Tag Archives: World Health Organization

The future of public health policymaking after COVID-19: lessons from Health in All Policies

Paul Cairney, Emily St Denny, Heather Mitchell 

This post summarises new research on the health equity strategy Health in All Policies. As our previous post suggests, it is common to hope that a major event will create a ‘window of opportunity’ for such strategies to flourish, but the current COVID-19 experience suggests otherwise. If so, what do HIAP studies tell us about how to respond, and do they offer any hope for future strategies? The full report is on Open Research Europe, accompanied by a brief interview on its contribution to the Horizon 2020 project – IMAJINE – on spatial justice.

COVID-19 should have prompted governments to treat health improvement as fundamental to public policy

Many had made strong rhetorical commitments to public health strategies focused on preventing a pandemic of non-communicable diseases (NCDs). To do so, they would address the ‘social determinants’ of health, defined by the WHO as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.

COVID-19 reinforces the impact of the social determinants of health. Health inequalities result from factors such as income and social and environmental conditions, which influence people’s ability to protect and improve their health. COVID-19 had a visibly disproportionate impact on people with (a) underlying health conditions associated with NCDs, and (b) less ability to live and work safely.

Yet, the opposite happened. The COVID-19 response side-lined health improvement

Health departments postponed health improvement strategies and moved resources to health protection.

This experience shows that the evidence does not speak for itself

The evidence on social determinants is clear to public health specialists, but the idea of social determinants is less well known or convincing to policymakers.

It also challenges the idea that the logic of health improvement is irresistible

Health in All Policies (HIAP) is the main vehicle for health improvement policymaking, underpinned by: a commitment to health equity by addressing the social determinants of health; the recognition that the most useful health policies are not controlled by health departments; the need for collaboration across (and outside) government; and, the search for high level political commitment to health improvement.

Its logic is undeniable to HIAP advocates, but not policymakers. A government’s public commitment to HIAP does not lead inevitably to the roll-out of a fully-formed HIAP model. There is a major gap between the idea of HIAP and its implementation. It is difficult to generate HIAP momentum, and it can be lost at any time.

Instead, we need to generate more realistic lessons from health improvement and promotion policy

However, most HIAP research does not provide these lessons. Most HIAP research combines:

  1. functional logic (here is what we need)
  2. programme logic (here is what we think we need to do to achieve it), and
  3. hope.

Policy theory-informed empirical studies of policymaking could help produce a more realistic agenda, but very few HIAP studies seem to exploit their insights.

To that end, this review identifies lessons from studies of HIAP and policymaking

It summarises a systematic qualitative review of HIAP research. It includes 113 articles (2011-2020) that refer to policymaking theories or concepts while discussing HIAP.

We produced these conclusions from pre-COVID-19 studies of HIAP and policymaking, but our new policymaking context – and its ironic impact on HIAP – is impossible to ignore.

It suggests that HIAP advocates produced a 7-point playbook for the wrong game

The seven most common pieces of advice add up to a plausible but incomplete strategy:

  1. adopt a HIAP model and toolkit
  2. raise HIAP awareness and support in government
  3. seek win-win solutions with partners
  4. avoid the perception of ‘health imperialism’ when fostering intersectoral action
  5. find HIAP policy champions and entrepreneurs
  6. use HIAP to support the use of health impact assessments (HIAs)
  7. challenge the traditional cost-benefit analysis approach to valuing HIAP.

Yet, two emerging pieces of advice highlight the limits to the current playbook and the search for its replacement:

  1. treat HIAP as a continuous commitment to collaboration and health equity, not a uniform model; and,
  2. address the contradictions between HIAP aims.

As a result, most country studies report a major, unexpected, and disappointing gap between HIAP commitment and actual outcomes

These general findings are apparent in almost all relevant studies. They stand out in the ‘best case’ examples where: (a) there is high political commitment and strategic action (such as South Australia), or (b) political and economic conditions are conducive to HIAP (such as Nordic countries).

These studies show that the HIAP playbook has unanticipated results, such as when the win-win strategy leads to  HIAP advocates giving ground but receiving little in return.

HIAP strategies to challenge the status quo are also overshadowed by more important factors, including (a) a far higher commitment to existing healthcare policies and the core business of government, and (b) state retrenchment. Additional studies of decentralised HIAP models find major gaps between (a) national strategic commitment (backed by national legislation) and (b) municipal government progress.

Some studies acknowledge the need to use policymaking research to produce new ways to encourage and evaluate HIAP success

Studies of South Australia situate HIAP in a complex policymaking system in which the link between policy activity and outcomes is not linear.  

