KEY POINTS:

• Health policy is defined as the collective effort of policymakers to achieve health goals by means of policy instruments during a certain time span. 

• Health policymaking is both an information-driven and politics-driven activity. Health policy is a combination of puzzling and powering.

• Health problems can be conceptualized as a political construct. The political con­struction of these problems involves the perception of a gap between a norm and an observed or expected situation or process, the perception of uncertainty and risk, the identification of the problem-owner(s) and problem-subject(s), and a causation story on how the problem has come about and who can be held responsi­bility for it. 

• Problem definition and health policy are closely connected. Problem definition gives direction to policymaking. 

• A distinction can be made between structured problems, moderately structured problems, and unstructured problems. 

• ‘The formulation of a wicked problem is the problem’ (Rittel & Webber, 1973).

• The concept of policy resolution is misleading because it suggests the possibility of a definite solution. 

• A distinction can be made between short-term, mid-term, and long-term policy goals, between intermediate and ultimate policy goals, political goals, and between quan­ti­fied and non-quantified policy goals. 

• A distinction can be made between authority-based, treasury-based, information-based, and organization-based policy instru­ments. A relatively new instrument is nudging. There are multiple criteria for the choice of policy instruments.

• Health policy rests upon a policy paradigm (policy belief) defined as the set of assumptions underpinning a policy. 

• Health policy requires an appealing narrative to be effective. An effective nar­rative consists of a well-crafted blend of logos, ethos, and pathos.

• Two well-known stories are the story of decline and the story of control. 

3.1 Introduction

The history of alcohol policy in the Netherlands is a history of gradual intensification. In the early nineteenth century, alcohol abuse was still viewed as the responsibility of local government. Only after decades of social and political pressure the state enacted the first Drink Act. The evolution of Dutch alcohol policy followed a path of continuous revision and extension. While the 1881 Act had primarily been intended to address the problem of public drunkenness and maintenance of public order, the policy goals of alcohol legislation have gradually been extended to moderate and discourage alcohol consumption and tackle the problem of alcohol consumption at a young age. The burgeon­ing stock of knowledge on the adverse health effects and social costs of alcohol consumption (De Wit et al., 2014) has stimulated the intensification of alcohol policy.

As in many other countries (Madureira & Galea, 2018), state policymaking on alcoholic drinks has always been a controversial issue in the Netherlands because of economic interests and ideological division. Opponents to strict regulation warned of the emergence of a ‘nanny state’. The alcohol lobby resisted, obviously for commercial reasons, each attempt to discourage the consumption of alcoholic drinks. Its message was that people should practice prudent drinking.

Alcohol policy is an example of health policy, the first building block in our model of health policy analysis (Figure 2.1). This chapter gives an overview of the basic elements of health policy. It starts with the conceptualization of public policy and the relationship between policy and politics. The purpose of health policy is to address public health problems. However, these problems have no ‘objective’ status and should be understood as political construct­ions. The next section introduces a classification of health problems. While some health problems are well-structured, other problems are ill-structured and difficult to resolve. Each policy consists of policy goals and policy instruments to achieve these goals. Two other important elements of health policy are policy paradigm and policy narrative. The policy paradigm encompasses the system of policy assumptions under­girding the formulation of the policy goals and choice of policy instruments. The purpose of the policy narrative is to legitimize public intervention and build public support for it. The big challenge for policymakers is to craft a persuasive and appealing narrative. The final section discusses the implications of the insights gained in this chapter for health policy analysis. 

3.2 What is public policy?

Policy is a concept with various meanings in the practice of policymaking (Colebatch, 2009). In some contexts, policy means a plan of action (‘my policy is …’) or a certain practice of thinking and doing (‘our policy in these circumstances is to act as follows …..’). In another context, the concept refers to policy decisions taken during a certain period (‘our policy over the last few years has been ……’). Policy is not only associated with argumentation and information (‘our policy rests upon evidence and experience’) but also with conflicts (‘we had to fight hard for this policy’). Policy is closely associated with politics which is defined in this book as the struggle for policy (Hoppe, 2010). While politics with a ‘big P’ is concerned with strategic questions on policy goals and instru­ments, politics with a ‘small p’ refers to daily skirmishes on the formulation of regulations, the determination of budgets, the contacts between actors, and many other tactical issues. 

According to Colebatch, policy refers to three underlying themes in contemporary Western discourse. First, the concept suggests order and consistency: poli­cy is the opposite of arbitrary or capricious action. Second, policy is associated with authority: it is endorsed by public authorities. The third theme is expertise: the term policy suggests that the course of action draws upon analysis and judgment by experts such as economists, legal experts, or experienced administrators (Colebatch, 2009). 

The concepts of policy and policymaking are closely connected with a dominant theme in Western discourse: the malleability of society. Policy is seen as a more or less deliberate strategy to direct and organize society. Policymakers see it as their task to resolve public problems. Though their resolutions may be disputed, pro­blem resolution is what the population expects from them. However, the term policy resolution is a misrepresentation. As will be explained below, many public health problems miss a resolution in the literal sense of the word.

Multiple definitions of policy

The multiple meanings of policy resonate in the definition of the concept in the literature on policymaking. Marmor and Klein (2012) describe a policy as ‘what governments do or neglect to do’ (p. 1). Their definition associates policy with govern­ment intervention and non-intervention. A problematic aspect of this definition is the explicit connection of policy with the government. As will be discussed in various places in this book, health policy must be understood as collective action with the government as only one actor among many in the policymaking process. An interesting aspect of their definition is the option of policy as ‘doing nothing’. The Dutch government abstained from regulatory measures to address the problem of alcohol abuse for a long period in the nineteenth century because it considered it a matter of concern for municipalities. Two other reasons for policy abstention are that state intervention can do more harm than good, or that intervention is judged unnecessary because of self-correcting mechanisms in society.

