KEY POINTS:

• The conflict model postulates that health policymaking is the outcome of conflict. 

• Conflict, conceptualized as a condition, refers to a situation in which two or more actors have incongruent preferences concerning an issue (or set of issues) and seek to influence decision-making following their pre­ferences.

• An alternative model is to conceptualize a conflict as a process. A global distinc­tion can be made between three main stages: emergence, struggle, and settlement.

• There are many different types of conflicts: moral conflicts, informational conflicts, boun­dary conflicts, distributive conflicts, coordination conflicts, and power con­flicts. Another distinction is between content-related and process-related conflicts

• Conflicts with a common interest to achieve an agreement must be distinguished from conflicts without a common interest. The settlement of conflicts is easier for conflicts with a common interest than for conflicts without a common interest.

• The conflict potential of health policymaking has increased.

• Conflicts are an essential dimension of health policymaking in a democratic and pluralistic society. Without conflicts, legitimate interests and values would be neglected or downplayed. Nevertheless, conflicts can undermine the problem-solving capacity of health systems.

• The politicization of science involves the process of science becoming an instrument in or object of political conflict.

• Conflict resolution strategies are hierarchical decision-making, majority voting, negoti­ated agreement, broadening the negotiating field, arbitration and recon­ciliation, litigation, conflict avoidance, conflict displacement, and politici­zation.

• There are various types of power. In its simplest form, power is the ability of actor A (power holder) to determine the behavior of actor B (power subject). Related concepts are power resources, formal and informal power, enfor­cement power, and veto power. 

• The conflict model of health policymaking postulates that power trumps evidence. 

• The power of the state in public health has considerably extended since the onset of the 19th century. However, state power should not be overstated. 

• The medical profession has always held a strong position in healthcare. However, its traditional power has weakened.

• Corporate interests exercise considerable power in health policymaking and restrict the state’s room for policymaking. 

10.1 Introduction 

The creation of the National Health Service in Britain (Box 10.1) is a historical example of a deep conflict in health policymaking. Although the concept of a National Health Service drew upon an overarching consensus on the need for freely accessible and comprehensive health services, bitter conflicts between competing claims and interests profoundly impacted its shape. Only by accepting substantial concessions to the doctors’ demands Bevan managed to build political support for his reform. The creation of the National Health Service in 1948 did not terminate the conflict on its structure. Ever since, each reform of the NHS has sparked off conflicts between stakeholders on a wide range of issues concerning, among others, the public budget for health care, cost control mea­sures, the payment of doctors, the governance of the NHS, the ongoing privatization of health service provision role, waiting times, and the shortage of personnel (Klein, 2012).

The introduction of the NHS demonstrates another aspect of the conflictual nature of health policymaking: the impact of power on decision-making. Whereas doctors had excellent access to the health policy arena, other stakeholders, including the Approved Societies (health insurers) and voluntary hospitals, were largely excluded from the inner circle in the health policy arena. Despite its involvement in hospital funding, local governments proved unable to take a hard line. Patients were even completely absent. As a consequence, the organization of the health policy arena was profoundly biased to the advantage of powerful stakeholders.

The British experience with the politics of health care reform is by no means unique. Deep political divisiveness has frequently been the main explanation for the absence of national health insurance in the United States (Blumenthal & Morone, 2009). It is true that President Obama managed to build a majority for his Affordable Care Act, but not without bitter conflicts in Congress and many concessions to powerful interest organizations and mighty members of Congress. Ultimately, no Republican Congress member voted for it (Cohn 2021). In various countries, doctors have fought bitter disputes over payment issues (Marmor & Thomas, 2012; Wilsford, 1991). In Switzerland, doctors were able to block the reform of health insurance legislation for almost a century (Immergut, 1992).

Protracted conflicts about the organization and financing of health care have also left their imprint on the structure of Dutch health care. The introduction of statutory health insurance for employees took almost forty years. Successive proposals for a statutory scheme the first of which had already been presented in 1905 had failed because of deep differences of opinion between the state, doctors, and insurers. The doctors’ fear was to be degraded to an employee of sickness funds and subjected to the sick fund bureaucracy. Besides, they did not want to give up their profitable private patients. Sickness funds, on their part, were afraid of a loss of autonomy. The German occupier eventually settled the conflict in 1941 through the introduction of the so-called Sickness Funds Decree. After the war, however, old conflicts flared up again. The enactment of the Sickness Fund Act in 1964 was little more than the codification of the German Sickness Funds Decree. The ‘market reform’ in Dutch health care was no easy political ride either. It took almost twenty years of debate and struggle before the Health Insurance Act came into effect in 2006 (Jeurissen & Maarse, 2021).

Likewise, state regulations to protect and promote public health have elicited numerous conflicts. The introduction of the ban on child labor in the nineteenth century (in the Netherlands in 1874) proved a contested issue because of heavy resistance of employers. The tobacco industry was long successful in casting doubt on the harmful health effects of its products and resisting legislation that would erode its profitability. State programs to promote public health have frequently been denounced as patronizing and an infringement of freedom. Moderate proposals for restrictions on the sale of guns in the United States were effectively blocked by the political lobby of the National Rifle Association with an appeal to the Second Amendment of the American Constitution. Even mass shootings have not changed this pattern (Spitzer, 2020). Public protests against the (quasi-)mandatory character of mass vaccination programs to end the COVID-19 pandemic are still fresh in the memory. Conflicts on health issues also frequently appear as an important stumble block in negotiations on international trade treaties and in decision-making on regulations and directives in the European Union.

The conflict model of policymaking is radically antithetical to the rational model. Its central proposition is that health policymaking is the outcome of conflicts rather than the outcome of rational choice. Actors with incongruent policy preferences seek to influence the outcome of health policymaking accordingly. Powerful actors carry more weight in policymaking than actors without powerful resources. Politics is the struggle for policy (Hop­pe, 2010).

