Box 2.1 gives a brief view of the history of tobacco control policy in the Netherlands. Tobacco control became a policy issue in the mid-1970s because of mounting evidence of the harmful effects of smoking on health. In reaction, the tobacco industry organized a powerful and initially successful lobby against tobacco control measures that would undermine its commercial interests. The tobacco lobby used its excellent contacts with the Ministry of Economic Affairs to protect its commercial interests within the ranks of the government. The industry’s prime opponent was the Minister of Health, but her attempts in the nineties to discourage smoking and protect non-smokers against the risk of passive smoking met much political resistance. What also hindered her attempts to issue legislation was opposition in the Parliament. Right-wing political parties rejected legislation as an infringement of freedom of choice, while Christian Democrats criticized her legislative proposals as ‘too detailed and patronizing’. The brief history of tobacco control policy in the Netherlands demonstrates the impact of scientific evidence, lobbying, decision-making structures, political struggle, power relations, normative beliefs, and institutional structures upon health policymaking. Health policymaking is not only a matter of setting policy goals and selecting policy instruments to attain these goals but also a political struggle between proponents and opponents of tobacco control legislation in a changing social and political context.
This book aims at presenting an introduction to health policy analysis drawing upon concepts and insights from political science. Its purpose is to familiarize students with concepts and models to study health policy choices and health policymaking from a political perspective. The focus is on the role of health policymaking by the state, but the presented concepts and models can equally be used for health policymaking at the regional, local level or international level. This chapter describes a conceptual model for health policy analysis.
Box 2.1 How the tobacco lobby influenced tobacco control policy in the Netherlands
The political battle intensified in the 1990s after the publication of a government plan for a smoking ban in public spaces to protect non-smokers. The tobacco lobby used its contacts with industry-friendly parliamentarians, top-level civil servants, and the government to get this ‘infamous’ plan off the table. Political parties that emphasized free choice and individual responsibility supported the industry’s claim that a ban would devastate the national economy. The tobacco industry promised a system of self-regulation as a much better alternative. Although in the defensive after increasing evidence of the harmful health effects of smoking, the tobacco lobby managed to mitigate the first Tobacco Act in the 1980s. The government had to delete its plan to restrict the sales of tobacco products to specialty shops and introduce a ban on tobacco advertising from its initial legislative proposal.
For many years, the Ministry of Economic Affairs acted as the prime contact of the tobacco lobby. The excellent and ‘behind the scene’ connection of the National Employers Association with the Ministry was invaluable in warding off unwelcome policy measures. The lobby also used the Ministry as its main venue to support the economic interests of the tobacco industry in EU policymaking on tobacco control.
An important event occurred in 1996 when the primary responsibility for tobacco control policy shifted to the Health Department. The Minister of Health, who had a medical background, announced firm measures to decrease the number of smokers and protect non-smokers against the risk of passive smoking. However, her plan for a workplace smoking ban was skipped in the cabinet. Other proposals were a complete ban on tobacco advertisements and sponsorship, further sale restrictions, an age limit of 18 years for the sale of tobacco products, and financial sanctions for infringements. Once again, her legislative proposal met with much opposition. The tobacco lobby and the National Employers Association responded furiously, particularly because of the Minister’s plan to terminate the system of self-regulation which she held for ineffective: ‘It must be clear to you that we do not accept a more paternalistic government’ (p. 210). The parliamentary debate on the proposal in 2001 took almost 12 hours. Right-wing parties argued against a public smoking ban and an advertising ban. The Christian Democrats qualified the bill as ‘too detailed and patronizing’. After some concessions and promises, the bill was nevertheless adopted by the Lower Chamber. The Upper Chamber followed in 2002, again after a lengthy debate.
Despite a relatively positive stance toward the tobacco industry of some recent ministers of Health, the tobacco lobby has largely lost its grip upon tobacco control policy since the turn of the century. International developments, in particular, EU policymaking on tobacco control and the adoption of the WHO Framework Convention on Tobacco Control in 2015, played a prominent role in this respect. The social and cultural context of smoking has also radically altered. Was tobacco in the past seen as usual, even on television, nowadays it is no longer.
Has the government’s tobacco control been effective? Recent figures reported by the Trimbos Institute indicated that the percentage of adult smokers has dropped from 25,7% in 2014 to 18,9% in 2022. The rate of heavy smokers (a minimum of 20 cigarettes a day) was 2.4% in 2022. High-educated persons smoke less often than the rest of the population. In 2002 more than one-third of smokers had tried to stop smoking in the previous twelve months.