Jenkins (1978) defines policy as ‘a set of interrelated decisions taken by a political actor or group of actors concerning the selection of goals and the means of achie­ving them within a specific situation where these decisions should, in principle, be within the power of those actors to achieve’ (p. 15). This definition includes several important elements. First, the expression ‘a set of interrelated decisions’ suggests order and consistency. Second, the definition associates policy with goals (or objectives) and means (instru­ments). Policymakers formulate policy goals and select policy instru­ments to achieve these goals. Third, Jenkins’ definition connects policy with power: the choice of policy objectives and policy instruments should be ‘within the power’ of the policymaker. This element reminds us that policymakers often struggle with complex internal and external constraints such as lack of resources, formal and informal obstacles, political pressure, changing political circumstances, and sometimes even the absence of (legal) instruments. Their demanding job is to navigate between conflicting demands and interests. Desirable policy alternatives may be beyond the scope of feasibility for political, social, economic, judicial, or other reasons. The margins for policy change in a pluralistic and democratic society are usually small. As said before, the malleability of society is in many situations less than policymakers suggest or hope for. 

Definition of health policy

In this book, health policy is defined as the collective effort of policymakers to achieve health goals by means of instruments during a certain time span. This definition contains elements that need elaboration. First, it includes the terms policy goals (health goals) and instruments. Policy goals refer to a desirable situation policymakers want to achieve through the usage of policy instruments. 

The term collective effort indicates that health policy is not the product of a single actor but the outcome of a process many actors participate in. The term policy­maker refers to people and organizations that are closely involved in the policymaking process. Examples are the government, the minister of Health, the Department of Health, other government departments, members of Parliament, inspectorates, state agencies, and municipalities, each with its tasks, competencies, resources, and responsibilities. Stakeholder organizations representing the interests of healthcare providers, patients, citizens, the pharmaceutical industry, the tobacco industry, the food industry, the automobile industry, and many other actors participate as it were ‘from outside’ in the policymaking process. They exert pressure on policymakers by arti­culating their interests. Sometimes, some of them are so closely involved in policymaking that they actually act as co-policymaker.

The term effort in the definition expresses that a policy consists of more elements than documents and public statements. It also comprises decisions on policy goals and instruments (policy decisions) and activities to put these decisions into practice. Many policies develop their true face in the stage of policy implementation. Consequently, health policy analysts cannot confine themselves to an analysis of policy documents and public statements. They must be aware of a potential discrepancy between promises and decisions on the one hand and the ‘real world’ of health policy on the other hand. In other words, health policy analysis involves an investigation of how policies are put into practice. 

Finally, the definition includes the phrase ‘during a certain time­span’ to indicate a policy is no one-shot operation. The government’s health policy is its policy during a certain period. 

Problem-oriented policy and process-oriented policy 

Problem-oriented policies are directed at the resolution of issue-related problems. Examples are policies to improve healthcare quality, shorten waiting times, control health­care costs, quit smoking, or contain the spread of infectious diseases. These policies ask for expertise (policy-issue knowledge) from the medical profession, public health experts, legal experts, health economists, and other experts. Process-oriented policies on the other hand are concerned with the organization of the policymaking process. Typical process-oriented issues are the organization of decision-making or policy implementation, the development of strategies to overcome political resistance, and initiatives to foster accountability and transparency in policymaking. Pro­cess-oriented policy requires a different kind of expertise including, among others, expertise on the organization of complex organizations and inter-organi­zational rela­tions, a well-developed antenna for political threats and opportunities, commu­nicative skills, and know­ledge on how to deal with media. Problem-oriented and process-oriented policies are always closely intertwined. Successful policymaking requires both a problem-oriented and process-oriented approach. The best problem-oriented policy is of little value if it gets stuck in the labyrinth of the policymaking process. 

Health system reform

Health system reform is a specific type of health policy. Again, there is no universally accepted definition of health system reform. Policymakers assign different meanings to the concept and sometimes even ‘sell’ marginal or incremental policy changes as reforms, usually for political reasons (Saltman & Figueras, 1997: 2). In this book, health system reform is conceptualized as a collective effort directed at a major overhaul of a country’s health system. It is an orchestrated effort to bring about ‘system change’ drawing upon the belief that the existing system is failing or unable to respond adequately to future challenges. Health system reform can be directed at the provision of health care (e.g. sub­stituting primary health care for specialist care or introduction of diseases management programs), the financing of healthcare (e.g. the introduction of social health insurance or extending its scope), the payment of providers (e.g. the shift from a fee-for-service model to global budgeting or a quality-adjusted payment model) or the governance of health care (e.g. decentralization of health policymaking or the introduction of a model of regulated competition in health care). A comprehensive reform aims to restructure the financing, provision, payment of providers, and the regula­tion of health policymaking. 

Successful health system reform requires a well-crafted process-based ap­proach. Knowing that reform plans always meet political resistance and other obstacles, reformers must develop a strategy to accommodate their reform plans to these obstacles for being successful. They must balance the need for a carefully crafted implementation trajectory and flexible adaptation to changing circumstances. Two other challenges are the balance between central direction and local discretion, and the pace of the reform process. Which room should be left for policy learning and local accommodation? Is a ‘big bang’ or a ‘blueprint’ approach the most appropriate strategy to restructure the health landscape (Tuohy, 2018)? These questions demonstrate the need for a well-designed process-oriented strategy. Even the best reform plan may be deadlocked in a swamp of political resistance, setbacks, and delays. 

Health policy as a multi-layered cake

Many health policies have a complex structure. They are made up of multiple, not seldom conflicting, goals that are pursued by a broad repertory of policy instruments. What is presented as the government’s policy may actually consist of many interlocked policies. Quality management and cost control cut across all health policy­making. Large parts of health policies are closely connected with other public domains, such as public security, public financing, education, and international trade. Health policy initiatives to tackle the problem of overweight, depression, or other major health problems require a comprehensive and intersectoral approach. Other factors explaining the complex structure of health policy are the ambiguity of stated policy goals and instruments, the conversion of words into concrete action (policy implementation), the uncertainty problem and dilemmas policymakers cope with, resistance and political division as well as the involvement of many actors at different political/administrative levels in the policymaking process, each with their own goals, interests, expertise, conventions, and standard operating procedures. Other complexity-increasing factors are the co-existence of differing versions of the same policy, the possibility of a gap between the paper version of a policy and daily practice, and the occurrence of policy changes, some­times even in a short period as happened during COVID-19, to accommodate policy activities to altered circum­stances or new information and insights. Health policy can be best typified as a ‘multi-layered cake’ of ideas, decisions, structures, and processes. Most policies have a less coherent and consistent structure than pretended in policy documents or public statements. 