Studies of Nordic HIAP show that a commitment to municipal responsibility and stakeholder collaboration rules out the adoption of a national uniform HIAP model.

However, most studies do not use policymaking research effectively or appropriately

Almost all HIAP studies only scratch the surface of policymaking research (while some try to synthesise its insights, but at the cost of clarity).

Most HIAP studies use policy theories to:

  1. produce practical advice (such as to learn from ‘policy entrepreneurs’), or
  2. supplement their programme logic (to describe what they think causes policy change and better health outcomes).

Most policy theories were not designed for this purpose.

Policymaking research helps primarily to explain the HIAP ‘implementation gap’

Its main lesson is that policy outcomes are beyond the control of policymakers and HIAP advocates. This explanation does not show how to close implementation gaps.

Its practical lessons come from critical reflection on dilemmas and politics, not the reinvention of a playbook

It prompts advocates to:

  • Treat HIAP as a political project, not a technical exercise or puzzle to be solved.
  • Re-examine the likely impact of a focus on intersectoral action and collaboration, to recognise the impact of imbalances of power and the logic of policy specialisation.
  • Revisit the meaning-in-practice of the vague aims that they take for granted without explaining, such as co-production, policy learning, and organisational learning.
  • Engage with key trade-offs, such as between a desire for uniform outcomes (to produce health equity) but acceptance of major variations in HIAP policy and policymaking.
  • Avoid reinventing phrases or strategies when facing obstacles to health improvement.

We describe these points in more detail here:

Our Open Research Europe paper (*awaiting peer review*) The future of public health policymaking… (europa.eu)

Paul summarises the key points as part of a HIAP panel: Health in All Policies in times of COVID-19

ORE blog on the wider context of this work: forthcoming

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Filed under agenda setting, COVID-19, Evidence Based Policymaking (EBPM), Public health, public policy

Why does public health policy change?

Some public health policies have changed radically in the post-war period. The extent of change varies considerably, from issue to issue, and country to country. For example, the UK has one of the most comprehensive tobacco control regimes in the world, but China does not. While the UK has changed its post-war tobacco policy radically, the same amount of policy change cannot be found in alcohol (or in newer concerns such as sugar, saturated fat and salt in food). While public health policy is often quite similar across the UK, there have been significant differences, in timing and/ or content, in devolved and UK Government policies.

My interest is in the extent to which we explain these developments in (broadly) the same way. With colleagues, Donley Studlar and Hadii Mamudu, I focus on the extent to which actors, in favour of tobacco or alcohol control, operate within a ‘policy environment’ conducive to their aims.

What makes a conducive policy environment?

  1. Institutions. Policymaking responsibility has shifted, to a government department sympathetic to the policy, and following rules which enable its successful delivery.
  2. Networks. The balance of power within departments has shifted in favour of public health and medical, not industry, groups.
  3. Socioeconomics. Social behaviour (e.g. there is a low number of smokers/ drinkers and amount of smoking/ drinking) and attitudes to control have become more in line with policy aims, and there are fewer economic penalties to public health controls (e.g. a loss of tax revenue or economic activity).
  4. Ideas and ‘framing’. There is now an acceptance of the scientific evidence on unhealthy behaviour within government, control is high on its agenda, and it now ‘frames’ the issue in terms of a pressing public health problem (rather than, say, an economic good).

This broad focus can help us explain a range of global, national and subnational developments in public health policy, including:

Global Tobacco Policy

There is a policy environment conducive to tobacco control at a global level – the Framework Convention on Tobacco Control, led by the World Health Organisation – and in many ‘leading’ countries, but not in most countries. Consequently, most countries in the world have signed the FCTC but this is not yet reflected in policy outcomes.

Blog posts and pages:

Global Tobacco Control

The Tobacco ‘Endgame’

The WHO Framework Convention for Tobacco Control (FCTC): What would have to change to ensure effective policy implementation?*

Articles and Book

Hadii Mamudu, Paul Cairney and Donley Studlar (2015) ‘Global Public Policy: does the new venue for transnational tobacco control challenge the old way of doing things?’ forthcoming in Public Administration. ‘Green’ version: Mamudu Cairney Studlar Global Public Policy FCTC 6.11.14

Paul Cairney, Donley Studlar and Haddii Mamudu (2012) Global Tobacco Control: Power, Policy, Governance and Transfer (Basingstoke: Palgrave)

Paul Cairney and Haddii Mamudu (2014) ‘The Global Tobacco Control ‘Endgame’: change the policy environment to implement the FCTC’ Journal of Public Health Policy, Advance Access doi: 10.1057/jphp.2014.18

Donley Studlar and Paul Cairney (2014) ‘Conceptualizing Punctuated and Non-Punctuated Policy Change: Tobacco Control in Comparative Perspective’, International Review of Administrative Sciences, 80, 3, 513-31

UK Tobacco and Alcohol Policy.

