12.1 Why this book?

Health policy analysis, described as the analysis of and for health policy­making, informs health policy analysts on how health policymaking works and offers them knowledge for supporting health policymakers in practice. A distinction can be made between two types of knowledge. Policy-issue knowledge is pertinent to a specific policy and involves specialized knowledge concerning a specific problem. An analy­sis of policy interventions to tackle, for instance, the problems of obesity, chronic ob­structive pulmo­nary disease, or health disparities requires substantive expertise of these health pro­blems. How­ever, policy-issue knowledge only falls short. Needed is also policymaking know­ledge or knowledge on how policy choices are made and put into practice. Although policy-issue knowledge should always be leading, policymakers must be familiar with the structure and political dynamics of health policymaking to succeed. They must under­stand the complex relationship between information and policymaking, the pres­sure of interest organizations upon policy decisions, the governance structure, the pro­blem of collective action, the role of power in policymaking, the impact of the context on health policymaking, and so on. There is no ‘linear path’ from policy-issue knowledge to what is eventually decided and implemented.

This book concentrated on the health policymaking process from a political science perspective. The first reason for this choice was that, so far, health policymaking has received little systematic attention in the study of public health. Most studies on public health focus on policy-issue knowledge. By its focus on the health policymaking process, this book is complementary to studies presenting policy-issue knowledge of public health. The second reason is that public health experts often tend to underestimate the complexity of health policy­making. In their view, health policymaking should be driven by evidence and research, not by politics and power relations. In doing so they accentuate the instrumental dimension in health policymaking but misjudge its political face. In their view, health policymaking should be depoliticized as much as possible. This reasoning fails for the simple reason that health policy is political. Health policy rests upon political choices that could have been different. Health policy analysts must understand the political dimension of health policymaking. 

12.2 Building blocks as starting-point of health policy analysis

The second part of the book presented five building blocks health policy analysis: policy content, policymaking process, actors and policy arena, governance and policy effects. Each block focused upon a specific aspect of health policymaking. The study of the content of health policy gives insight into the political construct­ion of health problems (problem framing), the policy goals of state intervention, and the instruments to achieve these goals. The challenge in health policy analysis is to map these elements and investigate the policy paradigm (assumptive world) underpinning the problem framing and the policy decisions made. The choice of policy instruments entails information on the concrete meaning of policy goals and the priority given to each of them. Policy analysts must be aware that policy statements should not be confused with policy choices and actions. For this reason, they should not confine the analysis of the policy content to policy documents and verbal statements only, but include an investigation of what policymakers actually decide and what they do to put these decisions into practice.

The health policymaking process consists of the dynamic process of events, decisions, and actions concerning health problems. The study of health policymaking highlights its non-linear structure: there is no straightforward path from problem to action. There are several strategies for studying health policymaking. The first strategy is to conceptualize health policymaking as a cyclical process consisting of subsequent stages. This strategy starts with an analysis of the stage of agen­da-building and problem framing. Who has access to the policy agenda? An important aspect of the policy development stage is what kind of expertise has been mobilized to underpin the policy choices in the policy formation stage. If these choices are contentious, an important research question is which attempts policymakers have made to bridge political differences. Ultimately, health policymaking is (also) a matter of the exercise of power. Health policy analysts should not make the error of under­estimating the impact of policy implementation on the policy effects. Policy implementation is the Achilles Heel of all policymaking. The next theme is policy evalu­ation. Here, the key question is how policy effects are evaluated, which information sources are used for evaluation, which evaluative conclusions are drawn by whom, and whether these conclusions are reasons for policy accommodation or policy termination. The second strategy is to focus the inves­tigation upon the successive decision rounds in the policymaking process during which key decisions are made, revised, and sometimes revoked. Third, health policy analysts can investigate the interdependence between policymaking processes. Health policymaking is always part of a complex set of processes influencing each other back and forth. The challenge is to disentangle the interconnections between these processes. Finally, policy analysts may investigate how a policy has developed over a certain period and how it has been accommodated to changing insights and circumstances. The study of a policy path gives insight into the historical dimension of health policymaking and the political dynamics of policy expansion and contraction. 

The third building block is policy actors and health policy arena. Health policymaking takes place in an imaginary health policy arena consisting of all actors participating in health policymaking, the relations between these actors, and the rules regulating the interactions between them. A distinction was made between policymakers, experts, interest organizations, activist groups, producer organizations, the media, and the judiciary. Actors operate in policy networks. The composition of these networks is an important topic of research in health policy analysis. Which actors participate in which policy network, and what is the structure of this network? Other research topics are the relationship between policy­makers and policy experts and the role of interest organizations, the media (including social media), and the judiciary in health policy­making. The analysis of the health policy arena often demonstrates how a thick clay layer of vested interests restricts the political room for policy change. Another research topic is the role of governmental and non-govern­mental organizati­ons in the global health policy arena.