3.3 The double face of health policy

As pointed out by Colebatch, policymaking is associated with rationality and deliberation. The choice of policy goals and policy instruments should draw upon infor­mation, analysis, arguments, and professional expertise. Health policymaking should be organized as an information-driven activity directed at finding ‘optimal solutions’ for policy problems with experts and experienced people in the driving seat. This is the instrumentalist or technocratic dimension of health policy. 

However, health policymaking has a political dimension too. It involves making choices concerning the goals that should be achieved, the instruments that are used to achieve the stated goals, and the time horizon. These choices certainly contain technical elements but cannot be reduced to a technocratic exercise only. This is because health policymaking takes place in an environment characterized by divergent value orien­tations, conflicting interests, inter-organizational rivalries, hard and subtle power games, party politics, the need for political profiling, and so on. Many policy decisions are actually negotiated agreements (compromises) to settle conflicts rather than the outcome of an information-driven process. The absence of political escape routes sometimes results in a policy deadlock that may drag on for many years. Health policy is, according to Hoppe (2010), the outcome of a combination of puzzling and powering. This is the double face of health policy. 

The contested nature of health policymaking is no surprise. Health has become an overriding value or, as Lupton (1995) has put it, an imperative. Health issues deal ultimately with the question of who shall live and how. Health policy has direct consequences for health services' access, quality, and costs. The population also expects state protection from health risks beyond individual control. At the same time, health policy interventions frequently evoke political resistance. Population-based inter­ventions that are obvious to public health professionals can be hard to sell to generalist policymakers, for instance, because voters assign low priority to improvements in public health or because hard evidence of their effectiveness is absent. State interventions may also stir controversies regarding their legitimacy. Besides, public health interventions frequent­ly clash with commercial interests. Finally, public health and health care in particular have developed as a multi-billion sector with huge material interests (Starr, 1982). The history of health policymaking offers many examples of the contested nature of health policy issues such as abortion, mass vaccination, tobacco control, food safety, co-payments, health insurance legislation, doctors’ revenues, or the profit-driven strategies of ‘big pharma’. In many situations, the state’s enforcement power appeared less strong in practice than formal decision-making and accountability rules suggest. Due to strong pressure from both inside and outside, the margins of policymaking and policy change are often small. The problem-solving capacity of health policy is less than pretended or hoped for. 

Communication is another aspect of the political dimension of health policy. While some health policy decisions go unnoticed, other decisions draw public attention, particularly if they have direct consequences for people. COVID-19 is a textbook example of this situation. How must policymakers communicate about their choices, dilemmas, and uncertainties in the knowledge that public confidence is pivotal for policy success and can easily dissipate? Health policy requires a credible, persuasive, and appealing policy narrative to build and maintain public confidence where political opponents do not hesitate to discredit policy failure for political gain.

The double face of health policy means for health policy analysts that they avoid the mistake of reducing health policy to an information-driven and instru­mental activity. They must understand its political dimension. Disparaging the political face of health policy is unprofessional and naïve. Accordingly, one of their tasks is to make policymakers aware of the political face of health policy.

3.4 Health problems as political construct

The purpose of health policymaking is to pursue public health by resolving public health problems. A problem refers to a perceived gap between a desired situation or process (norm or standard) and an observed or expected situation or process. The challenge is to bridge this gap.

Health problems have no objective status. They are not ‘given’ but a political construct. Facts never speak for themselves: they must be interpreted or framed. For instance, AIDS has been framed as a public health problem, a humanitarian crisis, a human rights issue, and a threat to security (Shiffman, 2009). Advocates adopting a ‘pro-life’ frame reject abortion or only allow for it under strict conditions, while advocates adopting a ‘pro-choice’ perspective consider it a morally justified option. Is COVID-19 a severe public health threat justifying radical restrictions to social and economic life or only a severe flu, as some fierce opponents to freedom-restricting measures have argued? Attaching the label of crisis to a problem is a well-known political strategy to legitimize direct state intervention and the extension of state power (centralization). Policymaking can be analyzed as a struggle between alternative problem constructs or problem frames. In other words, policymaking can be under­stood as a frame contest.

Problem formulations are not innocent because they involve moral, political, and economic implications. For instance, framing obesity in terms of individual behavior is only one step away from framing it as a problem of individual responsibility or lack of willpower (Saguy & Riley, 2005). The term ‘nanny state’ is a powerful frame device used by libertarians and the industry to discredit state initiatives to promote public health (Wiley et al., 2013). President Trump, obviously for political reasons, spoke about the ‘China virus’ to blame China for the outbreak of the pandemic instead of using the neutral term SARS-CoV-2. He labeled the virus a ‘hoax’ that the Democrats used to politicize it. During the Ebola pandemic, the Western African countries involved down­played the severity of the problem for fear of negative repercussions for tourism. The World Health Organization made a colossal mistake by adopting the general identifier ‘Swine Flu’ instead of ‘Mexican Flu’ to avoid damage to the Mexican economy. The new name had dramatic unintended consequences. The Egyptian government ordered the mass culling of all pigs in the country, and the Iraqi government the culling of three bears in a Baghdad zoo. Other countries imposed trade imports of all live pigs, pork, and pork products because of assumed risks for animal-transmitted diseases (Kamradt-Scott 2018). 

Problem definition as sense-making

Defining a situation as a public problem can be conceptualized as sense-making or framing. This concept refers to the cognitive and social processes of observing and interpreting what is going on, right or wrong, justified or unjustified, and to what can or should be done. Sense-making also involves an estimation of the scope of the problem, its causes and consequences, and (potential) risks. Perceptions and judgments are mediated by culture, power, and interests. Sense-making is a collective process (Douglas, 1986). Sense-making from a top-down perspective can considerably deviate from sense-making from a bottom-up perspective. It explains why people ‘at the bottom’ feel unheard or ignored. 

The political construction of health problems as public or collective problems involves the claim that their resolution requires state intervention. The history of Dutch alcohol policy illustrates that the acceptance of state responsibility is not evident. Box 3.1 showed that the state held for decades to the prevailing political concept of the ‘night watch state’: it had to concentrate its interventions on the maintenance of public order and protecting its citizens against foreign threats. The pursuit of public health was considered something for which the state did not feel a political responsibility of its own. It viewed public health as a matter of concern for municipalities and civil society organizations.

