literally be a matter of life and death and is often an essential influence on quality of life, it is charged with strong emotions and is concerned with fundamental societal values. Despite attempts to ‘roll back the role of the state’ public health and healthcare are still regarded as primarily the responsibility of governments. In Australia, more than two-thirds of total health expenditure comes from government sources (see Ch 4, Fig 4.2; Ch 6, Table 6.1). Not surprisingly, health is a major electoral issue.
SEMANTICS: THE PROBLEM OF THE WORD ‘PROBLEM’
Before exploring the place of the problem in policy analysis, it is important to consider how we will use this concept since the context in which this word is used (or not used) is revealing about the very process of problem definition. The observer of both popular and official usage cannot fail to note how the word ‘problem’ is no longer applied where once it was regarded as appropriate. During the writing of this chapter a major power blackout in Victoria was explained in a radio interview with an official of the electricity corporation as a bushfire causing ‘an issue’ with the power grid! A computer-based word search of the most recent annual review from the Secretary of the Australian Government Department of Health and Ageing failed to find a single instance of the word ‘problem’.
Perhaps too blunt and negative for an era of ‘spin doctoring’ in which language is increasingly tempered by public relations considerations, the word ‘problem’ is often eschewed by policy makers, and even some policy analysts, in favour of the more neutral ‘issue’. Sometimes the two terms are used interchangeably. On occasions ‘concerns’, ‘matters’ and ‘situation’ are referred to. Increasingly the optimistic term ‘challenge’ is employed in lieu of ‘problem’, a usage that taps into the notion of problems as ‘opportunities’ demanding an attempt to make things better. When greater linguistic impact is needed, the often hyperbolic ‘crisis’, ‘disaster’ or even ‘chaos’ might be invoked.
Yet the conventional usage of problem, described in the Shorter Oxford Dictionary as a ‘difficult question proposed for a solution’ or a ‘proposition in which something is required to be done’, also adequately suits the purpose of policy analysis. As Kingdon puts it, for a condition to become a problem ‘people must be convinced that something should be done to change it’ (Kingdon 1984 p 118). It is common for a problem to be seen as something undesirable (Weimer & Vining 1992 p 206) or as a ‘mismatch between observed conditions and one’s conception of an ideal state’ (Kingdon 1984 p 116). However, for Dery, author of a major study on problem definition in policy analysis, it is not useful to approach problems as ‘undesirable situations, discrepancies between a given state and a desired state, or bridgeable discrepancies’ (Dery 1984 p 26). Rather, they ‘are better treated as opportunities for improvement’ (Dery 1984 p 27).
PROBLEM SOLVING AND POLICY ANALYSIS
The centrality of the problem to policy analysis is commonplace in the literature. Parsons regards policy analysts as being ‘in the business of problem-structuring and ordering so as to facilitate problem solving by decision makers’ (Parson 1995 p 88). For Quade, the purpose of policy analysis is ‘to help (or sometimes influence) a decision maker to make a better decision in a particular problem situation’ (Quade 1989 p 13).
Problem recognition and definition is identified as the first stage of the policy cycle by a number of writers (see e.g. Bridgman & Davis 2000 p 49; Davis et al. 1993 pp 160–1). Howlett and Ramesh (see Table 1.1) suggest various phases at which a problem-solving approach relates to the policy cycle or process commonly suggested in policy analysis texts.
Table 1.1 The relationship of the policy cycle to applied problem solving | |
| Phases of applied problem solving | Stages in the policy cycle |
|---|---|
| 1. Problem recognition | 1. Agenda setting |
| 2. Proposal solution | 2. Policy formulation |
| 3. Choice of solution | 3. Decision making |
| 4. Putting solution into effect | 4. Policy implementation |
| 5. Monitoring result | 5. Policy evaluation |
Source: Howlett & Ramesh 1995 p 11 | |
But a number of caveats apply to such a linear approach and also to some of the assumptions inherent in the language used. Both Wildavsky and Dery pose a ‘reality check’ which might be startling for some students of public policy: that policy analysis is concerned with creating problems which are worth solving and which have some prospect of being solved, thereby suggesting that solution identification leads to problem definition rather than vice versa (Wildavsky 1980 p 17, Dery 1984 pp 23–5). For Dery, problem definition ‘must be instrumental to problem solving’ (Dery 1984 p 26) since there is no useful purpose served by defining problems that cannot be solved or can only be solved by violating other values, thereby making the solution unacceptable (p 9). Indeed, these concerns with practicality are common to the very definition of policy:
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 specified situation where these decisions should, in principle, be within the power of these actors to achieve.
(Roberts quoted in Jenkins 1978 p 15, emphasis added)
Notwithstanding the ways in which problems are perceived and interpreted and the influences shaping interpretation, the fundamental concern with problem definition is that of solutions. As Dery concludes, problem definition has to be instrumental to problem solving (Dery 1984 p 26). The process of problem definition involves the ‘search, creation and initial examination of ideas for solutions until a problem of choice is reached’ (p 27).
