatory on Health Systems and Policies, 2012. 5 Greer SL, Jarman H, Azorsky A. A reorganisation you can see from space: The architecture of power in the new NHS. London: Centre for Health and the Public Interest, 2014. Available at: http://chpi.org.uk/ wp-content/uploads/2014/01/The-architecture-of- power-in-the-NHS-Scott-Greer-Jan-2014.pdf 6 Smith KE, Fooks G, Collin J Weishaar H, Gilmore AB. Is the increasing policy use of impact assessment in Europe likely to undermine efforts to achieve healthy public policy? Journal of Epidemiology and Community Health 2010:64:478 – 87. New Policy Summary on what is the evidence on the economic impacts of integrated care? By: Ellen Nolte and Emma Pitchforth Copenhagen: World Health Organization/European Observatory on Health Systems and Policies, 2014 Number of pages: 45, ISSN 2077-1584, Policy Summary 11 The rising burden of chronic disease, and the number of people with complex care needs in particular, require the development of delivery systems that bring together a range of professionals and skills from both the cure (health-care) and care (long-term and social-care) sectors. Failure to better integrate or coordinate services along the care continuum may result in suboptimal outcomes. This Policy Summary analyses published reviews on the economic impacts of integrated care approaches. Given the wide range of definitions and interpretations of the concept, it proposes a working definition that builds on the goal of integrated care and which considers initiatives seeking to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care. The review covers three economic outcomes: utilisation, cost–effectiveness and cost or expenditure and also looks at data on core health outcomes such as health status, quality of life or mortality, as well as process measures. POLICY SUMMA RY 11 What is the evidence on the economic impact s of integrated care ? Ellen Nolte, Emm a Pitchforth Available evidence of integrated care programmes points to a positive impact on the quality of patient care and improved health or patient satisfaction outcomes. However, uncertainty remains about the relative effectiveness of different system- level approaches on care coordination and outcomes, with particular scarcity of robust evidence on the economic impacts of integrated care approaches. In addition, it is important to come to an understanding as to whether integrated care should be considered an intervention or whether it should be interpreted, and evaluated, as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are being delivered and that involve multiple changes at multiple levels.