Constructing public health as a public problem the state must address is an important dimension of the political construction of policy problems. This is also true for risk perception. Policymakers can overlook health risks or underestimate their magnitude but also perceive them as serious problems. Sometimes, it is in the interest of policy actors to deny risks or, conversely, magnify risks to draw public attention, call for hard measures or an extension of its intervention power, claim a larger budget, discredit incumbent policymakers for policy failures, and so on. 

Another dimension of the political construction of problems concerns the identification of the problem owner(s) and problem subject(s). The problem owner is the person or organization held accountable for resolving a problem. Problem subjects are the victims of a (potential) problem. Who are they and how large is the category of problem subjects? Which criteria should be used to demarcate the category of problem subjects? These questions can have far-reaching repercussions for policymaking in terms of scope, costs, and responsibility. 

Finally, the construction of health problems includes a causation story (Stone, 1988). Policymakers need explanations for problems to find indications of how to resolve them. This is the instrumental role of causal stories: investigating the causes and ramifications of health problems and working out policy alternatives. At the same time, however, causation stories have a political dimension. They are an instrument to identify who should act, who should be held accountable for policy failure, and who should compensate the victims of policy failure. Blame games in policymaking rest upon a politics-driven causation story (Box 3.2).

The impact of the political construction of public health problems upon policymaking can hardly be overstated. A pro-life or pro-choice perspective on abortion directs the route policymakers will take. Seeing obesity as a matter of individual responsibility or as a result of an obesogenic social and economic environment influences the direction of policy resolutions. Solution fits problem. Interestingly, the reverse – problem fits solution – is equally true. For instance, it is no coincidence that libertarians are likely to attribute obesity to a lack of willpower or that policymakers who prefer public solutions are likely to underscore the role of factors beyond individual control in explaining and tackling obesity. Their preference for certain types of policy resolutions directs their construction of the obesity problem. You should not be surprised to hear market believers advocating competition in health care as their standard resolution of what they call system inefficiencies.

3.5 Structured, moderately structured, and unstructured problems

Some public problems in health policymaking are, at least in theory, relatively simple. Their solution is mostly a matter of legal, economic, medical, or other ‘technical’ expertise that can easily be mobilized. However, in practice, even seemingly simple problems may unexpectedly unfold as complex problems (Turnbull & Hoppe, 2019). The purchase of personal protective equipment for healthcare workers is a relatively simple (structured) problem for experienced purchasers but not in the context of a pandemic outbreak and huge equipment scarcity.

Most problems in health policymaking miss a simple structure. They have not only a public health dimension but also a legal dimension, a political dimension, an economic dimension, a public confidence dimension, and so on. Problems are also often interlocked. The outbreak of the mad cow disease in the United Kingdom demonstrates how public health problems escalated into a major and transboundary crisis with an international dimension in only a short period (Box 3.3).

Hoppe (2010) distinguishes between three types of problems: structured problems, moderately structured problems, and unstructured problems. Structured problems require relatively little discussion on what the goal of public intervention should be (high consensus) and the knowledge necessary to resolve these problems can easily be mobi­lized (high expertise). There are two types of moderately structured problems. The first type combines a lack of goal consensus with a high level of information. The problem with abortion is not a lack of expertise but a fundamental disagreement on how to judge abortion from a moral point of view. Technical expertise cannot resolve the dispute between proponents and opponents. The second type of moderately structured problem combines a high level of goal consensus with uncertainty on how to reach these goals. During the outbreak of the Q-fever in the Netherlands from 2007 to 2010, policymakers agreed on the priority of public health over economic interests but dis­agreed on the necessity of hard policy measures to get the epidemic under control (see Box 5.1 for more information). A policy problem is unstructured if instrumental knowledge is missing or contested and there is no goal consensus. Escalating healthcare expenditures are an unstructured problem. Fundamental disagreement on facts, explanations, and the effectiveness and acceptability of policy interventions to control expenditure growth goes hand in hand with fundamental disagreement on the need for expenditure cuts or other cost control measures. 

Hoppe’s classification of policy problems is an ideal typology. There are no clear boundary lines between each type of problem and public problems may combine the characteristics of structured, moderately structured, and unstructured problems. Nevertheless, the typology is a useful analytical instrument for the analysis of public problems. Each type of problem has repercussions for the organization of the policymaking process. An instrumental (technocratic) approach may work well to resolve structured problems but prove a ticket to misery for unstructured problems. The resolution of problems ensuing from a lack of goal consensus requires another approach than the resolution of problems ensuing from a lack of information or lack of consensus on the effects of alternative policy instruments.

It should be noted that moderately structured (or structured) problems can turn into unstructured problems, and conversely. The outbreak of the mad cow disease in the United Kingdom rapidly shifted from a moderately structured problem into an unstructured issue because of its repercussions for the human food chain, inter­national trade, and public trust. Health policymakers struggling with unstructured problems must convert unstructured problems into moderately structured or structured problems to make them manageable. 

Tame and wicked Problems 

Rittel and Webber (1973) have coined the term ‘tame’ problem and ‘wicked’ problem for structured and unstructured problems respectively. They point out that wicked problems miss a definite formulation and a stopping rule. Solutions are neither true nor false but either good or bad. There is no immediate or ultimate test for solutions and solutions may have irreversible effects. Every wicked problem is essentially unique and a symptom of another or deeper problem. There are always alternative explanations for a wicked problem and by implication alternative resolutions. What also makes wicked problems difficult to handle is the involvement of a large number of actors with differing views, expertise, and interests. Rittel and Webber conclude: ‘The formulation of a wicked problem is the problem’ (p. 161). 

3.6 Problem resolution: a misleading concept?

A basic assumption underpinning health policy concerns the malleability of society. Well-crafted health policies are a blessing for mankind. The burgeoning stock of know­ledge on health and disease makes it possible to overcome health calamities mankind has struggled with for centuries. Many diseases that were once incurable have become curable. When the Spanish Flu broke out in 1918, governments had only non-pharmaceutical interventions at their disposal to fight the disease that cost millions of people their life. How different was the situation during COVID-19!

Nevertheless, there are good reasons to be skeptical of the malleability assumption. First, the term ‘policy reso­lution’ is misleading because it assumes a non-existent degree of malleability. Many health problems cannot be resolved in the same way technical problems can be resolved. Even worse, public health experts expect the outbreak of new pandemics in the future. The question is not whether they will break out but when and how. The best strategy to prepare is to reinforce the resilience of their health systems to cope with new pandemics. 