Nevertheless, we should not let the magnitude of some problems prevent efforts to deal with them. Efforts to deal with global climate change, which rely upon common action on the part of all nations and the probability of reduced standards of living, might be portrayed as impractical, undesirable or impossible and consequently not permitted on the policy agenda. Yet the potential consequences of policy inaction are literally disastrous.
Quade enjoins modesty in approaching the task of problem solving, observing that since it is rare that a single alternative to deal with a problem is obvious, ‘the analyst does not even try to offer more than suggestions as to what the choice should be – there is too much uncertainty and too many differing views of equity and of values for that’ (Quade 1989 p 14). The analyst, therefore, can often do little more than contribute to the quality and quantity of information available to the policy decision maker.
It is common to include a ‘feedback’ loop in policy process models since decisions by policy makers often lead to further demands upon the decision makers. Wildavsky reminds us that solutions are usually both temporary and partial, since conditions producing the initial problem often change over time and new problems arise, sometimes even caused by the initial attempts to provide solutions (Wildavsky 1979 p 390). Subsequent evaluation of problem definition and chosen solutions should therefore be an integral element of applied problem solving.
PROBLEM DEFINITION
It is clear from the preceding discussion of problem solving and policy analysis that, while problem definition is central to a problem-oriented approach to policy analysis, problems are not necessarily self-evident. Parsons puts it simply, maintaining that a policy ‘has to be defined, structured, located within certain boundaries and given a name’ (Parsons 1995 p 88). This task must, of necessity, involve both individual and societal perceptions, which in turn are influenced by values. As Brewer and deLeon caution, the ‘very recognition of a problem implies a certain set of values and goals on the part of the individual’ (Brewer & deLeon 1983 p 35). The availability of information about a particular problem, and how this is transmitted, will also be significant. Where data about a problem are not collected, or their dissemination is suppressed, agenda setting is hampered or can even be made impossible. For example, at Federation, the Australian Constitution excluded the Aboriginal population from being counted in any census. Although this provision was overturned by the 1967 referendum, policy on Indigenous health has historically been hampered by serious deficiencies in the collection of statistics. Finally, the ‘discourse’ or ‘policy story’ gives the problem its shape and meaning, although in some cases there is more than one account of the problem. The whole enterprise of policy definition is therefore subjective. As Wildavsky muses, ‘our rationalisations, once made, are just as real as our other creations’ (Wildavsky 1980 p 390).
Brewer and deLeon point out that the ‘perception and recognition of a policy problem can be treated as both individual and institutional phenomena’ (Brewer & deLeon 1983 p 35). Wildavsky goes as far as conceding that it is difficult to say ‘whether what we consider a policy problem is in us or in society’ (Wildavsky 1980 p 389). The individual analyst needs to bring the problem to the attention of the organisation.
The perceptions of individual analysts might, or might not, be accepted by institutions or organisations that play instrumental roles in shaping the policy agenda. It is only when the political system embraces problems that they become part of the policy process. Indeed, it is usually only when problems are recognised by agencies of the state and seen to have wider societal ramifications that they are placed on the policy agenda. Such agencies are commonly governments, parliaments and municipal councils, bureaucracies, the judiciary and councils of state. In Australia, medical associations have been concerned about the commercial endorsement of non-prescription therapeutic products and the selling of alternative medicines by registered medical practitioners, but it took some time for the Australian government to recognise this as a problem and take steps to prohibit such practices.
For those concerned with the exercise of power in the policy process, the ways in which problems reach the policy agenda, or are prevented from so doing, is of particular concern. Governments might choose to ignore problems, since the economic or political costs of attending to them is considered too great. Moreover, in the first place there must be consciousness about the problem, and its nature, on the part of individuals or groups. As Lukes reminds us, the shaping of people’s thoughts and desires is the supreme exercise of power (Lukes 1994 p 23). Keeping problems off the policy agenda, or preventing or limiting consciousness about them, is thus an exercise of political power.
Howlett and Ramesh emphasise the significance of institutions and also of values in problem definition, observing that:
The context of societal, state and international institutions and the values these institutions embody condition how a problem is defined, facilitate the adoption of certain solutions to it, and prohibit or inhibit the choice of other solutions.
As will be seen in Section 3 of this book, values are an essential element of health policy and are often contested. At times, support for the realisation of cherished values comes at a high economic price and stands in contrast to such economic values as efficiency, since special services must be provided for particular population groups. At other times, symbolic recognition is sufficient to satisfy demands for incorporating certain values in public policy. Moreover, some values are recognised in multilateral treaties and these are sometimes invoked as part of efforts to influence the shape of policy.
CATEGORIES OF HEALTH POLICY PROBLEMS
The first step in a problem-oriented approach to policy analysis is to seek to establish the type or category of problem. As Dery admonishes, ‘… in order to define a problem it is necessary to determine what kind of problem it is’ (Dery 1984 p 4, emphasis in original). In so doing, we need to be mindful that the very process of categorisation serves to define how we look at a problem. Table 1.2, while not exhaustive, suggests some types of problems to be found in health policy in Australia.
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