This chapter provides an introduction to the conflict model in health policy analysis. It consists of two main parts. The first part starts with a conceptual analysis of conflicts. A conflict can either be conceptualized as a condition or a process. Next follow the presentation of some classifications of conflicts and a brief discussion of the increased conflict potential of health policymaking. An important question is how conflicts influence the problem-solving capacity (system performance) of health systems. Do they undermine its problem-solving capacity or are there reasons for an alternative view? It will be argued that conflicts are inherent to health policymaking in a pluralistic society and an effective mechanism to counter the dominance of specific values and interests. Conflict-free health policymaking would come with great risks for society. The first part ends with the presentation of a number of conflict-resolution strategies.

As said above, the conflict model is closely connected with power. This concept is central in the second part of the chapter. After a concise overview of the dimensions of power follows a discussion of information as an instrument of power and the politicization of science in health policymaking. The concept of power also raises the issue of the (changing) power balance in the health policy arena. In this respect, attention will be paid to the power of the state and non-state actors respectively. The chapter ends with a brief exploration of some research suggestions of for health policy analysis. 

10.2 Conflict as condition

A conflict can be defined as a condition in which two or more actors with incongruent preferences to an issue or set of issues seek to influence decision-making on this issue following their preferences. In this book, we are particularly interested in conflicts on state intervention (or non-intervention) as the object of conflict. Conflicts vary in intensity ranging from mild to intense. While some conflicts ensue from deep-felt norma­tive beliefs, for instance, conflicts on abortion, medical assistance to dying, or state interventions restricting freedom of choice, other conflicts concentrate on material issues such as conflicts on payment issues, working conditions, or regulations that the corporate sector perceives as a threat to their business. Another contested issue is the structure of governance, particularly the distribution of decision power in the health system. Notice that ideological beliefs may mask material interests. This is, for instance, the case when corporations frame state interventions to moderate the consumption of sweetened drinks as an infringement of individual freedom.

Conflicts are usually associated with the policy formation stage in the policymaking process because policy formation is considered the stage par excellence to struggle on regulations, budgets, moral issues, governance rules, power relations, accountability, etc. Building a political majority for a heavily contested piece of legislation requires lengthy negotiations and skillful political maneuvering. Nevertheless, it should be emphasized that conflicts occur in each stage of the policymaking process. For instance, powerful actors use their agenda power to frame policy issues to their advantage or depoliticize sensitive political issues (non-decisionmaking). Unresolved political conflicts can be passed on to policy implementation through ambiguous and incoherent compromises as a consequence of which the political struggle continues in the stage of policy implementation. In some situations, policy implementation even becomes more politicized than policy formation. Policy evaluation and policy termination are other potential sources of conflict. 

10.3 Conflict as process

An alternative approach is to conceptualize a conflict as a process. While some conflicts drag on for many years or even decades, other conflicts have a relatively short duration. A global distinction can be made between three stages: emergence, struggle, and termination. In the stage of emergence, actors realize that they are confronted with a (potential) conflict. Their focus in this stage is on recognizing the conflict, determining one’s interests that are at stake, and assessing the potential repercussions of the conflict. The stage of struggle comprises the development and implementation of strategies to protect one’s interests, the identification of (potential) allies and adversaries, and the process of moves and countermoves to serve one’s interests. The conflict ends or fades away in the stage of termination. Conflict termination does not necessarily imply the definite resolution of a conflict. Mutual adjustment through an ambiguous compromise or halfway solution may only provide temporal relief. The boundary lines between emergence, struggle, and termination are fluid.

Another approach is to distinguish between the stages of mobilization, negotiation, and acceptance. In the mobilization stage, actors mobilize their constitu­ency by formulating firm claims and demonstrating to opponents their unitedness and willingness to get their claims accepted. The second stage involves negotiating an agreement which each negotiator must sell as the best result achievable in the acceptance stage. The distinction between mobilization, negotiation, and acceptance highlights the internal and external dimensions of policy conflicts. The external dimension refers to the mobilization of the constituency and the acceptance of the negotiated agreement and the internal dimension to the negotiation process.

Some conflicts have a pattern of successive conflicts during a certain period. Decision-making in the European Union on the ban on tobacco advertising took almost a decade (Boessen, 2009). As spelled out above, the introduction of social health insurance in Dutch health care even dragged on for several decades. While some conflicts in no time escalate, other conflicts develop slowly. Policy interventions that were hardly controversial in the beginning may become controversial at a later point. For instance, governments in many countries learned that the initial broad public support for their measures to contain the spread of the coronavirus (‘rallying around the flag’) started crumbling after some months. A growing number of critical commentators began questioning the necessity and proportionality of the draconic policy measures the government had taken. Retailers and the hospitality sector were dissatisfied with the financial compensation they received. The priority given to COVID patients was criticized because of its consequences for non-COVID patients needing hospital care. The (quasi-) mandatory character of the government’s vaccination strategy provoked fierce protests from some groups. After a few months, the initial ‘crisis honeymoon’ was largely over.

On the other hand, numerous conflicts lose much of their intensity with time. Regulations once dismissed as unacceptable have become gradually accepted or even considered self-evident. The contest about the ban on child labor in the 19th century is hardly conceivable nowadays. Public opposition to strict tobacco regulation has also largely vanished.

Some conflicts have no end. Healthcare reforms may remain contested. An example of ‘post-reform politics’ is the continuation of the political struggle after the enactment of the Affordable Care Act (‘Obama Care’), which even intensified under the Trump Administration by its attempts to undermine its implementation and repeal the legislation altogether (Patashnik & Oberlander, 2018; Rocco & Haeder, 2018). 

10.4 Types of health policy conflicts

Health policy conflicts occur in many versions. One model is to classify conflicts according to the five P’s of public health policymaking (chapter 1). Conflicts on food-safety standards or emission rates are conflicts on protecting the population against exposure to illnesses that are contagious person-to-person or health risks from environmental sources. Mass vaccination programs have elicited conflicts on prevention. Health promotion programs have been criticized as paternalistic and programs directed at the identification and anticipation of public health risks through surveillance and monitoring (prognosis) as a risk for privacy and individual freedom. Conflicts on healthcare financing or the state’s role in health care have colored the history of the provision of health services. 

An alternative is to classify policy conflicts according to the type of conflict. Each type draws attention to a specific dimension of policy conflicts. A distinction can be made between the following types of conflicts:

• Moral conflicts are conflicts on normative issues. For instance, is the state permitted to take coercive measures restricting individual freedom to fight a pandemic? 