A second reason for skepticism is that solutions often create new problems. The more medicine has been able to avert amenable death, the higher the prevalence and incidence of other diseases, such as cancer and Alzheimer’s disease. Gruenberg 2005 spoke in an article with the striking title ‘Failures of Success’ about ‘the surprising fact that the net effect of successful technical innovations used in disease control has been to raise the prevalence of certain diseases and disabilities by prolonging their average duration (p. 779). ‘As the result of advances in medical care, we are seeing a rising prevalence of certain chronic conditions which previously led to early terminal infections, but whose victims now suffer from them for a longer period’ (p. 781). This paradoxical result is not unique to medicine and health policy. Many public inter­ventions are intended to resolve self-inflicted problems. ‘Policy as its own cause’, according to Wildavsky (1987). 

Third, the term problem resolution suggests consensus on how a solution should look like. As pointed out before, this suggestion rests upon a serious misconception. In a pluralistic society, fundamental disagreement on the best solution is common.

A fourth reason to criticize the malleability assumption has to do with the inherent weaknesses of so many health policies. Poor knowledge, lack of capacity, the trans­boundary and interlocked structure of health problems, uncertainties, risks, as well as political, legal, and moral constraints are important explanations for why a ‘definite’ resolution is an illusion. There is good reason for modesty. Nevertheless, policy­makers prefer to talk in terms of policy resolutions pretending that real resolu­tions are available. Acknowledging the impossibility of definite resolutions is no option for them because it would suggest powerlessness and failure. The media reinforce this attitude. Journalists want to hear immediate resolutions from policymakers: ‘Minister, what is your solution to this problem?’

However, the illusion of a definitive resolution does not mean that nothing can or should be done. Health policymakers can mitigate people's problems by removing barriers to access to health care, making extra budgets available to relieve persons with serious psychiatric disorders, issuing legislation to improve working and living con­ditions, introducing incentives to promote health or disincentives to discourage un­healthy behavior, and so on. However, a radical or ‘definite’ resolution is in many situations unfeasible. Much health policymaking is little more than ‘moving away’ from a problem instead of ‘moving towards’ a solution (Bray­brooke & Lindblom, 1963). 

The interconnectivity and multi-level structure of policy problems also confront policymakers with a dilemma. Should they tackle the deeper causes of a policy problem or only direct their activities upon its symptoms? Is an ambitious approach preferable to an approach of small steps? Feasibility and the political imperative of immediate action influence their choices. In many situations, incremental interventions to confine or mitigate the problem are the only realistic option. The Austrian-British philosopher Karl Popper (1957) even manifested himself as a fierce opponent of what he called utopian solutions. His alternative was ‘pie­cemeal engineering’ to avoid policy disasters. Unsurprisingly, this alternative has been criticized as equivalent to ‘muddling through’ with potentially serious consequences for later.

3.7 Policy goals

The legitimization of health policymaking is to achieve policy goals or policy objectives. A policy goal can be defined as a desirable situation policymakers set out to achieve. The formulation of policy goals is a critical component in all health policymaking. The investigation of health policy goals is an important theme in health policy analysis. However, it is in many situations no easy task. 

Ambiguous policy goals

The content of most health policy goals is ambiguous. For instance, the government declares to improve the quality and efficiency of health care, preserve solidarity in health care financing, eliminate unfair health disparities, or transform health care from a ‘supply-driven’ system into a ‘demand-led’ system. The question is what these policy goals really mean. Each of them shines in abstractness. Agreement on abstract policy goals never guarantees agreement on their concrete meaning. This explains why so many conflicts in health policymaking concentrate on making abstract policy goals concrete. Policymakers agreeing on the need for an efficient and universally accessible system of healthcare provision may fundamentally disagree on how such a system should look in practice. Efficiency and universal access can be interpreted in many different ways. 

Identically worded policy goals may hide different ambitions. See, for instance, how governments have formulated the primary goal of their COVID-19 policy. Everywhere, they declared the containment of the spread of the coronavirus the cornerstone of their policy. Nevertheless, there were noticeable differences in how they made this policy goal operational. While some governments (e.g. China, South Korea) chose for a radical eradication of the coronavirus, other govern­ments aimed at the mitigation of the spread of the virus (‘flattening the curve’) to avert an overwhelmed hospital sector (e.g. the Netherlands). A third alternative was to opt for group immunity (e.g. Sweden). These differences in goal formulation are not semantic but correspond with remarkable differences in how governments sought to fight the pandemic (Greer et al., 2021).

The pursuit of public health, the enhancement of the quality of health care, or the improvement of universal access to health care, are textbook examples of aspirational policy goals: they only set out the direction but do not make concrete what exactly must be achieved for whom and when. Aspirational goals have a mobilizing function. They are a linguistic instrument to mask conflicts, smooth out inconsistencies, build popular support, or mobilize public resistance. Furthermore, abstract goals are invaluable in negotiations because they enable each participant to interpret these to their advantage (Stone, 1988). 

Multiple policy goals

Health policies usually contain several policy goals, mostly without a clearly formulated priority order. A frequent problem with multiple policy goals is that they conflict with each other. Not everything can be achieved at the same time or to the same degree. Equity often sits uneasily with efficiency. Conflicting policy goals and scarce resources confront policymakers with policy dilemmas: how to craft a balance between two or more conflicting goals? The 2006 Health Insurance Act in the Netherlands involved a complex balancing act between the policy goals of two conflicting goals. A primary goal of the reform was to give each person greater freedom of choice in health insurance. At the same time, the new legislation had to respect the principle of solidarity in health insurance. To uphold solidarity, the new legislation included various restrictions on freedom of choice. One of these restrictions was to make health insurance mandatory (Jeurissen & Maarse, 2021). 

‘Empty goals’

Policy goals make no sense without instrumentation. What policy goals really mean for public health depends on the choice of policy instruments (instrumentation) to attain them. Which instru­ments do policymakers choose, and how many resources are they willing or able to spend on their attainment? Policy goals without effective instruments are ‘empty’ goals with only political or symbolic value. 

