Keywords

1 Introduction: The Search for Political Science Within Public Health

This book explores how to combine insights from public health and political science. In Chapter 2, Fafard et al. (2022) present the crucial distinction between different roles for political science in this collaboration, used: instrumentally to help public health advocates improve their political strategies (research for public health) or empirically to explain the lack of public health policy progress (research of public health). Our collective ambition may be to encourage a third, more collaborative and integrated role (political science with public health) while accepting that few studies of public health policymaking achieve this aim (yet).

In that context, this chapter explores not only the consequences of the lack of public health and political science integration but also the possibilities for collaboration. To do so, it focuses on preventive public health policy in general and the global public health strategy ‘Health in All Policies’ (HiAP) in particular. First, we describe exemplars of public health approaches to policy change which are not informed heavily by political science. Such studies identify the large amount of scientific evidence on the social determinants of health and seek an amount of public policy change that is consistent with the size of the policy problem. One key theme is the need to pursue some variant of ‘evidence-based policymaking’ (EBPM) in which public health advocates identify and seek to close an evidence-policy gap (Cairney, 2016). Another is the need for high strategic commitment and ‘political will’ behind health equity policies.

Second, we describe and explain the gap between public health expectations and public policy. Governments often use the right language to signal their sincere commitment to preventive approaches and public health policy, but there remains a major gap between policy and outcomes. Public policy theories help to explain this gap, with reference to the ambiguity of preventive policy initiatives exacerbated by policymaking complexity in which no actor or organisation has strong coordinative capacity. Political science accounts connect major or minor policy change to two key limits to individuals and governments: the role of bounded rationality in limiting attention to, and understanding of, policy problems; and complex policymaking environments over which policymakers have low knowledge and even less control (Cairney, 2020; Cairney et al., 2019). Both factors explain ever-present limits to policy change. They apply to policymakers regardless of their sincerity or commitment. A vague focus on the ‘political will’ of policymakers distracts us from a focus on the limits to their resources in relation to their policymaking environments.

Third, it relates these discussions to key themes to emerge from our qualitative systematic review of HiAP research (Cairney et al., 2021). We focus on the small proportion of HiAP articles that use policy theories to explain policymaking. This ‘best case’ analysis highlights an enduring obstacle to political science with public health: the tendency to use theories instrumentally to improve (a) practical advice to advocates as part of a HiAP playbook, or (b) a HiAP programme logic in the service of better policymaking. Most policy theories were not designed for this specific purpose. Their practical lessons come from critical reflection on the limits to political actor agency in various policymaking contexts (Weible & Cairney, 2021). As such, an integrated public health/political science would foster deliberation on policymaking dilemmas rather than simply identifying political obstacles to overcome.

2 Public Health Provides a Coherent Narrative on Policy Change

‘Public health’ is an umbrella term covering different approaches, professional backgrounds, and practices. Still, it is possible to highlight a small number of elements to emerge from published public health research, such as a common focus on health equity and addressing the ‘social determinants of health’, coupled with common references to the same texts, including:

  • The working definition of social determinants promoted by the World Health Organization (WHO) (2019), describing ‘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’.

  • Whitehead and Dahlgren’s (2006, p. 4) argument that ‘all systematic differences in health between different socioeconomic groups within a country’ are unfair and avoidable, since ‘there is no biological reason for their existence’ and ‘systematic differences in lifestyles between socioeconomic groups are to a large extent shaped by structural factors’.

  • Solar and Urwin’s (2010, p. 6) argument that a country’s socioeconomic and political context underpins variations in education, occupation, and income in relation to class, gender, and ethnicity, which influence people’s ‘living and working conditions’, mental health, and behaviour, which contribute to their health.

We can then show how such elements combine to produce common public health narratives regarding the policy problem, how to understand it, and the processes necessary to address it. To that end, we drew on earlier published and in-progress work—literature reviews and documentary analysis underpinning our studies of tobacco policy (Cairney et al., 2012), prevention policy (Cairney & St. Denny, 2020), and HiAP (Cairney et al., 2021)—to identify a list of assumptions and expectations among public health research. We then sought to sense-check this list in conversations with public health practitioners and academics in two workshops (at Public Health England, June 2019 (n = 10); at Integrating Science and Politics for Public Health workshop, June 2019 (n = 12)).