• Informational conflicts are conflicts about the inference of information from observations. Actors contest each other’s figures, explanations, predictions, assump­tions, analytical models, and inferences. 

• Boun­dary conflicts are conflicts on where to draw the line. Classic examples are conflicts on the scope of state intervention in public health, conflicts on the benefits catalog of statutory health insurance, and conflicts on the limits to health care. 

• Distributive conflicts entail conflicts on the allocation of scarce resources and the distribution of the costs and benefits of health care. 

• Coordination conflicts arise from the collective nature of health policymaking. A frequent cause of coordination conflicts is that actors prioritize their private inter­ests at the expense of collective interests. 

• Power conflicts ensue from the pursuance of power. 

Finally, a distinction can be made between problem-oriented and process-oriented conflicts. Examples of problem-oriented or content-related conflicts are conflicts on budgets, the payment of doctors, tobacco control regulation, food-safety standards, healthy-living initiatives, or moral issues. Process-oriented or governance conflicts pertain to the rules of the game for policymaking. Examples are conflicts on the relationship between state, civil society, and market in health policymaking, conflicts on participation and decision rules, and conflicts on the scope of professional auto­nomy. 

10.5 Conflicts with a common interest and without a common interest

Many conflicts in health policymaking have the structure of a mixed-motive conflict: actors have incongruent preferences concerning an issue but also a common interest in reaching an agreement (Bacharach & Lawler, 1981). For instance, they agree on the need to resolve a policy problem but disagree on how such a resolution should look. Political parties in a government coalition are deeply divided on a specific health issue but have a common interest in averting a coalition crisis that would necessitate new elections. Therefore, they do their utmost best to negotiate a compromise. Actors may also opt for a compromise in the know­ledge that they need each in other or future dossiers. Mutual dependency implies they have to fall back upon each other in other situations, as a consequence of which a conflictual atmosphere is detrimental for both con­testants. The relational dimension in conflicts forces them to find an acceptable compromise and preserve a cooperative relationship.

The settlement of conflicts without a common interest ensues from deep ideological division. These conflicts are by comparison hard to settle, particularly if they arouse strong emotions. Society is so deeply divided that a political compromise is extremely difficult. Conflicts have the structure of a zero-sum game instead of a positive-sum game as in the case of conflicts with a common interest. The political struggle for the Affordable Care Act in the United States occurred in a very hostile political atmosphere. Opponents denounced the plan as ‘socialized medicine’. In an attempt to win voters, the Republican vice-president candidate Sarah Palin did not even refrain from framing the provision of end-of-life counseling in ACA as a recipe for ‘death panels’ (Tuohy, 2018). With the slogan that ‘the only thing that can stop a bad man with a gun is a good man with a gun’, the National Rifle Association has uncompromisingly taken action against most proposals for gun regulation (Spitzer, 2020). The controversy over using embryos for medical research in the Netherlands illustrates how moral considerations can thwart legislation for many years (Box 10.2).

The distinction between conflicts with and without a common interest is not absolute. Much depends upon the context in which they are fought. Changed political circumstances sometimes compel contestants to strike a deal on an intensely disputed issue. The price of a non-agreement is higher than the price of an agreement. 

10.6 The conflictual nature of health policymaking

Conflicts are a normal part of social life: a society without conflicts does not exist. Public health is no exception. From its very beginning, health policymaking has raised conflicts on state intervention to pursue public health. Disputes on the necessity and direction of state intervention or the degree of coercion in state intervention have permanently colored health policymaking. There are several reasons for arguing that its conflictual nature has increased. Health care has grown into a large economic sector or ‘industry’ representing the interests of providers, care workers, and manufacturers of health products and services. Another factor is the differentiated structure of health care. Doctors, nurses, hospitals, patients, third-party payers, public health experts, and other stakeholders have interests that may not run parallel. The technological advance in medicine has not only extended the range of treatment options for ever more categories of patients but simultaneously raised fundamental normative questions about the moral acceptability of these options and the limits to health care. The pharmaceutical industry has developed tremendous market and political power to protect and promote its commercial interests. The tobacco industry has a legendary history of resisting legislation to discourage the use of its products (Neumann et al, 2002). The automobile industry has used its contacts at the highest political levels to mitigate or delay ‘unfriendly’ legislation to reduce the emission of toxic aerial particles. The digitalization and datafication of public health will fundamentally alter power structures in the future health policy arena.

The number of global conflicts is also rising. During the outbreak of Ebola in Africa, various countries prioritized their national interests and disregarded the International Health Regulations they had signed only a few years earlier. The way China initially dealt with the SARS pandemic, the use of the term ‘China virus’ by the Trump administration, the export bans on personal protection equipment and ventilators within the European Union in the early stage of COVID-19 and the uneven distribution of vaccines against the coronavirus highlight the increased global dimension of public health conflicts. Public security experts consider the unequal distribution of health across the world a global security risk. At the global level public health has transformed from a low politics issue into a high politics issue.

Finally, the emergence of populism should be mentioned here (Box 10.3). Right-wing populist politicians claim a close link between welfare state problems and immigration. They plea for ‘welfare chauvinism’ by restricting welfare benefits largely to the native part (‘ethnically defined community’) of the population (Greer, 2017). As pointed out earlier, populists also exhibit a deep skepticism of evidence-based medicine, which they denounce as an instrument of a worldwide political elite to restrict freedom of choice.
 

10.7 Impact of conflicts on the problem-solving capacity of health systems 

Discourses on policymaking resonate with a preference for rational policymaking. Health policymaking should draw upon information and analysis: it should be information-based. Rational policymaking maximizes the problem-solving capacity or system performance of health systems. Following this line of reasoning, conflicts have a negative connotation. They are seen as unproductive and result in policy increment­alism or policy inertia. Technocrats harbor ‘a deep-seated suspicion of politics (Hajer & Wagenaar, 2003: 18).

Do conflicts restrict the problem-solving capacity of health systems? This question requires an answer to a preceding question: how to measure the problem-solving capacity of health systems? On conceptual and methodological grounds, there is no simple answer to this question (chapter 7). A universally agreed definition of optimal problem-solving capacity does not exist, and what is optimal is also context-bound. Urgent health problems in lower and middle-income countries differ from urgent problems in rich countries.