UK Tobacco control is now far more comprehensive than alcohol control.

After the War on Tobacco, Is a War on Alcohol Next?*

Alcohol: the Harmful versus Healthy Debate

Why is there more tobacco control policy than alcohol control policy in the UK?

Paul Cairney and Donley Studlar (2014) ‘Public Health Policy in the United Kingdom: After the War on Tobacco, Is a War on Alcohol Brewing?’ World Medical and Health Policy, 6, 3, 308-323

Multi-level Policymaking: tobacco control in EU, UK and devolved government.

Although the EU provides some common standards, they are followed more or less enthusiastically by member states. Although key policies, such as the ban on smoking in public places, exist in all parts of the UK, it is important to explain the ‘window of opportunity’ for policy change in each territory.

Bossman Asare, Paul Cairney and Donley Studlar (2009) ‘Federalism and Multilevel Governance in Tobacco Policy: The European Union, the United Kingdom and the Devolved UK Institutions’, Journal of Public Policy, 29, 1, 79-102 PDF Paywall Green

Paul Cairney (2009) ‘The Role of Ideas in Policy Transfer: The Case of UK Smoking Bans since Devolution’, Journal of European Public Policy, 16, 3, 471-488 PDF Paywall Green

Paul Cairney (2007) ‘A Multiple Lens Approach to Policy Change: the Case of Tobacco Policy in the UK’, British Politics, 2, 1, 45-68 PDF Paywall (plus corrected table) Green

Paul Cairney (2007) ‘Using Devolution to Set the Agenda? Venue shift and the smoking ban in Scotland’,  British Journal of Politics and International Relations, 9,1, 73-89 PDF Paywall Green (it’s also stored by a US University here)

For the broader argument on ‘evolutionary theory, see:

Policy Concepts in 1000 Words: Evolution

Paul Cairney (2013) ‘What is Evolutionary Theory and How Does it Inform Policy Studies?’ Policy and Politics, 41, 2, 279-98

What is ‘Complex Government’ and what can we do about it?

 

 

 

 

 

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The Tobacco ‘Endgame’

The journal Tobacco Control has a section discussing the idea of an endgame. Previously, the focus was on controlling the tobacco market and reducing smoking. Now, the focus is often on eradicating both. So far, there are two main types of paper:

  • Those which propose new, harder, policy instruments – from introducing new regulations on tobacco products (including nicotine content) and the sales practices of the industry, to a ban on the sale of cigarettes altogether or to people born after a particular date.
  • Those which discuss politics and policymaking – including discussions about the level of consensus on the scientific and ethical case for endgame policies. Some papers consider the most-likely organisations to foster an endgame approach, although most are examining the peculiarities of the US.
  • One paper by Myers argues that the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) remains a key means to ensure global tobacco control: the problem is not a lack of new policy instruments, but the ‘political will’ to implement the ones we have.

This is where our (soon to be submitted) paper comes in. Hadii Mamudu and I aim to draw on the insights from the public policy literature (and interviews with policymakers and advocates across several countries) to (a) demonstrate the importance of this focus on politics and policymaking; and (b) explain in detail how and why that is important.

I won’t post the paper yet (to address concerns by the Journal ) but here is the draft abstract, followed by a draft set of bullet points which will accompany the submission:

The tobacco ‘endgame’ represents a major shift in focus, from controlling the tobacco market and reducing smoking, to eradicating both. Yet, the uneven spread of effective global tobacco control suggests that this outcome is far more likely in some countries than others.  We analyse the implementation of the FCTC to identify this problem, and synthesis the public policy literature to present a solution. The aim is to come as close as possible to the ideal-type of ‘comprehensive tobacco control regimes’, in which countries have policy environments conducive to the introduction of a wide range measures to reduce the demand for, and supply of, tobacco products. This would require the following policy processes in each country: their department of health takes the policy lead (replacing trade and treasury departments); tobacco is ‘framed’ as a pressing public health problem, not an economic good; public health groups are consulted at the expense of tobacco companies; socioeconomic conditions (including the value of tobacco taxation, and public attitudes to tobacco control) are conducive to policy change; and, the scientific evidence on the harmful effects of smoking and secondhand smoking are ‘set in stone’ within governments.