Source: Willemsen, 2018; website Trimbos Institute
Health policy analysis encompasses the analysis of and for health policymaking. Its purpose is to acquire empirical knowledge on health policy and health policymaking that can be used in the daily practice of health policymaking. In this respect, a distinction can be made between policy-issue knowledge and policymaking knowledge. Policy-issue knowledge is pertinent to a specific policy and involves specialized knowledge concerning a specific policy problem. Policymaking knowledge, on the other hand, comprises knowledge of how policy choices are made and put into practice (Dror, 1968).
Tobacco control policy illustrates the difference between policy-issue knowledge and policymaking knowledge. Policy-issue knowledge involves, among others, knowledge about the harmful effects of smoking on health. Smoking is an important cause of lung cancer and several other diseases including COPD (chronic obstructive pulmonary disease), cardiovascular diseases, gastric ulcers, and Crohn’s disease. It also negatively influences the development of other diseases (e.g. degenerative diseases). Furthermore, nicotine in tobacco products has an addictive effect. Policy-issue knowledge further includes epidemiological knowledge of smoking behavior, for instance, that smokers live approximately five to ten years shorter than non-smokers. Epidemiological studies also give insight into the development of smoking behavior, the spread of smoking across men and women, youngsters smoking, and socio-economic categories. It speaks for itself that policy-issue knowledge on smoking is of critical importance for successful tobacco control.
Health policy analysis puts other issues central. For instance, what were the goals of the tobacco control policy of the Dutch government, and which instruments did it use to restrict the number of smokers? How did the quest for tobacco control reach the political agenda? Which actors played a prominent role in tobacco control policymaking? How was the anti-tobacco control lobby organized and how did its influence on health policymaking compare to the influence of the pro-tobacco control lobby? Which instruments did anti-tobacco control lobbyists use to thwart tobacco control policy? Has lobbying been successful? What was the role of science in tobacco control policy? Which normative beliefs influenced political decision-making on tobacco control policy? Has tobacco control been effective? How has tobacco control policy in the Netherlands developed since the mid-seventies, and how does it compare to tobacco control policy in other countries? What is the role of the World Health Organization and the European Union in tobacco control policymaking?
The purpose of this book is to train students in health policy analysis. Successful health policymaking requires not only policy-issue knowledge but also policymaking knowledge. However, this book focuses on the policymaking dimension of health policy. This choice has two reasons, one practical and one more fundamental. The practical reason is that many excellent studies with policy-issue knowledge on public health are available. By contrast, the policymaking dimension has received less systematic attention, though there are exceptions (Buse et al., 2005; Oliver, 2006; Walt, 1996).
The second reason for focusing on the policymaking dimension relates to the aversion to ‘politics’ in circles of public health professionals. Brown (2010) attributes this aversion to the subjective nature of policymaking and the role of power relations and competing interests in the health policy arena. These characteristics contrast with the alleged scientific and objective nature of public health knowledge. Health policymaking should remain free of political considerations and be unequivocally directed at the protection and promotion of public health. However, this aversion to the political dimension of health policymaking is misjudged because it ignores the daily practice of health policymaking. Although policy-issue knowledge should always be leading in policymaking, public health experts need a good understanding of the political dimension of health policymaking to be effective. It is naïve to believe that policy-issue expertise only is sufficient for success, the more so because expertise is frequently disputed. Experience shows that even hard evidence of potential interventions' (in) effectiveness never automatically finds its way to practice. Evidence never magically turns into solutions (Greer et al., 2017). Public health professionals cannot escape from this hard reality.
Figure 2.1 is a simple model of health policy analysis as worked out in this book. It brings together building blocks (basic concepts) that are central to conducting health policy analysis.
Health policy in Figure 2.1 refers to the policy goals and instruments to achieve these goals, the assumptions underpinning the formulation of the policy goals, and the choice of policy instruments. Process refers to the policymaking process which involves the dynamic process of events, decisions, and actions concerning public problems. Actors refer to the persons and organizations participating in the policymaking process. Governance structure refers to the rules for policymaking. For instance, who is in charge of decision-making and policy implementation? Other key concepts are accountability, transparency, and integrity. Effects refer to the results or outcomes of policymaking. For instance, to what extent have the policy goals been achieved (effectiveness), and at what costs (efficiency)? What is known about the side effects of policymaking, or its short-term and long-term effects? Health policymaking and health policy effects are influenced by contextual factors. The previous chapter contained a concise description of six important contextual factors (culture, demography, economy, technology, politics, and globalization) and their impact on health policymaking.
Finally, our model of health policy analysis includes four analytical models each of which provides an analytic lens alerting policy analysts to specific aspects of the policy content, the policymaking process, the actors participating in the policymaking process, the governance structure, and policy effects. The four models are the rational, conflict, normative, and institutionalist model.