That conflicts can undermine the problem-solving capacity of health systems is evident. If necessary interventions due to enduring and bitter conflicts do not come off, problems will continue to exist and may even worsen. The risk of a political stalemate in health policymaking is imminent if conflicts connect with deep political cleavages in society are purposively exploited by politicians to profile themselves and react against their enemies. Such cleavages help explain the political struggle for universal health insurance in the United States or the political struggle for introducing statutory health insurance in the Netherlands over half a century.

On the other hand, however, it should be realized that conflict-free policymaking also entails great risks. Conflict-free policymaking would mean that legitimate values and interests are downplayed or ignored. Conflicts are inherent to policymaking in democratic and pluralist societies. Mutual adjustment by negotiating compromises is an effective and respectable way to bridge differences of opinion and conflicting interests peacefully. It is a strategy that respects the legitimacy of conflicting preferences. Finding a middle path is preferable to a command-and-control style of policymaking that shows no respect for deviating opinions. Besides, conflicts can help to avoid policy disasters and stimulate creativity.

Meanwhile, the negative impact of conflicts on the problem-solving capacity of health systems should not be overstated. The need for compromises to bridge incongruent preferences has not hindered the creation of relatively-well functioning health systems. Current health systems perform much better than in the past, although some countries do better than other countries. Life expectancy has increased worldwide since the middle of the nineteenth century. Many more people than in the past have access to medical care nowadays. State legislation has removed or mitigated many health risks.

The need for coordination also limits the impact of conflicts on the problem-solving capacity of health systems. Multiple mutual dependencies make contestants need a modus vivendi to pursue their objectives. Fighting only is no productive strategy. Health policymaking is a process of give and take. Finally, ideological conflicts may perfectly go together with cooperation on practical issues. In sum, conflicts are inevitable and part of the game. Health policymaking without conflicts does not exist and may be a risk. 

10.8 Politicization of science

In the previous chapter, we discussed the call of public health advocates for evidence-based or at least evidence-informed health policymaking. The ‘scientifi­cation’ of health policymaking will improve its effectiveness. The politicization of science is the mirror image of the scientification of policymaking. Politicization means that science becomes an instrument in or object of political conflict. Science is either disputed for political reasons or serves as a political weapon in policymaking (Cairney, 2016).

Before discussing the politicization of science in health policymaking, it is important to understand why science is an easy victim of politicization. First, science is inherently uncertain: ‘Scientific information is always, to some degree, vulnerable to concerns about uncertainty because scientists are trained on uncertainty’ (Dietz, 2013). Second, scientists see it as one of their challenges to criticize and challenge extant knowledge: falsification is the driving force of better knowledge. This makes science vulnerable in political debates. Third, scientists speak with many voices, making it easy for policymakers to pick up the voices that best suit their preferences and interests. Contradictory information stirs polarization and makes scientific expertise a plaything in the political game. Fourth, there is poor science that does meet methodological standards (poor science) but nevertheless attracts widespread public attention. Even after Wakefield’s contention of a causal relationship between MMR vaccination and autism had been shown up as completely false, anti-vaxxers continued to refer to his allegations that such a relationship did exist (Davidson, 2017). The very critical stance toward mainstream science sharply contrasted with the uncritical acceptance of poor science.

A recent example of how political interests and polarization cause a deep fissure between science and politics is how President Trump dealt with the COVID-19 pandemic. From the very beginning, Trump politicized the pandemic. On many occasions, he mitigated the impact of the pandemic and publicly contradicted what his health experts had told him. He called COVID-19 a ‘new hoax’ deliberately politicized by the Democrats to undermine his re-election as president (Bolsen & Palm, 2022). President Bolsonaro of Brazil is another example of a politician publicly demonstrating disdain for expertise and planting uncertainty about scientific knowledge. His strategy to fight the pandemic radically contrasted with the strategy of New Zealand’s Prime Minister Ardern (Box 10.4).

This example demonstrates again that the risk of politicization of science is most acute in a polarized political environment. Democrats and Republicans told different stories about the risks of the coronavirus. Consequently, public support among Democrats for precautionary measures was stronger than among Republicans (chapter 7). In other countries, too, opponents to freedom-restricting measures exploited COVID-19 to profile themselves and discredit their opponents. Populists agitated against what they called the elite and ‘deep state’ by purposefully disseminating misinformation, conspiracy theories (Douglas, 2021), and fake news via social media. Their political goal was to undermine public trust in government and public health experts. Strict state measures to fight the pandemic, such as a lockdown and a ban on social interaction, were not just framed as an unacceptable restriction of individual freedom but as a thin attempt of the world elite to suppress the population and get complete control over it. 

The denial or rejection of the results of scientific research is no recent phenomenon. The history of health policymaking offers plenty of examples of these practices. A telling example is the politics-driven rejection of the results of a scientific report by the National Cancer Institute and American Cancer Institute on the effectiveness of breast cancer screening. The screening was proved effective but did not reduce breast cancer mortality in the category of 40-49 aged women. For this reason, screening was no longer recommended for this age category. The study immediately prompted a heated debate, and one mammographer suggested that the research panel was actually condemning women to death. Politicians remained silent because they did want to risk an electoral punishment. A couple of years later, under the Obama Administration, a new panel of experts with women on board concluded again that breast cancer screening of women younger than 50 years did not make sense. The report got confused with the much bigger problem of cost control. Opponents even spoke about ‘death panels’. The responsible State Secretary quickly distanced herself from the findings of the report, obviously for political reasons (Welch, 2011).

Motivated reasoning

Another aspect of the politicization of science is motivated reasoning which can be described as ‘the people’s tendency to seek out information that confirms their prior beliefs’ (Druck­man, 2017). The phenomenon is also known as confirmation bias or myside bias. An instructive example of this bias was how anti-vaxxers dealt with Wakefield’s false claim of a causal relationship between MMR vaccination and autism. They embraced his findings because these confirmed their prior belief in the adverse health effects of childhood vaccination. Even after Wakefield’s claim had proven to be completely false and the Lancet had retracted his article, anti-vaxxers continued to refer to his claim to demonstrate that they were right (Davidson, 2017). What makes motivational reasoning puzzling is the extreme unbalance between the critical attitude to research findings that contrast with prior beliefs and the uncritical attitude to ‘research findings’ confirming these beliefs.