2.1 Public Health Provides a General Narrative of Policy and Policymaking

We were able to discern a common public health narrative on prevention policy that has the following recurring elements (Cairney & St. Denny, 2020). Most important is a focus on preventing ill health rather than treating it when it becomes too severe. For example, there is an emphasis on using health improvement (or health promotion) strategies to prevent an epidemic of non-communicable diseases (NCDs, such as heart disease, strokes, cancers, and diabetes) as well as health protection measures to prevent infectious disease pandemics. There is also a tendency to distinguish between types of prevention:

  • Primary. Focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment (generally the preferred form of prevention).

  • Secondary. Focus on at-risk groups to identify a problem at a very early stage to minimise harm (often the pragmatic approach to policy).

  • Tertiary. Focus on affected groups to stop a problem getting worse (last resort prevention, which can be difficult to distinguish from reactive health services).

Public health accounts of prevention policy also seek to promote health equity by focusing on the social determinants of health and health inequalities. There is an ongoing effort to promote ‘upstream’ measures designed to improve health equity or the health of the whole population rather than ‘downstream’ measures targeting individuals. Similarly, there is much use of scientific evidence to identify the nature of problems and most effective solutions. There is also a resolute focus on the role of industry causing public health problems (the ‘commercial determinants of health’) or undermining the political will to regulate commercial activity. Thus, there is an interest in conceiving of public health and prevention as a form of social protection in which there is a moral imperative to intervene (in sharp contrast to arguments that emphasise individual responsibility for ‘lifestyles’, and opposition to the ‘nanny state’). In that context, ‘prevention’ sums up an overall policy goal and ‘preventive policymaking’ is an approach to that end, including a focus on joined-up government, since the responsibility for health improvement goes well beyond health departments.

Our workshops explored some variations in this narrative. First, there are many approaches within this umbrella, drawing more or less on biomedical versus social perspectives on the causes of ill health, and tying arguments more or less to economic conceptions of efficient ways to foster health equity (such as via WHO ‘best buys’). Second, although there is a common focus on evidence, there is not always a common definition of what counts. Some describe evidence quality in relation to methods, as part of a ‘hierarchy’ in which the systematic review of randomised control trials often represents the gold standard and ‘systems modelling’ often plays a key role (although see Cairney, 2021 on the many types of ‘systems thinking’). However, others challenge that hierarchy energetically, particularly when prevention policy goes beyond health (Cairney, 2019a). Third, there remains some ambiguity about the meaning of ‘upstream’ in relation to the ultimate causes of health inequity (see McMahon, 2021a, 2021b, and compare Shankardass et al., 2011, p. 29; Brownson et al., 2010, p. 6). Fourth, there is more or less support for using tobacco control as a model for other specific issues (e.g. alcohol use, obesity, salt) and the prevention agenda more generally (Studlar & Cairney, 2019). Finally, some key terms remain ill-defined. Most importantly, the phrase ‘political will’ is central to public health accounts but remains ‘hollow political rhetoric’ unless operationalised (Post et al., 2010, p. 654). It appears to describe two different factors:

  1. 1.

    Agency. A sufficient number of powerful policymakers, with the same understanding of a policy problem, committed to supporting the same policy solution (2010, p. 671).

  2. 2.

    Context. Policymaking contexts influence their motivation and ability to act, with key factors including: the ‘path dependency’ of existing policy and policymaking, the importance of the issue to a party’s election chances (and scope for cross-party action), its individualist v collectivist philosophy, and the dominant framing of policy problems (Baum et al., 2020, p. 2).

As such, in Chapter 3, Greer (2022) highlights the potential for ‘political will’ to be operationalised usefully, such as to identify ‘whose political will matters and why’, and the context in which political agency and leadership are used. However, Cairney et al. (2021) show that almost all accounts use the phrase ‘political will’ loosely, to describe the low motivation or determination of key policymakers to do the right thing, without relating willpower to context in the way recommended by Baum et al. (2020) or Greer (2022).

2.2 Health in All Policies (HiAP) Takes It One Step Further

Our review of HiAP policymaking studies (Cairney et al., 2021) finds a tighter and more coherent presentation of a similar narrative:

  1. 1.

    Policymakers need to focus on the social determinants of health to promote health equity (by reducing unfair health inequalities).

  2. 2.

    Major policy measures—to redistribute income, improve public services, reduce discrimination, and improve social, economic, and physical environments—are not in the gift of health departments.

  3. 3.

    An effective policymaking response requires collaboration across all sectors of government, and with key stakeholders and citizens outside of government.

  4. 4.

    Long-term success requires high and enduring levels of political will.