The rational model conceptualizes health policymaking as a process driven by information and argumentation. The model corresponds with an instrumentalist perspective on health policymaking. Health policymaking is analysed as an information-based attempt to resolve public health problems. A central concept is evidence-based health policymaking. What does this concept mean and what are its limits? Another theme inherent to all health policymaking is uncertainty and risk. How do policymakers seek to eliminate or restrict risks that are (potentially) harmful to public health?
Health policymaking is fraught with complex moral dilemmas concerning the balance between the ‘public good’ and the ‘individual good’. The central proposition of the normative model is that all health policymaking rests upon explicit or implicit normative orientations. Health policymaking should not be reduced to an information-driven and technocratic process; it is also a morally-driven activity.
The conflict model is the opposite of the rational model. It postulates that health policymaking is not the outcome of rational choice but the outcome of conflicts. Power trumps evidence instead of the other way around. There are many types of conflicts in health policymaking and several strategies for conflict resolution. Two concepts closely interwoven with conflict are the politicization of information (science) and power. The power balance and power strategies influence the settlement of conflicts and, consequently, the content and outcome of health policymaking.
The institutionalist model conceptualizes health policymaking as an ‘embedded’ process: health policymaking is ‘regulated’ by formal and informal rules (institutions) on what is regarded as true or untrue, what works or does not work, and what is morally acceptable or unacceptable. These rules are often rooted in the past and create some order in policymaking. They make policymaking largely path-dependent. A central proposition of the model is that health system changes and policy changes develop evolutionary rather than radically. Two important themes are institutional continuity and institutional change.
The rest of this book consists of two parts. The second part makes students familiar with five building blocks of health policy analysis.
Chapter 3 discusses the concept of public policy and its constituent elements. Attention will be paid to the political construction (framing) of policy problems, the goals, and instruments of public policy, the underlying policy paradigm or set of assumptions or beliefs underpinning the choice of policy goals and policy instruments, and the importance of an appealing policy narrative.
Chapter 4 introduces the concept of the policymaking process that can analytically be thought of as consisting of five consecutive stages: agenda-building, policy development, policy formation, policy implementation, policy evaluation, and policy termination. Furthermore, attention will be paid to two alternative analytical models of the policy process: the rounds model and the crisscross model. The rounds model postulates that policy processes consist of various decision rounds, often with alternating policy actors in new policy arenas. The crisscross model underscores the interconnectivity of policy processes. The final topic discussed is policy path, police expansion, and policy contraction.
The focus in Chapter 5 is on actors operating in the health policy arena. It starts with the classification of actors and the concept of health policy arena. Two central concepts are policy network and interest organization. Furthermore, the chapter includes a discussion of the role of experts, provider organizations, citizen groups, media, public opinion, and the judiciary in health policymaking. The final part of the chapter examines the international health policy arena. Special attention will be paid to the role of the World Health Organization and the European Union in containing the spread of the coronavirus.
Chapter 6 discusses health policymaking from a governance perspective. What are the rules for the production of policy? How do governance rules influence the effectiveness and legitimacy of health policymaking? The chapter investigates several alternative governance models and their impact on health policymaking. The final part of the chapter analyzes the complexity of global health governance using two examples: the International Health Regulations and WHO Framework Convention on Tobacco Control.
Chapter 7 includes a discussion of policy effects. It describes various types of policy effects, including side effects and counterproductive effects, as well as the concept of system performance (problem-solving capacity) and the concept of health system resilience. Another category of effects includes political effects. These effects relate to the political construction of policy effects and their consequences for health policymaking.
The third part introduces four analytical models to study health policymaking and gives insight into how they can be used in health policy analysis. The rational model is the topic of discussion in Chapter 8, the normative model is the topic of discussion in Chapter 9, the conflict model is topic of discussion in Chapter 10, and the institutionalist model is topic of discussion in Chapter 11. The final chapter briefly summarizes the five building blocks and four models.
Buse K, Mays N, Walt G (2005). Making Health Policy. Open University Press.
Dror Y (1968). Public Policymaking Reexamined. Chandler Publishing Company.
Greer S (2017). Medicine, Public Health and the Populist Radical Right. Journal of the Royal Society of Medicine, 110(8): 305-308. doi:10.1177/0141076817712250
Oliver T (2006). The Politics of Public Health Policy. Annual Review Public Health, 27: 195-233. doi:10.1146/annurev.publhealth.25.101802.123126
Walt G (1996). Health Policy: An Introduction to Process and Power. Zed Books.
Willemsen M (2018). Tobacco Control Policy in the Netherlands: Between Economy, Public Health and Ideology. Palgrave MacMillan.