Motivated reasoning is no new phenomenon, but the context in which it takes place has radically changed. First, the amount of scientific or so-called scientific publications has enormously increased. The outbreak of the COVID-19 pandemic triggered an explosion of publications many of which had not been peer-reviewed. Consequently, it became relatively easy to find research that confirmed the receiver’s prior beliefs or suited the receiver’s interests best. Second, there was much media attention to research findings. However, media messaging could be influenced by political color. For instance, research has brought to light that right-leaning news sources in the United States (Fox News, Breitbart, Limbaugh) were more likely than other sources to disseminate specific pieces of misinformation, for instance, that coronavirus was a conspiracy (Gollust et al., 2020). Third, the world-wide-web has made it possible that information is nowadays only one click away. The transformational power of the web has substantial implications for the public impact of science and how science itself proceeds (Drucker, 2017). Social media messages compounded the politicization of the virus through the wide circulation of false claims on the transmission of the virus and pseudo-scientific health therapies (Motta et al., 2020). 

Interests of scientists

Scientists have interests that may influence their relationship with policymakers. An influential role in policymaking gives them prestige but requires them to abstain from forceful critique, at least in public (Cairney, 2021). Preserving their influential position may seduce them to deliver ‘serviceable truths’ (Jasanoff, 1990), for instance, through weakening or accentuating the conclusions of commis­sioned research projects. Self-interest can also motivate scientists to keep a conflict of interest hidden. There is much evidence of scientists who failed to disclose their relationship with the pharmaceutical industry in advising the health authorities on the merits of prescription medicines or vaccination programs (Angell, 2004; Brevis, 2008). Weingart (1990) concludes that ‘science is one actor among many in the political system’ (p. 155). He also observes that many scientists do not refrain from providing recommendations ‘far beyond their realm of expertise’ (p. 157) and emphasizes that ‘scientific know­ledge cannot be separated as neatly from value judgment as both the decisionist and technocratic model of advice suggest’ (p.156).

The politics of the expert-policymaker relationship

Another aspect of the politicization of science concerns the expert-policymaker relationship (Cairney, 2021). The classic model of this relationship is simple: experts advise, and policymakers decide. In practice, however, the relationship can be much more complicated. The first complicating factor is disagreement among experts. Because disagreement undermines the weight of its advice, an expert committee is interested in maintaining internal unity and speaking with one voice. Consequently, its advice to the government can be negotiated knowledge. Nothing would be more detrimental to the committee’s prestige than demonstrating internal division. Second, if governments say to rely heavily on expert advice to justify hard policy decisions, experts risk getting involved in political disputes. Critics of these decisions will argue that the expert committee instead of the government is in the lead. In their joint evaluation of how the British government had managed the first stage of COVID-19, two committees of the House of Commons concluded that the government had failed to take a critical stance on the advice it had received from public health experts. The government should have given critical attention to the many uncertainties about the spread of the pandemic, the infection rate, the reproduction factor, and other issues (House of Commons, 2021).

10.9 Conflict resolution strategies

Conflicts need to be settled but how? This section gives an overview of important conflict resolution strategies. These strategies can be pursued in combination. 

Hierarchical decision-making

A hierarchical institutional structure makes it possible to settle conflicts through top-down decision-making. The responsible decision-maker or decision-making body is formally competent to make binding decisions. The practical meaning of this conflict-resolving mechanism should not be overstated. As spelled out in this book, the picture that policymakers can unilaterally impose binding decisions upon insurers, professional communities, regulatory agencies, and large provider organizations is a caricature of how health systems really work. Hierarchical decisions are usually ‘predigested’ in consultations and negotiations before ultimate decision-making takes place. What further makes conflict resolution by hierarchical decision-making less attractive is the lack of legitimacy in political and health systems with a political tradition of consultation and consensus-seeking. Conflict resolution by hierarchical decision-making is a strategy of last resort. 

Majority-voting 

Conflict resolution by majority voting is often the endpoint of a long trajectory of negotiations and revisions of legislative proposals to build a political majority in the Parliament. The formal decision-making procedure determines in which situations majority voting is necessary and which kind of majority (simple or qualified majority) is requested. The majority decides. Majority voting is considered an essential element of liberal democracy. If no majority can be built, policymaking inevitably stagnates. Box 10.2 illustrated how the absence of a political majority in the Dutch Parliament blocked the adoption of legislation on embryo research for many years. Conflict settlement by majority voting requires a governance structure that allows for this type of conflict resolution. Majority voting is problematic in policy networks in which actors are used to negotiating on par to reach an agreement.

Negotiated agreement (compromise)

Negotiating an agreement or compromise is the most common strategy to settle policy conflicts. The strategy is most effective when actors with differing preferences have a common interest in striking a deal (mixed-motive game). A process of give and take often settles distributional conflicts. Although the settlement may require tough negotiations, distributional conflicts are relatively easy to fix compared to governance conflicts. Conflicts on governance issues such as decision-making procedures or accountability structures miss an easy settlement because of their impact on future policymaking. Negotiating an agreement by give and take is also problematic in conflicts on moral issues, such as the authorization of a disputed new medical technology. A possible way out is to negotiate strict conditions for its use in practice. Negotiating detailed procedural arrangements for decision-making is another strategy to settle highly contested issues. 

Broadening the scope of negotiating

This strategy aims to facilitate the reaching of a negotiated agreement by extending the number of issues in the negotiating process. The strategy's rationale is to make accepting a loss on a specific issue easier in return for a win on another issue. 

Arbitration and reconciliation

If a conflict cannot be resolved by hierarchical decision-making, majority voting or negotiation, contestants may decide to install an arbitration committee consisting of trusted experts and an independent chairman to come up with a binding decision. The governance structure may also contain specific regulations on how to deal with deadlocks in decision-making. An example is the conciliation procedure in the European Union to settle conflicts between European Council and European Parliament (Greer et al., 2019).