This literature also contains (what we describe as) a playbook for HiAP, in which the same advice appears frequently, including: focus on win–win solutions to foster trust-based intersectoral action; avoid projecting a sense of ‘health imperialism’ in the pursuit of health equity; and identify policy champions and entrepreneurs (Baum et al., 2014). Relatively, few articles engage critically with this HiAP story (at least in the way pursued by De Leeuw and Clavier [2011] and De Leeuw and Peters [2014]), and few engage with studies of politics and policy to make it (at the level of Carey & Friel, 2015; Carey et al., 2014; Greer & Lillvis, 2014). Rather, such assumptions tend to underpin high expectations for the role of government and provide a stylised frame of reference to assess the overall substance and direction of policy.

3 Governments Adopt Similar Arguments, but There Is Always a Gap Between Commitments and Outcomes

Many governments adopt similar ways to discuss policy and policymaking. For example, there is a widespread international commitment to the adoption of a specific project such as HiAP (as tracked by the WHO, 2014), while many countries also use the broader language of prevention to signal the use of public health ideas across government.

To demonstrate the general focus on prevention, here we draw on Cairney and St Denny (2020) to track the extent to which the UK and devolved governments appear to have embraced this way of thinking. Many successive UK governments have used the general language of prevention to describe policy agendas in health and fields such as ‘families policy’ and justice. The UK Labour government (from 1997 to 2010) used this language more seriously, included reference to the social determinants of health, and encouraged early years policies such as Sure Start. From 2011, the Scottish Government declared a ‘decisive shift to prevention’ across government (2020, pp. 116–118). NHS England’s (2014, p. 3) Forward View argued that, ‘the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health’. ‘Prevention is better than cure’ was the title of the most recent (relevant) policy paper by the Department of Health and Social Care (2018). The UK and Scottish governments also tied prevention policy to policymaking, emphasising: joined-up and evidence-based policymaking, localism, service-user-driven policymaking (‘we need to make policy with you, not do it to you’), partnerships between government departments and the public sector, and support for long-term measures of quality of life (Cairney & St. Denny, 2020, pp. 10–12).

However, in each case, there is an unusually large gap between this description and outcomes. It is beyond the usual ‘implementation gap’ that we would expect in any policy: ‘there is great potential for governments to pursue contradictory policies at the complete expense of their prevention agendas’, such as when they pay lip service to prevention but devote most resources to reactive or acute services (2020, p. 2). Cairney and St Denny (2020) describe the three main steps from vague commitment to limited progress:

  1. 1.

    Policymakers show support for prevention policy before they attach meaning to it, beyond the vague idiom that ‘prevention is better than cure’. By choosing a vague solution to an unclear problem, they ‘do not appreciate the scale of their task until they define prevention while producing strategies and detailed objectives’. Then, they ‘find the evidence base to be limited and no substitute for political choice’ and realise that these political choices (such as on the role of the state in personal and family life) are divisive (2020, p. 221).

  2. 2.

    When they begin to make enough sense of prevention policy to produce specific aims and objectives, their high-level attention is fleeting. When they relate prevention to their wider agenda, it becomes a relatively low priority, often secondary to—or undermined directly by—other policy aims. When they ‘encounter major trade-offs between long-term preventive aims and short-term objectives’, they favour the latter and ‘devote most resources to reactive services’ (2020, p. 221).

  3. 3.

    Policymakers try to deliver governance reforms within a complex policymaking environment over which they have limited understanding and even less control. In many cases, they settle for the appearance of success, based on the popularity of their response or narrow indicators of outcomes, without addressing the ‘root cause’ of the problem they profess to be solving: ‘Policymakers begin to think of problems as too ‘wicked’ to solve. They use prevention as a quick fix, passing on responsibility and less funding to delivery bodies … they focus on telling a story of their success rather than achieving it’ (2020, p. 221).

In some cases, governments persevere with specific policy agendas (such as the UK government’s ‘Troubled Families’ programme) or approaches to evidence and governance (such as the Scottish Government’s support for improvement methods) (2020, p. 227; Cairney, 2017b, 2019c). Or, they set up dedicated agencies to foster preventive health (Boswell et al., 2019). In other cases, they maintain a vague commitment without going any further. As such, even a high profile and sincere commitment to prevention-style policies and policymaking can have no effect. Or, the projection of political will behind a new approach can act as a substitute for more substantive action.

