Modelling the Health Policy Process: One Size Fits All or Horses for Courses?

Doing Health Policy Analysis: The Enduring Relevance of Simple Models Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses"

The analysis of health policy processes in low- and middle-income countries (LMICs) emerged as a research area in the early 1990s. In their recent editorial Powell and Mannion argue that such research can be deepened by applying public policy theory. In response, we raise three questions to consider: are public policy models fit for purpose in today's world in LMICs (and what other theory can be used)? Is using theory the most important factor in deepening such research? Why do we, as researchers, do this work? Ultimately, we argue that the value of simple models, such as those already used in health policy analysis, lies in their enduring relevance and widespread use. They are supporting the development of the shared understandings that can, in turn, provide the basis for collective action addressing inequities in health and well-being.

Perceptions of key stakeholders on taxes on tobacco and alcohol products in Nepal

BACKGROUND

Non-communicable diseases (NCDs) are on the rise in Nepal. Consumption of alcohol and tobacco products remains high. Taxes on these products are significantly below the rate recommended by the WHO. In an effort to understand the reasons behind the slow progress towards the adoption of higher health taxes to curb NCDs, we documented the perceptions of key stakeholders on health taxes, including perceived barriers and facilitators to adopting higher health taxes.

METHODS

We conducted 45 in-depth interviews with individuals comprising government officials; producers, wholesale distributors and sellers of alcohol and tobacco products; and consumers and representatives from civil society organisations. We conducted a thematic analysis of the resulting data.

RESULTS

Respondents from alcohol and tobacco industries are not supportive of higher health taxes. They argued that higher taxes can increase illicit trade and worsen inequality. Strikingly, several government officials shared the industries' concerns, arguing that health taxes have limited potential to reduce consumption of alcohol and tobacco products to help curb NCDs. In terms of barriers to adoption of higher health taxes, several local government representatives opined that close ties between industries and politicians at the federal level is a major hindrance.

CONCLUSIONS

In order to adopt higher health taxes, the government will need to counter the false narrative pushed by alcohol and tobacco industries on the negative economic effects of such taxes. Health taxes earmarked for NCDs need to reflect the amount of revenue raised, reoriented towards prevention efforts and communicated clearly to the public.

Policy Makes Politics Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion's review of reviews maps the landscape of health policy research, showing a number of problematic and longstanding features. This commentary focuses on the extent to which health parochialism is good for the scientific development of the literature, the extent to which a "tournament of theories" actually develops our understanding of health policy process, and, finally, whether circumscribed theories of the policy process might be missing some of the most important and useful findings of broader comparative politics, which focus on the ways policies create politics over time. It concludes that health parochialism and focus on a circumscribed policy process is not likely to be helpful because it distracts attention from the ways in which coalitions and institutions over time shape politics and policy, a finding explored by scholars of many sectors whose findings should influence health policy research.

Health Policy Analysis Requires Attending to Institutions Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Manion present an important review of reviews about health and policy research. They zero in on theories of the policy process as the most likely to unearth what is really going on in health policy. Here I contend that their analysis insufficiently attends to institutions. Powell and Manion situate 'institutions' (with 'Ideas' and 'Interests') as a 'health policy process models' that 'tend to' list factors rather than connect them. Rather, I show how there is a rich history of considering institutions in the political science literature that is under considered by Powell and Manion. By necessity for a Public Health audience I quickly pull back the covers on 'rigour' and 'causation' to demonstrate what is 'fit for purpose' in rigorous institution focussed policy analysis. I conclude by arguing how institutionally focussed public health policy analysis is vital for understanding and addressing heath inequities. That focus necessitates research that provides better, explicit, conceptualisations of power in health policy: especially drawing out the roles played by structure and agency. I offer some recent examples.

Why Should Health Researchers Use Policy Theories? Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion suggest that 'health policy process' research should draw more lessons from 'the wider policy process literature.' While health research could continue with sector specific models, the wider literature is 'conceptually stronger.' In that context, I clarify how and why health researchers should use policy theories. I describe a review of the use of policy theories in public health research to show that many researchers use them to not only understand policy-making but also influence policy and policy-making. Most policy theories are not designed for that purpose, but it is still possible to produce practical lessons. I outline the issues that arise when repurposing theory-informed insights, such as that policy change takes a long time, and the scale of policy-making is potentially overwhelming. I then highlight the valuable role of theories in raising dilemmas in relation to modes of governance and evidence production.

A Social, Not a Natural Science: Engaging With Broader Fields in Health Policy Analysis Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Powell and Mannion's recent editorial discusses how different 'models' of the policy process have been applied within the health policy field. They present two ways forward for scholarship: more 'home grown' development of health-specific models, or deeper engagement with broader public policy scholarship. In this paper I argue for the latter approach for several reasons. First, health policy analysis is a social, not a natural science - and as such is not exceptional to other forms of policy scholarship. Second, many 'health policy models' are often grounded in conceptual work from elsewhere (or may not be health specific). Finally, there has been significant work to develop more nuanced understandings of theories, models, and frameworks available to particular analytical tasks and questions. As such, the growing body of global health policy scholarship may find it can benefit more from deeper engagement with existing conceptual work than constructing its own new models in most cases.

Using a Stages Model to Reveal the Politics in the Health Policy Process Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

Models of the health policy process have largely developed in isolation from political studies more widely. Of the models which Powell and Mannion's editorial considers, a stages model of the policy process offers a framework for combining these specifically health-focused models with empirical findings and more general explanatory models of the policy process drawn from other political studies. This commentary uses a stages model to assemble a bricolage which combines some of these components. That identifies a further research task and suggests ways of revealing in more life-like ways the politics involved in the health policy process: that is, how that process channels wider, often conflicting, non-health interests, actors, policies, conflicts, ideologies and sources of power from outside the health system into health policy formation, and introduces non-rationality.

Is It Time to Explore the Health Policy Process Within Governance and Health Systems Frameworks? Comment on "Modelling the Health Policy Process: One Size Fits All or Horses for Courses?"

There is clearly a need to improve the use of more robust policy theory on health policy analysis. Powell and Mannion in an editorial on the relationship between health policy analysis and the wider field of public policy theory note, as others have done before, the limited application of policy theory in health policy analysis. However, they also highlight that within the health policy analysis arena new models have emerged which have wider use within policy analysis such as the health policy triangle. While Powell and Mannion suggest that health policy analysis can take one of two paths I argue that we should be developing more integrated frameworks of health policy processes, governance and systems which would involve the use of robust public policy theories and models.