Litigation

Filing a lawsuit is a frequently used strategy to settle conflicts. This strategy is used in situations where two or more actors conflict with each other on a specific issue and where actors request the court to revise or annul a policy practice. An example is the European Court of Justice ruling in 1998 that cross-border care was, in principle, not exempted from the principles of free movement of persons and services applied. Another example is the successful attempt of pro-life advocates in the United States to repeal its decision on the acceptability of abortion. 

Conflict avoidance

All strategies mentioned so far are explicitly intended to settle a conflict. An alternative strategy is conflict avoidance. Policymakers do not engage in a conflict, fearing that none of them might win the battle or considering it opportune to evade a conflict, at least for a certain period.

Conflict displacement

Policymakers can alternatively choose a strategy of conflict displacement by agreeing on a compromise that each actor interprets in its way. The conflict is not really resolved but postponed to later or displaced to another arena with other actors. Conflict resolution often appears only temporary.

Depoliticization

Finally, actors may follow a strategy of depoliticization, for instance, by waiting for better times, installing an expert body to study the issue and advice on new solutions, or agreeing on a cooling-off period. Alternative strategies are starting a dialogue in an informal setting or agreeing to disagree. 

10.10 Power

Power and conflict are inextricably connected. Accordingly, the conflict model of health policymaking underscores the impact of the power balance on decision-making in the health policy arena. Health policymaking and the organization of health systems are not the result of an information-based rational design but mirror the impact of the power balance in the health policy arena. The idea that health policymaking is primarily a morally-driven or information-driven activity directed at the optimal protection and promotion of public health is naïve because it ignores the role of power in policymaking, Policymaking, according to Hoppe (2011), is a matter of puzzling and powering. 

Conceptualization of power

What is power? In its simplest form, power can be defined as the ability of actor A (power holder) to determine the behavior of actor B (power subject). The power holder can decide what the policy subject must do or not do. Noncompliance is sanctioned. A subtler form of power is when the power holder is able to shape the political agenda or prevent sensitive policy issues from reaching the political agenda. This type of power is called agenda power. A radical face of power is thought control. Here, the power holder is capable to shape what power subjects should believe and prefer (Lukes, 1988). The emphasis on health education and promotion can be interpreted as a ‘light’ form of thought control. Thought control in its most extreme form is indoctrination and brainwashing.

Power is often distinguished from influence. While power refers to the ability to determine policymaking, influence is defined as the ability to shape policymaking through some form of pressure (Heywood, 2004). A clear demarcation line between power and influence does not exist. Interestingly, however, policymakers often prefer to speak about influence instead of power because of the negative connotation of the term power. They do not appreciate being seen as the power holder and prefer to mask their power in policymaking.

Power is both an instrument and a goal in itself. Actors use power as an instrument to influence or direct policymaking. Power is a precondition for them to align decision-making with their convictions and interests. At the same time, actors fight for power. They aim to protect or reinforce their power base. The pursuit of power belongs to the ‘heart’ of politics. Electoral loss means less power. Governance rules greatly affect the power balance in the health policy arena. The fact that these rules critically influence policymaking explains why contests on governance rules can be bitter. 

Power resources

Power rests upon resources or objective power. Important power resources in policymaking are formal position, governance structure, information and expertise, financial and human resources, majority of seats in the Parliament, direct access to policymakers, technical capabilities, friendly media, and authority. Actors seek to strengthen their power resources by forging alliances. However, power does not depend only on power holders' objective resources. It is as much a matter of perception or subjective power. Both power holders and power subjects can overestimate or underestimate the power of the other. Influencing each other’s perception of the power balance is therefore an important component of negotiating processes and power games. Bluffing is a well-known strategy to manipulate the opponent’s perception of the power balance (Bacharach & Lawler, 1981; Lewicki al., 2006).

Formal and informal power

Formal power differs from informal power. Actors with formal power may not act as the most powerful players in health policymaking. Top-level civil servants, individual members of Parliament, or leaders of major interest organizations can build up such a strong position in the health policy arena that they are able to direct decision-making. The inner circle of health policymaking does not necessarily coincide with the formal locus of policymaking.

Actors often derive their informal power from the collective structure of health policymaking and the corresponding high degree of mutual dependency in the health policy arena. Achieving health policy goals requires coordination between public and private actors, each of whom possesses specific resources such as expertise, capital, organizational capability, and formal competencies. If policymakers are heavily dependent on the resources of other actors and have no alternatives for these resources at their disposition, the owners of these resources can be tempted to exploit their strong negotiating position. This is what happened in the first stage of COVID-19 when countries had to pay skyrocketing prices for face masks and other protective equipment. The monopoly on the production of medicines enables pharmaceutical companies to follow a similar strategy.

Exercise of power

Power holders can exercise power in many ways. The exercise of power is most visible if the power holder uses authority-based instruments to push policy decisions through and enforce compliance with these decisions. Authority-based power strategies comprise a broad set of options, ranging from formal instruments to informal instruments, such as threats and intimidation. A subtler way of wielding power is the exercise of economic power or informational power. Actors who possess large financial resources to pay the best experts are likely to exercise more power than actors with fewer resources. This is why the struggle between corporate interests and public health advocates often resembles a struggle between David and Goliath. Another important form of wielding power is to push up the (political) price for cooperation. Actors make their willingness to cooperate contingent upon the extent to which their demands are accepted.

Enforcement power versus veto-power

From a policy perspective, power can be conceptualized as the capability of an actor to get something done. ‘Power to’ or enforcement power requires effective resources, including political and psychological capabilities (e.g. courage and perseverance) to overcome resistance to change. Important barriers limiting the state’s ‘power to’ are deficient governance rules, lack of financial resources or legal competencies, failed organizational capabilities, political fragmentation, and polarization. Notice that enforcement power involves more than the capability to push policy decisions through. Policymakers must also be able to implement these decisions and enforce compliance. The inability to implement policy decisions and enforce compliance indicates weak states.

The mirror image of enforcement power is veto power. An actor with veto power can mitigate, delay or obstruct the policy initiatives of another actor (in particular the state), for instance, through a successful lobby, a legal procedure to annul legislation, or the threat to do so. Other factors restricting the enforcement power of the state are political fragmentation, political division, and lack of legal competencies. Box 10.5 describes how medical associations in Switzerland, France, and Sweden made clever use of veto points in their country’s governance and political system to protect their interests in national health insurance. 