Classification of policy goals

There are several models to classify policy goals. First, it is common to distinguish between long-term, mid-term, and short-term goals. The emphasis on short-term goals is mostly at the expense of long-term goals. A second distinction is between primary and secondary policy goals. Primary goals have a higher priority than secondary goals. However, priority setting frequently appears as a source of political trouble. The minister of Health may set other priorities in times of budgetary scarcity than the minister of Finance. Third, a distinction can be made between ultimate and intermediate policy goals. Policymakers set intermediate goals to achieve ultimate goals. Thus, intermediate goals play an instrumental role in attaining the ultimate goals. For instance, the introduction of regulated competition in Dutch health care in 2006 has never been intended as the ultimate goal of the market reform. The creation of the market was intended as intermediate goal to increase freedom of choice and make health care more efficient, innovative, and client-driven. An imminent risk of intermediate policy goals is that their instrumental role is lost out of sight and that they gradually develop as a policy goal of their own. Fourth, a distinction can be made between problem-oriented goals (e.g. improving access to health services) and process-oriented goals (e.g. a re-ordering of the relationship between state, market, and civil society in health policymaking). Policy goals can also be political such as the preservation or extension of one’s power base. The pursuit of an electoral victory is a respectable political goal of political parties. Sometimes political goals remain obscured.

A final distinction is between quantified and non-quantified policy goals. Though most health policy goals are qualitative or aspirational (see above), quantified goals are not uncommon. For instance, it is the government’s policy goal to save (x) billions of euros in a given period, keep health expenditures under a predetermined ceiling or reduce alcohol consumption in a given period by (x) percent relative to a pre-selected baseline year. Another method of quantification is to specify the year a policy goal must be achieved. The purpose of quantified goals is to make health policy more ambitious and concrete and force policymakers to take effective measures to attain them. Quantified policy goals also make it easier to measure the success or failure of health policy. Nevertheless, policymakers can be hesitant to formulate quantified policy goals for fear that they will be pinned down on their attainment. Disagreement on the realistic character of quantified policy goals and political resistance are other reasons to abstain from quantitative goals. A final reason is the risk of legal claims if a quantified goal is unattained.

3.8 Policy instruments

The pursuit of public health requires policy instruments defined by Howlett and Ramesh (2003) as ‘the actual means or devices governments have at their disposal for implementing policies’ (p. 87). Because policy goals without policy instruments are ‘empty’ goals, the study of policy instruments is crucial in health policy analysis. The study of policy instruments not only yields information about the assumptive world of policymakers (next section) but also information on the concrete meaning of policy goals and the importance policymakers attach to them. 

Classification of policy instruments

There are several classifications of policy instruments. Bemel­mans-Videc and her colleagues use the metaphors stick, carrot, and sermon to describe three types of instru­ments to influence the behavior of individuals and organizations (policy subjects). The stick is the most coercive instrument: it makes a certain kind of behavior mandatory and sanctions noncompliance. Carrots are intended to encourage policy subjects to adopt or abstain from a particular behavior. For instance, governments make vaccination costless to motivate the target population to get vaccinated (incentive) or raise taxes on tobacco products to discourage smoking (disincentive). Incentives and disincentives are, strictly speaking, non-coercive instruments. In practice, however, the distinction between coercion and (dis) encouragement gets easily blurred. High taxes can make smoking so expensive that low-income people can no longer afford to purchase tobacco products. Even if vaccination is voluntary, people may still feel coerced to be vaccinated. The same problem may arise for the sermon as an instrument to persuade policy subjects to adopt a desired type of behavior through information or a moral appeal (Bemelmans-Videc et al., 2011).

Howlett and Ramesh (2003) distinguish between authority-based instru­ments, treasury-based instruments, information-based instruments, and organiza­tion-based instru­­ments. Authority-based policy instruments rest upon a control-and-command model. The most common type is regulation through obligations and prohibitions that are supported by sanctions to punish norm-breaking behavior. Authority-based instru­ments can also be used to pressure opponents (e.g. using threats in negotiations). Central to the concept of authority-based instruments is the existence of a power relationship between the power holder and the power subject. The category of treasury-based instruments contains a broad range of instruments: taxing, tax incentives and disincentives, financial transfers, loans, expenditure cuts, user charges, and many others. The purpose of these instruments is, among others, the collection of financial resources, the facilitation of programs, and the encouragement (incentives) or dis­couragement of behavior (disincentives). Information-based instruments are intended to influence behavior by conveying information. Examples are public infor­mation campaigns, persuasion, consultation, doing or commissioning research, recommendations, moral appeals, and naming and shaming. Marketing and propaganda also fall into this category. Besides, information can be used as a political instrument to create confusion, for instance, by overwhelming the population with abundant information or spreading false information.

The distinction between authority-based, treasury-based, and information-based policy instruments in part overlaps with the distinction above between the stick, carrot, and sermon. This is not the case for what Howlett and Ramesh call organization-based instruments. These instruments are directed at the provision of goods and services to the population. Examples are hospital care, vaccination programs, social and healthcare services for long-term care, family care, pharmaceutical care, and the accomplishment of a healthy living environment. The category of organization-based instruments also includes other instruments including centra­lization and decen­tralization, reorganization, privatization, market creation, and outsourcing of publicly-funded services. Table 3.1 illustrates the classification of policy instruments that have been used to fight the COVID-19 pandemic.

Table 3.1 Classification of policy instruments to suppress COVID-19 

The classification of policy instruments gives no information on their concrete shape. For instance, the design of authority-based instruments may be very strict or offer policy sub­jects some freedom of choice. It matters whether regulations are supported by hard or soft sanctions. The discouraging effect of ‘sin taxes’ on tobacco products, alcoholic beverages, or sweetened drinks depends on the tax rates. Sometimes, treasury-based instruments represent little more than a ‘pocketful of money’: the government makes a budget available to tackle a problem but largely leaves open how to spend the money in practice. 