Why the issues discussed are important in terms of controlling tobacco use:

  • It makes a crucial contribution to Tobacco Control’s endgame debate.
  • Too many academic articles recommend policy instruments alone, to solve problems, without considering how effective they will be implemented
  • The policy process is not a ‘black box’. Instead, it is a system or environment that has to be understood in considerable depth – using the wealth of policy sciences literature.
  • The scientific research on tobacco control will not be fully evidence-based if we focus solely on the evidence on smoking related behaviour, or the efficacy of some policy instruments in isolation.
  • Instead, we need to consider the global context and use country comparisons to learn lessons about policy progress.
  • So far, most endgame papers in Tobacco Control have focused on instruments or the politics and policymaking of the US.
  • Only one paper supports the combination of the FCTC and ‘political will’.
  • Our paper supports and goes well beyond that argument. It gives more meaning to the vague idea of ‘political will’, which could relate (for example) to exceptional individual policymakers or organisation at various levels and types of government. It often represents vague criticism of the political process in general without trying to understand how it works.
  • We show that the policy environment, in which governments implement international agreements such as the FCTC (containing a combination of major tobacco control instruments), is just as important as the FCTC itself.
  • We suggest that the effective implementation of the FCTC could take decades – an outcome that may be frustrating, but not should not come as a surprise or necessarily prompt a shift of approach.

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After the War on Tobacco, Is a War on Alcohol Brewing?*

The United Kingdom now has one of the most comprehensive tobacco control policies in the world, a far cry from its status two decades ago. Some influential public health voices have called for a similar campaign against alcohol consumption. But is the comparison appropriate? We identify the factors which were important in the relatively successful campaign for tobacco control, then analyse the obstacles and opportunities facing the movement for more stringent alcohol control. Alcohol policy today bears a striking resemblance to tobacco policy pre-1990s, when the UK started on its path to becoming a major regulatory state in the world. Can alcohol policy be changed in a similar way?

Paper here  Cairney Studlar 2014 WMHP Alcohol and Tobacco Policy UK

See also – https://paulcairney.wordpress.com/public-health/

See also: http://blogs.lse.ac.uk/impactofsocialsciences/2013/07/16/evidence-matters-tobacco-and-alcohol-comparison/

*We submitted the paper to a US journal, where this framing is more normal. The idea of a public health crusade is also in good currency in some libertarian circles.

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Filed under agenda setting, alcohol, alcohol policy, Evidence Based Policymaking (EBPM), Public health, tobacco, tobacco policy, UK politics and policy

The WHO Framework Convention for Tobacco Control (FCTC): What would have to change to ensure effective policy implementation?*

Background
The World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) is one of the most widely accepted treaties in the United Nations system. It represents an attempt by governments to address the global tobacco epidemic. It contains a ‘comprehensive’ set of measures to reduce the demand for, and supply of, tobacco products worldwide. In most countries, it has prompted an increase in the number and depth of policy instruments. It primarily sets the agenda for change rather than providing the means to ensure the domestic implementation of policy. Implementation has been uneven; it is more evident in ‘developed’ than ‘developing’ countries. We identify the policy processes that would have to change to ensure more successful global implementation.
Results
The number of policies adopted across the globe has increased markedly since the negotiation of the FCTC. However, the implementation of policy has been uneven. The developed-developing country distinction provides an important way to describe this outcome, since most progress has been made in developed countries. However, it does not explain the uneven implementation of the FCTC; ‘development’ is not the causal factor. We synthesise the public policy literature to identify the key causal factors [1]. We identify the most relevant characteristics of the policy processes within ‘leading’ countries with the most comprehensive tobacco control: their department of health has taken the policy lead (replacing trade and treasury departments); tobacco is ‘framed’ as a pressing public health problem (not an economic good); public health groups are more consulted (often at the expense of tobacco companies); socioeconomic conditions (including the value of tobacco taxation, and public attitudes to tobacco control) are conducive to policy change; and, the scientific evidence on the harmful effects of smoking and secondhand smoking are ‘set in stone’ within governments. These factors tend to be absent in the countries with limited controls. We argue that, in the absence of these wider changes in their policy environments, the countries most reliant on the FCTC are currently the least able to implement it.

The long version of the paper is here: Cairney Mamudu 2013 Implementing the FCTC_ Insights From Public Policy

See also

https://paulcairney.wordpress.com/public-health/

Global Tobacco Control

Alcohol: the Harmful versus Healthy Debate

http://blogs.lse.ac.uk/politicsandpolicy/archives/34735

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