10.11 Power and information 

The central claim of the rational model in health policy analysis is that information-based policymaking is superior to policymaking driven by private interests, ideological struggle, and political games. In other words, evidence should trump power. The conflict model follows a different line of reasoning. Information is not conceptualized as input for policymaking but as an instrument in power games. Actors controlling access to information control the outcome of policymaking. Evidence does not trump power but, conversely, power trumps evidence. Thus, the conflict model puts the relationship between information and power on its head (Hoppe, 2011).

There are several ways for power holders to use information to serve their interests. The first way is to withhold or manipulate information. An alternative method is to use or produce information to influence policymaking. Unsurprisingly, corporations spend huge amounts of money on commissioning research that serves their interests. Actors who do not argue on the basis of ‘hard facts’ are in a disadvantaged position to actors who can refer to research to make their point. According to the European Corporate Observatory (2016), trade lobby groups and the food industry actively sponsor research projects to raise doubt about the health risks of their products and set industry-friendly parameters in legislation. The tobacco industry, well aware of the dangers of smoking as early as 1953, hired in top-scientists to obscure the truth of the causal relationship between smoking and lung cancer. ‘Doubt is our product’ ran the famous memo of the industry in 1969, ‘ since it is the best way of competing with the ‘body of facts’ that exists in the minds of the general public’ (Oreskes & Conway, 2010: p. 35). Recruiting experts who are sympathetic to their ideas and interests is a third method to influence policy decisions.

Power ultimately determines which information is accepted as ‘true’ or ‘untrue’ and how it should be interpreted. This is most salient in contests on information and the interpretation of information. Furthermore, power plays a decisive role in how policymakers deal with uncertainty. If information falls short, power ultimately fills the information gap. The power holder can be an astute and experienced actor but also a myopic or ideology-driven actor demonstrating disregard for information or politically unwelcome information.

Information is also an instrument of public health advocates. They use the instrument to influence the public and political agenda by raising attention to pressing public health issues, exploring uncertainties, bringing dubious practices to light, and unveiling the lobbying strategies of the corporate sector in health policymaking. 

10.12 The changing power balance in the health policy arena

The power balance can be defined as the distribution of power in the health policy arena. Two questions are central in the analysis of the power balance. First, how can this balance be measured empirically? Second, what does the structure of the power balance in health policy arena care look like, and which changes can be observed in this structure?

Mapping the power balance

There are various methods to map the power balance in public policymaking. The first method is taking the formal position of actors as an indicator of their power. Two major problems with this model are that formal and informal power may not coincide and that the impact of mutual dependency between actors is underestimated. Consequently, an analysis of the formal power balance based on formal positions may give a biased picture of the real balance. A governance structure that looks on paper centralistic may work in practice much less centralistic. An alternative method is to measure power by taking an actor’s power reputation as an indicator. This method allows for identifying other actors than the formal power holder(s) as real power holder(s). However, the reputation of actors may be biased, and respondents may disagree about the reputation of actors as power holders. A third method is to conduct a detailed analysis of the policymaking process to determine which actors most influenced the policy decisions made. Though this method overcomes the methodological problems inherent to both previous methods, it can be very difficult to determine with certainty who exercised power when and where, and for which policy issue. Decisive events behind the scene may remain unobserved.

Aside from these methodological problems, mapping the power balance in the health policy arena is difficult, most notably because the scope of health policy has enormously extended over time and because, parallel to this development, the health policy arena has become densely populated. The power balance is also issue-bound and contingent upon political, economic, and social conditions. The rest of this section briefly discusses five trends.

The increased power of the state

The power of the state has significantly increased, particularly in the 20th century. The publicization of public health (chapter 2) meant that the state has adopted political responsibility for ever more aspects of public health and built up an extensive repertoire of authority-based, treasury-based, information-based, and organization-based instruments to attain its health policy goals. Present-day state intervention is incomparable to state intervention in the 19th century, both in scope and intensity. Nevertheless, there are reasons for not overstating its real power. Lack of effective legal instruments and financial resources, manpower shortages, absence of a firm political majority, a political struggle within the government, the lobby of powerful interest organizations, mutual dependency, the need for political compromises, the fight for the preservation of established rights and the presence of veto-points restrict state power. The margins for policy change in a pluralistic and democratic society are small. The state must deal with multiple constraints to its power and cautiously navigate between conflicting preferences and interests. Implementation of policy measures is always a critical issue. The globalization of many public health problems requires ever more international cooperation. 

The rise and decline of the power of the medical profession

Through successful initiatives to organize themselves in interest organizations in the nineteenth century, doctors in many countries were able to build up a strong position in the health policy arena. The profession viewed medical care as its exclusive responsibility backed up by state regulation to guarantee the quality of medical care (Freidson, 2001). The profession also successfully fought for the preservation of its material interests. On various occasions and in many countries, doctors successfully thwarted or accommodated policy initiatives they perceived as a threat to their exclusive position or material interests (Wilsford, 1991; Marmor & Klein, 2012). Remember that the introduction of the National Health Service in the United Kingdom could only be realized after Bevan had struck a compromise with the consultants and the British Medical Association. Nevertheless, the traditional power of the medical profession has weakened. The enormous differentiation within the profession resulting in ever more specialties makes it difficult to speak with one voice. Nurses and patients have organized themselves to articulate their interests. Another important factor is the penetration of the health policy arena by the corporate sector. Health has become business with huge financial interests. 

The declining power of employers and employees

Employers and employees have always had a stake in health policymaking. The primary interest of employers was to contain costs of health care and the primary interest of employee organizations to improve access to health care and achieve a fair distribution of the financial burden of health care. On the European continent employee associations have always supported the introduction of public financing arrangements to establish a solidarity-based distribution of the financial burden. In the United States, they have been less successful. Navarro mentions the absence of strong unions in combination with the lack of a mass-based socialist party as the most important explanation for the fact that the United States has no national health insurance or national health service (Box 10.6).

Employers and employees have lost some of their traditional strength in health policy­making. An important cause of this development is the emergence of new powerful actors in the health policy arena. 