Understanding health policymaking requires knowledge of the formal and infor­mal rules of the game for health policymaking called governance rules (fourth building block). The study of governance rules helps explain the effectiveness and legitimacy of health policy­making and gives insight into the problem of collective action and gover­nance gaps. Governance rules include authorization rules, participation rules, decision rules, compliance rules, coordination rules, financing rules, accountability rules, transparency rules, integrity rules, and legal protection rules. Health policy analysts should use typologies of basic models to unravel the complexity of governance systems. Based upon the modus of decision-making and compliance a distinction was made between the anarchic model, the hierarchical model, the majority-voting model, the network model, and the market model. An alternative typology built upon differences in the locus of policymaking. Here a distinction was made between the state-governance model, the self-governance model and several multi-level governance models. Each of these models has its strengths and weaknesses regarding the effectiveness and legitimacy of health policy­making. Another topic of research is the centralization and decentralization of health system governance and the impact of these changes in governance structures on health system performance.

Policy effects are the fifth building block. Health policy is not a goal of itself but a strategy to bring about desired changes. The leading question is to investigate to what extent these changes have been achieved and which side effects and counter-productive effects have occurred. Other research topics are long-term and distributive effects (the costs and benefits of health policy­making across the population). Health policy may also have political effects due to the political framing of policy effects. Classic examples of these effects are scandals, public outrage, and political crises. A research theme attracting increasing attention is the development of public trust in government and science. 

12.3 Four analytic models

The third part of this book presented four analytical models for health policy analysis: the rational model, the normative model, the rational model, and the institutionalist model. Each analytical model provides an analytical lens alerting health policy analysts to specific aspects of health policymaking.

The rational model postulates that policymaking should not be the outcome of political struggle, ideological convictions, or power relations but instead should rest upon the best available information, including evidence-based information. The synoptic model describes how policymaking should ideally be organized to achieve the best results. An alternative is the deliberative model, which underscores the role of argumentation, interpretation, multiple advocacy, and justification in policy analysis. Rational policymaking in the deliberative model requires multiple sources of information. An important research theme is how policymakers deal with risk and uncertainty in policymaking and which strategies they pursue to reduce risk and uncertainty.

The central proposition of the normative model in health policy analysis is that health policymaking cannot be reduced to an information-driven process. It always involves normative choices. A distinction can be made between ultimate and instru­mental values. A common critique is that ultimate values may become subordinated to instrumental values. Because of the presence of multiple values in society (value pluralism), policymakers are confronted with complex moral dilemmas for which no easy resolution exists. Judgment pluralism means that actors have different opinions of a good solution. Value pluralism and judgment pluralism are a source of normative conflicts. The purpose of the normative model is to investigate the explicit or implicit normative choices in health policymaking and how policymakers deal with complex normative dilemmas.

The conflict model postulates that health policy and health systems are not the result of a consistent and information-based design but the product of past political compromises between actors with incongruent preferences. Conflicts are inherent to policymaking in a demo­cratic and pluralist society. Though they are a risk to the problem-solving capacity of health systems, it should be emphasized that conflict-free policymaking also presents a risk to the problem-solving capacity of health systems. The outcome of policy conflicts is contingent on the power balance in the health policy arena. Infor­mation is a policy instrument in the hands of the power holder. Science (expertise) is increasingly politicized by making it an object of or instrument in political struggle. The power balance in health systems has a complex structure. Although the state has gained more power in health policymaking, its power should not be over­stated. The room for state health policymaking is constrained by political divisi­veness and political pressure of interest groups. The conflict model is a source of interesting research questions. For instance, which conflicts dominated policymaking? How did the conflict evolve over time? Which conflict resolution strategy or strategies have been used to end the conflict? How did the power balance influence the conflict and conflict resolution? Had the actors a common interest in resolving the conflict? What is the use of science in policymaking? Is there evidence for the politicization of science?

The institutionalist model focuses on how institutions, defined as broadly agreed rules of the game that give direction to social action, regulate medical practice, patient expectations, organizational behavior, health policymaking, and the state-society relationship. Three central propositions of the institutional model are that society cannot endure and prosper without institutions, that institutions influence actor behavior, and that institutional changes are gradual rather than radical. Successive incremental changes can nevertheless fundamentally alter the institutional structure of health systems over a more extended period (gradual transformation). Health­care reform can be conceptualized as a combination of institutional change and continuity. Institutions set constraints on the pace and scope of reforms. Some research questions ensuing from the institutionalist model are: which institutions dominate the content, process, and effects of health policymaking? To what extent are policy decisions path-dependent? Which factors influence institutional continuity and change?