4 Policy Theory Relates This Gap to Bounded Rationality and Complexity

The simplest explanation for this outcome requires minimal political science or policy theory input: policymakers act in bad faith. They deliberately choose a vague policy solution. They engage in strategic ambiguity. The language of prevention and EBPM helps them to depoliticise issues and generate superficial cross-party or public support. They do not intend to deliver or have no belief that they will follow through. They measure their success (in McConnell’s, 2010 terms) according to how popular the policy makes them, or how easy it is to process, rather than the long-term health outcomes.

We push back against this argument largely because the assumption of bad faith can exacerbate the policy problem by drawing attention from more important explanations (Cairney & St. Denny, 2020). We argue that the problem of policy ambiguity, and a policy process over which policymakers have limited knowledge and even less control, would exist even if policymakers exhibited high sincerity, competence, commitment, energy, and will.

4.1 Bounded Rationality Causes Uncertainty and Ambiguity

Policymakers do not possess the cognitive and organisational capacity to gather and process all information relevant to their decisions and then make clear, consistent, and well-ranked choices. Rather, they face ‘bounded rationality’ (Simon, 1976), in which their possession and grasp of evidence, and their ability to make and implement consistent policy choices, are limited. Individuals can only pay attention to—and understand—a small number of issues. Organisations have more capacity but rely on standard operating procedures to help them ignore most information (Baumgartner et al., 2018; Cairney, 2020; Koski & Workman, 2018). Policymakers prioritise some issues, some ways to define them as problems, and some information about them, and ignore the rest. These problems do not decrease when our ability to produce more information increases (Botterill & Hindmoor, 2012, p. 367; Cairney & Kwiatkowski, 2017).

This focus on bounded rationality helps identify the important distinction between policy uncertainty (a lack of information on a policy problem) and ambiguity (a lack of agreement on how to define the problem) (Zahariadis, 2007; compare with Tuckett and Nicolic, 2017). Actors produce more information to reduce uncertainty, but exercise power to frame problems to reduce ambiguity (Cairney, 2019b). They (a) cooperate with some actors, and compete with others, to (b) limit attention to their preferred way to understand public health policy problems and possible solutions, to (c) inform policy priorities and the selection of policy instruments.

Ambiguity is crucial because, although there may be a clear consensus on how to define policy agendas such as prevention in the abstract, it becomes illusory in practice. At the same time, we find a tendency among a small number of people in public health to believe that they know the precise meaning of terms like prevention, social determinants, and HiAP. Then, when things are not going well, they reinvent phrases to sum up the same policy intent in new ways. This response becomes counterproductive if the political aim is to generate much wider understanding and agreement. Resolving ambiguity is a contested process to address policy choice (e.g. on what problems do we focus?) and policymaking trade-offs (e.g. what should be the balance of funding between preventive/reactive services?). The process is political rather than technical, and generating vague agreement is like kicking the can down the road.

4.2 Complex Policymaking Environments Constrain and Facilitate Action

Policy theories identify five conceptual elements—Fig. 1—to describe the ‘environment’ in which this competition takes place (Heikkila & Cairney, 2018; John, 2003; compare with elements of complex policymaking ‘systems’—Cairney, 2012):

Fig. 1
figure 1

Key elements of the policy process (Cairney, 2017a)

Full size image
  1. 1.

    Actors. A huge number of people and organisations make and influence policy across many levels and types of government. There are many ‘centres’ or policymaking ‘venues’ (defined as arenas for authoritative choice) (Cairney et al., 2019).

  2. 2.

    Institutions. This proliferation of actors contributes to a myriad of formal and informal rules (institutions) across many venues. Some rules are written and understood widely. Others are implicit and may not even be communicated verbally (Ostrom, 2007). In studies of EBPM, this insight is key to actors seeking to promote the same evidence in different venues with different rules (Cairney, 2016). In studies of joined-up government, it presents a challenge to the idea that different actors will use the same idea—such as prevention—in similar ways across government.

  3. 3.

    Networks. Each venue has its own relationships between policymakers and influencers. Classic studies of ‘policy communities’ highlight a logic of delegating policy responsibility to relatively junior civil servants, engaged in routine consultation with interest groups who trade information and advice for access (Jordan & Cairney, 2013; Jordan & Maloney, 1997; Richardson & Jordan, 1979). Most policy is processed out of the spotlight, at a low level of central government, in silos that have their own logic. Or, policymaking reforms, such as localism, encourage the shift of policy communities outside of central government altogether (Cairney & St. Denny, 2020).

  4. 4.

    Ideas. The existence of many different venues, with their own rules and networks, contributes to the endurance of different ways to understand the world and key policy problems within it. Public health ideas may be taken for granted in one venue but seem alien or unthinkable in another.