The rising power of the corporate medical sector 

The emergence of a vast corporate medical sector, including large provider organizations (both for-profit and not-for-profit), health insurers and other financial agents, the pharmaceutical industry, and the providers of medical equipment and ITC services has fundamentally altered the power balance in the health policy arena. A sector with immense financial interests is the pharmaceutical industry. Research shows that the industry nowadays controls nearly the entire biopharmaceutical chain in cancer care and does so with clear economic interests. The invention of new medicines is closely associated with the rise of the pharmaceutical industry as an economic and political power in health care. The industry has set up a vast network of national and transnational organizations to represent its commercial interests in policymaking at the national and international level (e.g. the European Union). Key topics for the industry are market authorization of new medicines, price regulation, patent regulation (extension of monopoly rights), and international trade regulation (Angell, 2005). The sky-rocketing prices of new medicines illustrate how the industry is able to exploit its market power governments have been unable to cope with effectively. An interesting question is whether government and non-governmental organizations representing public interests can restrict the industry's market power. In some European countries, state agencies have successfully fined the industry for unjustified skyrocketing prices.

What has been said about the rising power of the pharmaceutical industry also applies to other corporate players. The rise of a vast health insurance industry has fundamentally altered the traditional power balance between industry and the medical profession. A new development with potentially far-reaching consequences for the structure of power relations in health policymaking is the ‘Googlization’ and datafication of health care (Sharon, 2021). The consequences of this development can hardly be overseen yet, but one may expect a further penetration of the new information industry into public health. Paradoxically, this development also enhances the toolbox of the state to control social life for reasons of public health. 

The rise and power of new commercial interests

The extension of the scope of health policymaking to more fields in public and social life has boosted interest representation. Emblematic is the fight of the tobacco industry against tobacco control regulation. However, the tobacco industry is not the only corporate sector that has used its power to obstruct unwelcome legislation (Mindell et al., 2012). For instance, the producers of alcoholic drinks also have a history of lobbying against market regulation and taxes to restrict or discourage the use of alcoholic beverages (Savell et al., 2016; Atkinson et al., 2021) and the food industry against, among others, soda taxes, unrealistic food safety standards, and state-sponsored dietary advices (Nestle & Wilson, 2012; Corporate European Observatory, 2016). The industry also successfully fought against an initiative of the European Union to regulate the provision of food information to consumers (Nestle, 2002; Nestle & Wilson, 2012; Grant & Stocker, 2009) by arguing that this initiative reeked of paternalism and that soda taxes would lead to social injustice because persons on low-income would no longer afford to pay for their products. New regulation in the United States has made it easier for companies to challenge government-funded research they do not appreciate. After the World Health Organization had issued a list of recommendations on food milk, US producers, in vain, used its political influence for lobbying a withdrawal of the United States from this organization (Nestle & Wilson, 2012).

An interesting new development concerns the initiatives of non-governmental organizations to file lawsuits against the industry for unethical practices. There are some examples of success. For instance, pharmaceutical companies that were accused of abuse of their market power at the expense of public health have been compelled to admit the production and admission of generic medicines against HIV in South Africa. In some countries, including the Netherlands, the Pharmaceutical Accountability Foun­dation has successfully started a legal complaint against a pharmaceutical company (Leadiant) that had raised the price of an off-label medicine by 500% after it acquired exclusivity status of the European Medicines Agency (box 5.3).

10.13 Conclusion and suggestions for health policy analysis

The conflict approach to health policymaking fundamentally differs from the rational approach. Whereas the rational approach conceptualizes health policymaking as an information-driven or intellectual search for the best solution, the conflict approach postulates that conflicts shape health policymaking. Health policy and health systems are not the result of a consistent design but rather the product of past political compromises between actors with incongruent preferences. Conflicts are inherent to policymaking in a democratic and pluralist society. Though conflicts are a risk to the problem-solving capacity of health systems, the reverse is equally true: conflict-free policymaking is a risk to the problem-solving capacity of health systems.

Conflict and power are inextricably interconnected: the outcome of policy con­flicts is contingent on the power balance in the health policy arena. Information is an important policy instrument in the hands of the power holder to direct health policymaking. Science (expertise) is politicized by making it an object of or an instrument in political struggle. The power balance in health systems has a complex structure. While it is true that the state has strengthened its power base in health policymaking, its power should not be overstated. The political pressure of interest groups constrains the room for state health policymaking. Corporate interests use a variety of tactics to pursue their interests and resist legislation that will harm their profitability. 

The conflict model opens an important field of research in health policy analysis. Below is a list of research suggestions:

• Which conflicts dominate health policymaking concerning preselected state inter­ventions? What is the object of these conflicts, and which actors are involved in it? Does the conflict ensue from (deep-rooted) normative convictions, clashing interests or both?

• How did a conflict unfold over a more extended period of time? Has the conflict an incidental structure or does it extend over a longer period?

• What type of conflict is it (moral, informational, distributive, and so on)? Is it a conflict with or without a common interest? 

• Has the conflict-potential of a given policy issue increased or decreased and which factors explain the increase or decrease of its conflict potentiality?

• What is the impact of conflicts on the problem-solving capacity of the health system? 

• Are there indications of a politicization of science? Is science the object of a conflict or used as an instrument in a conflict? Are there indications of motivated reasoning?

• Are there indications of politicization of the expert-policymaker relationship?

• Which strategy or strategies are used to settle a policy conflict? 

• What is the structure of the power balance in health policymaking and which changes in this balance can be observed? To what extent does the formal power balance coincide with the informal balance?

• Which factors increase or decrease the enforcement power of the state in health policymaking? Are there any veto-points in the governance structure and how are these exploited in the policymaking process? 

• Is information used as a power instrument, and, if so, by whom and in which way?

The conflict model has consequences for health policy analysts in their advisory role to policymakers. Their task is to support policymakers in unraveling conflicts, reflecting the conflict potential of state intervention, considering the consequences of conflicts for policymaking and relationships in the health policy arena, identifying the potential proponents and opponents of state intervention, and developing strategies to overcome resistance or build up a political majority. Another task is to support policymakers in understanding their opponents’ strategies and developing effective counterstrategies.

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