Nudging

A policy instrument receiving much attention in current health policymaking is nudging. Nudging comprises a broad range of psychological techniques to motivate people to adopt behavior without forcing them to do so or eliminating choices. People remain free to make their own choices but are in a subtle way encouraged to make ‘better’ choices. For instance, they are unconsciously incentivized by psycho­logical techniques to choose healthy food or exercise daily. Examples are the presentation of healthy food at eye level and the framing or numbering of choice options (Thaler & Sunstein, 2008). Empirical research demonstrates that organ donation legislation based upon the opt-out principle (individuals refusing donorship must explicitly opt-out) yields more potential donors than legislation based upon the opt-in principle (persons opting for donorship must explicitly opt-in): the default option ‘steers’ individual choices. Nudging techniques also make use of individual biases in decision-making including inertia, preference for short-term rewards, uncertainty reduction, and risk aversion. Using peer pressure or referring to social norms are other techniques to motivate people to change their behavior (Oliver, 2013). Nudging is often propagated as a strategy to influence individual behavior without being paternalistic. For this reason, Sunstein and Thaler (2005) consider nudging a morally acceptable instrument to promote public health: ‘Libertarian paternalism is not an oxymoron’ is the provoking title of their article on this issue. 

Criteria for policy instruments

Policymakers use many criteria to justify their choice of policy instruments. A brief overview: 

• Necessity: an instrument is considered a precondition for attaining the stated policy goals. There is no alternative (TINA). 

• Effectiveness: an instrument must contribute to achieving the stated policy goals.

• Efficiency: policy goals should be reached with the least possible resources. Waste means inefficiency. 

• Proportionality: an instrument should constrain behavior no more than strictly necessary.

• Avoidance of negative side effects.

• Precautionary principle: uncertain but potentially severe (health) risks must be avoided. Better safe than sorry. 

• Feasibility: an instrument must meet the test of economic, judicial, political, orga­nizational, or social feasibility. 

• Equity: the distribution of the costs and benefits across the population must be fair. 

• Timing: which instrument(s) should be tried first?

• Political opportunity: an instrument must serve political interests, for example, the pre­servation of the power balance.

This overview highlights the complexity of the instrumentation of health policy. The choice of policy instruments does not depend on a single criterion. It is always the outcome of a balancing act. Instrumentation involves weighing of the pros and cons of alternative instruments on the basis of multiple and ambiguous criteria. What the criteria of necessity or proportionality, to mention two examples, really mean is a matter of judgment based on knowledge, normative choices (e.g. how to weigh effect­iveness versus proportionality?), and political estimation. What also complicates the instrumentation of health policy is that criteria may lead to different outcomes. For instance, a potential trade-off may exist between effectiveness and equity or between efficiency and feasibility. Another problem relates to the sequence in which policy instruments are used. Policymakers may opt for the immediate use of coercive instruments but also follow an alternative strategy of starting with non-coercive policy instruments to attain their goals (e.g. persuasion) and switching over to coercive instru­ments if non-coercive instruments have failed. 

3.9 Policy paradigm 

Each policy rests upon assumptions. Health promotion is based upon the normative assumption that the state should take policy measures to foster healthy behavior. The call for a shift from post-care to pre-care draws upon the assumption that disease prevention and health promotion help to avert that people fall ill. Holding the state morally obligated to guarantee its citizens broad access to health care is a moral assump­tion underpinning state intervention to protect and promote public health. Co-payments are assumed to temper the demand for health care. Competition is assumed to foster the efficiency and quality of health care. 

A policy paradigm can be defined as the set of assumptions underpinning a policy. Hall (1993) describes it as ‘a framework of ideas and standards that specifies not only the goals of policy and the kind of instruments that can be used to attain them but also the very nature of the problems [policymakers] are meant to be addressing’ (p. 279). In other words, a policy paradigm directs the framing of policy problems, the formulation of policy goals, and the choice of policy instruments. A policy paradigm can be coherent or incoherent, explicit or implicit, rest upon empirical evidence or personal experience, root in tradition, ideology or theory, serve as a justification of private interests, and so forth. Some alternative terms circulating in the policy literature are belief system (Sabatier & Jenkins-Smith, 1999), assumptive world (Vickers, 1965), policy theory, and policy discourse (Hajer & Wagenaar, 2003).

Figure 3.1 visualizes the structure of a policy paradigm. Policy assumptions are divided into three main categories: (a) reality assumptions about facts, causal relations, and expectations; (b) instrumental assumptions about what works and does not work in problem resolving; and (c) normative assumptions about what should be done or omitted. The distinction between these three types of assumptions is analytical. In practice, they are closely interconnected.

Some policy paradigms have a long history and sometimes even the structure of an unshakeable belief. They can be deeply rooted in the collective memory. Sabatier and Jenkins (1999) distinguish in this respect between deep core and policy core beliefs. While deep core beliefs include ‘basic ontological and normative beliefs’, policy core beliefs entail ‘basic normative commitments and causal perceptions across an entire policy domain or subsystem’. Examples of deep core beliefs are the Christian, socialist or liberal body of thought. The belief in the merits of state planning or competition is an example of a policy core belief. Deep core beliefs are relatively most resistant to change, where­as policy core beliefs are more flexible. Finally, Sabatier and Jenkins introduce the category of secondary beliefs which, if necessary or opportune, can be adjusted to new information, experience or strategic considerations.

Health policymaking can be conceptualized as a contest between rivalling policy paradigms. Examples are the struggle between the Sanitary Movement and local authorities in the nineteenth century on the need for a fundamental reorientation of local health policy to control cholera outbreaks (Box 1.1), the struggle between the proponents and opponents of mandatory childhood vaccination or the struggle between the believers in competition and the believers in state planning.

Policy paradigm and policy reform

The call for a fundamental reorientation in health policy corresponds with a call for a new policy paradigm. Reform advocates argue that the old paradigm fails and postulate the need for an alternative paradigm or in the terminology of Rein and Schön (1994) ‘policy reframing’ (Box 3.4). However, the call for a paradigm may turn into a protracted ideolo­gical trench warfare, not only because the hegemonic paradigm is not easily given up but also because a paradigm shift can impact material interests and power relations. A new paradigm that is perceived as a threat to established rights will meet much resistance. This aspect of policy reform will be further discussed in Chapter 11 in the section on institutional change and continuity. 