  5. 5.

    Policy context (or conditions) and events. Socioeconomic factors such as geography, demography, social attitudes, and economic activity are often out of the control of policymakers, and they contribute to non-routine events such as ‘crises’. Routine events such as elections can also produce major shifts in policy agendas or outcomes.

These factors contribute to the sense that elected policymakers or central governments are not in full control of policymaking. They set high-level aims but rely on many other actors to make sense of and deliver them. There is debate within policy studies about the extent to which central governments can control the governance of policy (compare Bevir, 2013 with Sørensen & Torfing, 2009). For example, one reading of the literatures on ‘multi-level’, ‘polycentric’, or ‘complex governance’ is that elected policymakers should not even try to seek control (Cairney et al., 2019). They should be pragmatic enough to diffuse policymaking responsibility across political systems to give local actors the flexibility to respond to an ever-changing context or accept that this power diffusion will happen anyway. Elected governments may still try to project an image of central control, but to address their need to demonstrate governing competence when held to account (particularly in Westminster systems).

Even in accounts more sympathetic to the idea of central control, we find a story that policymakers have to prioritise a small number of issues, while the delivery of their aims depends on the behaviour of a large number of actors. They can set the policy agenda, by identifying the target populations most worthy of support and directing resources towards some problems at the expense of others. However, a sole focus on these choices ignores the wider policymaking context over which they have far less control. A government’s energetic focus on the implementation of specific policies helps, but at the expense of attention to other policies.

Identifying this context is crucial to any long-term consideration of prevention policies or initiatives such as HiAP. Although it is tempting to conclude that policies fail because politicians engage in bad faith, even the most sincere and committed policymakers would face major obstacles that they may never overcome. Political enthusiasm is not a good predictor of policy outcomes. Indeed, policymaker stoicism may reflect a more practical realisation that they can only enjoy limited success (Boswell & Corbett, 2015).

5 These Factors Help Explain: But not Close—The HiAP Implementation Gap

These discussions provide a lens through which to view the key findings and themes of our qualitative systematic review of HiAP (Cairney et al., 2021). The review includes 113 journal articles (2001–2020, research and commentary) that provide a non-trivial reference to policymaking processes. Initially, we set a low bar to allow comprehensive coverage: the HiAP article provides at least one reference to a policy theory or concept and a corresponding entry in its bibliography (compare with the higher bar set by Embrett and Randall [2014]). In this chapter, we focus on the much smaller subset of articles that use policy theories in a meaningful way. Although to policy scholars this initial bar would seem too low, and distinction too vague, it has proven useful in interdisciplinary academic fields where policy theory is used rarely and meaningful engagement jumps out (Munro & Cairney, 2020). The bigger problem is the skewing of our review towards South Australia, which accounts for over one-quarter of policy theory-informed HiAP studies and most of the examples in themes 2 and 3.

5.1 Theme 1: HiAP as a Symbol for High but Unfulfilled Expectations

The largest set of articles tells a story of unfulfilled expectations. Put simply, the less they draw on policy theories, the higher expectations they have for substantive policy change. Since most HiAP articles draw superficially on policy theories, they focus more on the potential than evidence for implementation success. There is a common narrative with the following elements:

  1. 1.

    Problem. A discussion of the evidence for the social determinants of health and health inequalities, often accompanied by an estimated economic cost.

  2. 2.

    Solution. A description of HiAP as a model, to represent a solution (a combination of policy instruments to reduce health inequalities) and style (joined-up and collaborative governance), bolstered by high political commitment. HiAP is an ambitious, coherent, and feasible approach. A government’s HiAP strategy represents the beginning of major policy change.

  3. 3.

    Implementation gap. A report of a large gap between expectations and outcomes, even when there is initially high political will. HiAP becomes a symbol of unfulfilled expectations.

When combined with our more general discussion of preventive policymaking, this work provides a useful cautionary tale in which a government’s commitment to a HiAP strategy does not tell us if it will come to fruition. HiAP proves to be an ambiguous approach, exacerbated by policymaking complexity in which no actor or organisation has strong coordinative capacity or the ability to define HiAP consistently. A consensus within one group of specialists—on the nature of policy problems, and HiAP as the solution—is not the same as wider understanding and ownership. Rather, these studies find a heterogeneous mix of experiences when many different policy actors try to make sense of HiAP in different contexts.

However, the conclusions to these articles often undermine the moral to the tale: it would be a mistake to treat HiAP as a uniform model to be implemented in full rather than to be discussed, clarified, and amended by the actors—outside of health departments—deemed crucial to its success. We argue that the ‘politics’ of HiAP should describe democratic processes to make sense of HiAP in the real world. Yet, too many studies either ignore the positive role of politics or imply that politicians get in the way of the aims of HiAP advocates.

5.2 Theme 2: Use Policy Theory Insights to Inform Programme Theory and Reframe the Evaluation of HiAP

Some studies use policy theories to inform the programme theories that underpin the design, delivery, and/or evaluation of HiAP strategies. Programme theory is akin to a theory of change to guide action (Baum et al., 2014: i135), rather than a policy theory used to explain general policy processes:

Theory-based evaluation makes the causal assumptions behind policy interventions explicit, ie, it explains how and why a program or policy is thought to work, which forms the logic that underpins an initiative. As Leeuw and others note, program theory is often drawn from stakeholder knowledge and is considered distinct from substantive social science theory, which may nevertheless inform and enrich program theory. A distinction can also be drawn between program theory and implementation theory. Program theory is concerned with mechanisms leading to the desired changes rather than the activities per se. Implementation theory sheds light on how a particular initiative is operating, and program theory seeks to understand how program effects are realized. (Lawless et al., 2018, p. 512)

In other words, researchers identify HiAP aims and combine their own experience with interviews or focus groups with stakeholders to identify the practices that they expect to work, including ‘developing relational systems’, ‘joint problem identification and problem-solving’, and ‘governance systems that connect HiAP work with senior decision-makers’ (2018, pp. 513–514). In that context, policy concepts help HiAP advocates recognise that the success or failure of a programme relates to factors other than the programme itself (2018, p. 511).

Six commentary articles engage with Lawless et al.’s (2018) study, and their conclusions reflect an enduring confusion about how policy theories contribute to HiAP programme theories. To some extent, this confusion relates to general uncertainty about how to interpret a complex world with simple-enough models and concepts, since there are so many from which to learn and it is not clear how they fit together. If so, the use of multiple policy theories can provide more obfuscation than clarity. If so, Lawless et al. (2018) help visualise complexity but not navigate complexity well enough to support and evaluate interventions (De Leeuw, 2018, pp. 763–764; Harris, 2018; Holt & Ahlmark, 2018, p. 758; Shankardass et al., 2018).

However, it also relates to two profound limitations to HiAP as a policy agenda and focus of study. First, there is a gulf between the assumptions underpinning HiAP theories of change and actual politics and policymaking. The former suggests that the pursuit of intersectoral action, built on win–win strategies and avoiding health imperialism, will foster more collaborative policymaking, better policy, and health equity. Yet, the current evidence does not back up these assumptions, to the extent that it is time to rethink them by drawing more on studies of political economy and power (De Leeuw, 2018, p. 765; Harris, 2018, p. 875). A focus on programme logics, structures, and systems presents HiAP as a technical project, which distracts from the power imbalances and dominant ideologies that undermine HiAP as a global political project (Holt & Ahlmark, 2018, p. 758; Labonté, 2018, p. 656; Peña, 2018, p. 761; Shankardass et al., 2018, p. 757).

5.3 Theme 3: Political Science as a Source of Practical Lessons for Public Health

Second, there is a gulf in intentions between the use of policy theories to (1) explain policymaking and outcomes versus (2) facilitate new forms of policymaking and outcomes. Many studies use political science to serve the latter: translate the insights of policy theories into practical lessons for HiAP advocates (in other words, political science for public health—see Chapter 2, Fafard et al., 2022). For example, some use Kingdon (1984) to present a case study of the agency of policy entrepreneurs, describing their role in the famous ‘window of opportunity’ for major policy change when problem, policy, and politics streams come together. In doing so, they omit references to modern developments in ‘multiple streams’ analysis, recognising that most entrepreneurs fail, or noting that an entrepreneur’s success may relate primarily to their policymaking environment (Cairney & Jones, 2016; Cairney, 2018, 2021; Herweg et al., 2018; see also Chapter 3, Greer, 2022).