Alternative policy paradigms for policy failure

Hood (1998) has developed a typology of policy paradigms of policy failures, or in his terminology, responses to public-management disasters. The first paradigm is the hierarchist paradigm which attributes policy failure to a lack of hierarchy and stresses the need for expertise and management. Poor compliance with established procedures and lack of expertise are viewed as important causes of failure. Consequently, the remedy is sought in greater expertise, tight procedures, in short, more hierarchy. Watchword is ‘steering’. The egalitarian paradigm sees hierarchy and expertise as the main explanation of failure. Top-level policymakers are accused of power abuse. The solution is sought in more democracy and empowerment of people at the bottom. Watch­word here is ‘participation’. The individualist paradigm constructs policy failure as the result of faulty incentive structures through ‘overcollectivization’ and lack of price signals. Market-like mechanisms, competition, league tables, and information to support rational decision-makers are recommended as the most effective response to failure. Watchword here is ‘enlightened self-interest’. The fourth paradigm is the fatalist paradigm which sees failure as inherent to human action. The world is unpredictable and unintended effects are unavoidable. Policies never work as intended. The best remedies are minimal anticipation and ad hoc responses after the event. Watchword of this paradigm is ‘resilience’. 

3.10 Policy narrative

Health policy is more than a system of policy goals and instruments. It also involves a storyline or narrative about what is going wrong, what will happen if no action is taken, what should be done, what will happen if no action is undertaken, and so on. Successful policymaking requires a persuasive narrative that goes beyond a ‘techno­cratic’ enumeration of facts, graphs, and tables. The story must connect information with normative convictions and arouse emotion. In short, a successful policy narrative is a well-crafted blend of logos, ethos, and pathos (Hood, 1998). Crafting an effective nar­rative is a matter of framing and sense-making. Facts only to convince and mobilize people are not enough or as Lakoff (2009) has put it: ‘The truth will not set you free’. Crucial is to touch the right chord of people (Westin, 2008). Trust and credibility are other factors influencing the mobilizing impact of policy narratives. 

Policy narratives accomplish three main functions. The instrumental function is building support for policy choices, the empowering function helping people to make informed choices, and the political function legitimating public action and fostering public confidence in public authorities. Opponents use a policy narrative as an instru­ment to mobilize political resistance (Boin et al., 2021).

In her analysis of the role of narratives in policymaking, Stone discusses two popular problem narratives. The first narrative is the story of decline, which goes as follows: if nothing is done, a collapse will ultimately follow. This narrative is frequently used in health policymaking, for instance, in stories about escalating healthcare expenditures. Opponents use the story of decline as a rhetorical weapon to discredit policy decisions. For instance, critics of cost control measures warn of the risks of these measures for the accessibility or quality of health care. The second popular narrative is permeated with optimism and involves the story of control. What was once beyond our control can now be controlled! For instance, we are able to prevent disease because we now have better knowledge of its determinants. Disease is no longer a twist of fate but something amenable to handling. The story of control underscores human agency. There is a choice. The story can also be used to un­­mask the industry that has concealed the truth to its benefit (Stone, 1988). 

There are more policy narratives. For instance, policymakers claim that their decisions are necessary or inevitable (the ‘there-is-no-alternative’ (TINA) argument). They deliberately frame a problem as a ‘crisis’ to underscore the seriousness of a problem and legitimize radical intervention. Another strategy is to refer to external factors or ‘foreign agents’ to explain the cause of a problem. Sometimes, policymakers hide themselves behind the limits of hierarchical control to mask their incompetence. In a polarized political context, problems are often persona­lized by holding high-ranking persons responsible for failures and requesting their punishment (‘t Hart & Boin, 2001). A storyline popular among alt-right populists is to discredit state inter­vention in public health as a conspiracy of a world elite (e.g. the World Economic Forum) to control all people across the world. 

Stone underscores the role of rhetorical devices in crafting a policy narrative. Well-known rhetorical instruments are synecdoche and metaphor. The synecdoche is a figure of speech by which a part is put for the whole. Policymakers refer to ‘typical instances’ or ‘prototypical cases’ to describe a larger problem (Stone, 1988: 116). For instance, the long waiting time of an individual patient is presented as representative of the ‘waiting time problem’ in health care. A single dramatic number can make a policy narrative persuasive. Metaphors are used to accentuate a problem by comparison. The ‘war on drugs, the ‘medical arms race’, the ‘slippery slope’ argument, the ‘iceberg under the water surface’, or the ‘fight against the coronavirus’ are examples of metaphors in policy narratives. 

That terminology matters is illustrated by Boin et al (2010) in an analysis of the vocabulary of crisis communication (Box 3.5). They analyze crisis communication as a ‘layered cake’. For instance, an ‘explosion’ (first layer) is reframed in a later stage as a ‘disaster’ or ‘catastrophe’ (second layer) and finally as ‘a deep crisis’ (third layer). 

3.11 Conclusion and suggestions for health policy analysis

Health policy rests upon the belief that society is, at least to a certain extent, malleable and that well-crafted state intervention can improve public health. This book defines the concept as a collective effort of health policymakers to achieve health goals through instruments during a certain time. 

Health policy and health policy decisions are based on a political construction of the problem(s) to be addressed and a policy paradigm (assumptive world). Another defining characteristic of health policy is the narrative (storyline) told to justify the policy decisions made and build public support for these decisions.

Health policy has a double face. On the hand, a policy is information-driven. Policy­makers claim to base their decisions on information and analysis. This is the instru­mentalist face of health policy. The other face is political. Health policy is the outcome of a struggle between divergent value orientations, conflicting interests, and power games. 

Health policy analysts should use the concepts presented in this book as the analytical starting point for an empirical study of health policy. This study starts with an analysis of the political construction of the policy problem. How is a situation or process constructed as a problem? What do policymakers see as the main causes of the problem and what do they expect to happen if no action would be taken? The answer to these basic questions gives insight into the policy paradigm or assumptive world of policymakers. A second important topic of research concerns the formulation of policy goals and the choice of policy instruments. Which policy beliefs, normative criteria, and political considerations have influenced the formulation of policy goals and the choice of policy instruments? Which dilemmas policymakers had to cope with in their formulation of the policy goals and the choice of policy instruments? How did the poli­tical context and other contextual factors influence the formulation of the policy goals and the choice of policy instruments? Which policy narrative did policymakers present to frame the problem, explain and motivate their decisions and mobilize public support for their choices?

Health policy is not just words. Crucial are decisions and actions to put these decisions into practice. Therefore, the study of health policy should go beyond a study of written documents and public statements and include an analysis of what policy­makers have concretely done to achieve their policy goals. Health policy analysts should always be alert to a big gap between words and promises and what is actually done or, put differently, between theory and practice. 

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