In comparison, Kickbusch et al. (2014, pp. 187–192) describe (well) Kickbusch’s impact as a policy entrepreneur in South Australia. Kickbusch and others were able to convince policymakers that a strategic focus on the social determinants of health across government could help reduce the unsustainable burden on health services. This account also situates entrepreneurial action in context. Rather than simply describing the successful exploitation of a ‘window of opportunity’ for HiAP, they describe its establishment as an initial condition to help develop the policymaking environment conducive to specific solutions. In other words, try to establish HiAP as an approach to government and then work together on initiatives, rather than (as often experienced with Health Impact Assessments) being brought in after an initial decision is made (Lawless et al., 2018, p. 513). As Cairney and St Denny (2020) describe, there is a big difference between a ‘window’ to adopt specific policy instruments (as in experiences of tobacco policy change) and a vague solution to an unclear problem (as in prevention), but few explore the difference.

Further, some studies draw skilfully on policy theories to explore the implications for HiAP advocacy and strategy. Very few show this level of engagement with policy theories, so key articles are worth exploring as best case examples in this category. For example, Harris et al. (2018, p. 1090) seek to explain why health promotion gained a foothold in land-use policy in New South Wales, Australia. They compare explanations associated with policy theories to identify a window of opportunity, the role of advocacy coalition action, and venue shopping to challenge a monopoly of agenda setting power in one venue. In short, policy entrepreneurs exploited an opportunity caused by sudden perception in government that (a) the economic framing of the reform had fewer supporters and more opponents than expected, and (b) a focus on health benefits boosted support for policy change—the ‘public mood’ was against traffic jams and pollution and pro exercise amenities—while being unthreatening to most actors. Their Table 3 translates this experience into advice on advocacy:

  • ‘Be ready to recognize and exploit windows of opportunity’,

  • ‘Build a broad coalition of interested actors’,

  • ‘Know the main entrepreneurs and coalitions’,

  • ‘Where possible, be non-threatening and co-opt their support’,

  • ‘Ensure your issue and goal are prominent in the policy process’ (or ‘If it is not prominent, try to slip it in under the radar’), and

  • ‘If necessary, challenge the policy monopoly’ (2018, p. 1098).

Similarly, Townsend et al. (2020, p. 981) reflect on the advice for HiAP advocates that they can glean from their explanation for parental leave policy change in Australia:

Our analysis highlights the benefit of deploying multiple synergistic framings, building coalitions with non-traditional policy allies and using multiple policy venues. This is likely especially important when the dominant policy concern is economic and when public health actions directly confront private sector interest groups.

To some extent, they are reinforcing common HiAP messages on respectful collaboration, suggesting that HiAP advocates give up on health imperialism in favour of aligning their aims and frames with those of many potential allies (2019, pp. 9–10). However, the conclusions also suggest that there is a causal link between their ‘game changing’ strategies and policy change. As such, these articles reinforce the idea that we can use specific insights from policy theories and empirical case studies to design HiAP advocacy.

Yet, policy theories are primarily empirical tools to produce broad scientific conclusions. It is not obvious how they would translate into normative guidance or practical advice:

relatively abstract policy theories will rarely provide concrete advice of how to act and what to do in all given contexts. There are too many variables in play to make this happen. The complexity of policy processes, its continuously changing nature, and its diversity across contexts, prevent precise prediction for policy actors seeking influence or policy change. (Weible & Cairney, 2018, p. 186)

If we simply connect lessons from theories to ‘what to do’ or how to influence a policy decision or outcomes, it disposes us to overextend our conclusions to contexts where they might not apply. (Weible & Cairney, 2021, p. 202)

Theory-to-practice advice puts the agency of policy actors at centre stage. A small group of people draw lessons about policymaking systems to influence policy in them: define the HiAP policy problem, learn the ‘rules of the game’, show how contextual factors inform your predictions of your strategy’s impact, and make informed action on that basis. In contrast, policy process research situates agency in a highly crowded and competitive political system: analysts face high uncertainty and ambiguity, there is contestation by many actors to define the policy problem, the rules of the game are unwritten and ill-understood, the audience is more important than the analyst, the same strategy can succeed with one audience and fail with another, and windows of opportunity to secure policy change can be decades apart (Cairney et al., 2022).

In that context, van Eyk et al. (2019, p. 1169) exemplify a useful way to qualify the HiAP focus on agency-based strategy, by comparing ‘facilitators’ to ‘barriers’:

  1. 1.

    Recommendation. Exploit a window of opportunity to ‘create acceptance’ for a HiAP approach to policy (preferably backed by legislation and a ‘central mandate’).

    • Qualification. Anticipate a ‘lack of sustained commitment’ particularly during changes to staffing and departments and budget cuts that shift priorities.

  2. 2.

    Recommendation. Align the HiAP response to ‘existing mandates’ to try to create a ‘supportive authorising environment and central mandate for action’. For example, use research to show how a HiAP initiative aligns with the ‘core business’ of government departments, collaborate to produce joint ownership of policy aims, and make sure to avoid the ‘perception that this is a top-down imposition by Health (health imperialism)’.

    • Qualification. Expect existing mandates to prioritise economy over health frames, with a tendency to reduce public health budgets during state retrenchment.

  3. 3.

    Recommendation. Encourage key actors to show leadership and become HiAP champions.

    • Qualification. Anticipate resistance to their message if it suggests ‘organisational culture change and changing established ways of operating’.

Such accounts are rare in HiAP studies, but they show the potential to move away from a relative focus on the agency of key actors (such as policy champions and entrepreneurs) towards a recognition of the policymaking environments that constrain or facilitate (a) their actions and (b) policy change. Analytically, this approach would help to distinguish between the obstacles to policy change that can be addressed and the more enduring dilemmas of policymaking that we discuss in the conclusion.

6 Conclusion: What Are Policy Theories For?

Initially, policy theories provide a useful lens through which to observe public health policy implementation. Most public health studies of policymaking still emphasise the important role of models such as HiAP and identify the desire to see them implemented in practice. In that context, the policy process often represents a temporary and inconvenient barrier between expectations and outcomes, and politics is a pathological process to be overcome (French, 2012, connects the latter to a more general misunderstanding of politics among academics).

In contrast, policy theories help identify the evergreen reasons for an implementation gap, focusing on the difficulty of turning a general commitment to a vague policy agenda into actual outputs and positive outcomes in a complex policymaking environment out of the control of policymakers. As such, policy theories help close the expectations gap by reducing unrealistic expectations. Some studies of politics and public administration also draw crucial lessons on specific aspects of policymaking, such as leadership or joining-up government (Carey & Friel, 2015; Carey et al., 2014; Greer & Lillvis, 2014). However, the general role of policy theories is to explain rather than help change policy processes:

The policy process is inherently messy and marked by a sticky resistance to change. It is also diverse across contexts and constantly changing over time. Given this complexity, there are no easy solutions. Students and policy actors looking for that simple solution to influence or improve policy processes will be disappointed. Instead, policy process theories offer a way of thinking about policymaking-related phenomena. (Weible & Cairney, 2021, p. 207)

In that context, it may be understandable that public health scholars seek to use policy theories instrumentally, to improve programme theories, or to provide practical advice to HiAP advocates. However, if theories were not designed for this purpose, we can only expect so much from this attempt to retrofit policymaking prescription from the study of policy processes.

If so, what value do policy theories offer to public health actors, and what would ‘political science with public health’ look like in the context we describe? First, like studies of public administration, policy theories help manage expectations and warn against unnecessary or counterproductive action. The ability to help policy actors avoid disheartening reform programmes should not be underestimated. Second, they help shift attention from seeing HiAP and EBPM as technical exercises, towards the inevitable role of power and (often positive) role of politics. A theory-informed public health approach can be as simple as the adoption of a research question more suited to the policymaking context, such as: what is the policy process and how does evidence or HiAP fit in, rather than how can we close the evidence-policy gap or the implementation gap? Indeed, this approach is more consistent with those of experienced policy actors who do not have the time or inclination to redesign policy processes when something goes wrong, and seek lessons more in keeping with their stoicism on the limits to their powers (Boswell & Corbett, 2015).

Finally, and perhaps most importantly, theory-informed public health studies would focus on the trade-offs that arise when public health policy actors must navigate multiple (and often contradictory) objectives. Two key examples demonstrate the tensions in public health agendas that cannot be resolved with more evidence or political will. The first is a combined commitment to EBPM and collaborative forms of governance. Studies should prompt difficult questions about who should participate and whose knowledge matters, and a movement away from simply declaring that obstacles to HiAP relate to ‘policy-based evidence making’ (see Cairney, 2017b, 2022; Cairney & Oliver, 2017). The second is a HiAP commitment to centralisation, to foster high political will and strategic commitment, and decentralisation, and to foster local autonomy, collaboration, and sense making. Studies should prompt difficult questions on the potential for centralisation and decentralisation to undermine each other, and away from simply declaring that any obstacle is an ‘implementation gap’ (see Cairney et al., 2021, pp. 25–26). Political science with public health would encourage critical reflection on policymaking dilemmas. Researchers and advocates would recognise, adapt to, and engage with policy processes that exist, not fantasise about how they would like politics and policymaking to be.