CHAPTER 2
The chapters in this book are about how policy in the field of health is developed and modified according to problems that arise as society and its values change or as new technology makes necessary reflection about existing values. The authors are interested in tracing the origins of particular health problems and revealing the processes by which they develop and are placed on the policy agenda, and the extent to which they are resolved. What is the problem and how is it being addressed? This might involve examining the institutional structures, the information used in reaching decisions, the values held by the participants and the broader social, economic and political contexts within which policies are formulated. The contributors describe and analyse systematically the actual content of particular health problems and policies.
This chapter begins with an overview of some of the problems frequently encountered in analysing the policy process. These relate to such questions as What is policy? Who is involved? Is policy political? Do models help? and Can policy be rational?
WHAT IS POLICY?
In the media there are references to government policy on a range of topics on a daily basis. We read or hear about how the Australian government is conducting immigration or water resources policy, and of state government reactions to those policies. At other times, the reference is more specific and we read the intricacies of a particular policy, say on the administrative decentralisation of a particular state government’s municipal public health planning, or pressure on the Australian government from state blood banks to change the composition of blood for transfusions by removing white blood cells which could perhaps lead to some groups in the community contracting disease.
The use of the word ‘policy’ is widespread. Political parties have policies on topics ranging from biofuel to how wheat is exported. These might or might not be translated into action when a political party obtains government. They can be dropped from a party’s objectives if the electorate or media are dismissive of a particular policy, such as the Australian Labor Party’s (ALP’s) proposed health ‘gold card’ for all older citizens, not simply for war veterans. In an era in which all nations share a common concern with the consequences of global warming and carbon dioxide emissions, there are calls by scientists and governments for universal policies that transcend narrow national boundaries, as in the report released in February 2007 by the United Nations Intergovernmental Panel on Climate Change. There are policies to be found on the websites of public and private organisations. Most government departments and agencies have officers working in specifically designated units with full-time responsibility for assisting in the development and implementation of policy. In the age of the email and the worldwide web immediate access to a written statement of government policy on almost any topic has become the norm, although governments are sometimes less ready to issue such documents on contentious issues (e.g. abortion). Banks and finance companies have policies on lending to home buyers based on interest rates set by the Reserve Bank and monitored by treasurers, and hospitals have policies for various procedures ranging from patient discharge to the use of expensive new technologies in surgery (see Ch 19).
Governments are expected to be able to articulate their policies on any problem, often at short notice. Government health departments and organisations which collect and disseminate health research findings, such as the Australian Institute of Health and Welfare (AIHW), are expected to provide health trend data on anything from obesity in children and Type II diabetes to increases in the incidence of chlamydia or hepatitis C infections. Often a ‘snapshot’ of general health in the community is required. The convention of responsible government suggests that the bureaucracy receives policy guidelines or frameworks from the government upon which it is expected to act, but often of course it is the reverse and it is the public servants who develop the strategies and guidelines or frameworks (see Chs 3 & 7). The word ‘policy’ is often used to describe the decisions of government from which a pattern of related decisions, often as regulations derived from Acts of Parliament, is seen to constitute policy. This can be seen in mental health policy (Ch 18), pharmaceutical drugs policy (Ch 17) or environmental health policy (Ch 21).
The system of a political opposition means that government ministers are regularly challenged by their opponents to articulate policies for parliamentary and public scrutiny. Oppositions are similarly involved in defending their alternative policies. The expectation that a government will be able to articulate coherent policy is often dramatically demonstrated in the electronic media. Governments and oppositions often have to defend their own values in relation to health policy changes in sensitive areas, such as the introduction of the abortion drug RU 486 and changes to foetal stem cell research. In both cases, the Prime Minister and opposition party leaders allowed a conscience vote where members vote according to their own principles instead of according to party policy. In the former case, a consortium of women members from the different parties represented in parliament introduced the legislation as a private member’s bill (that is, non-ministerial). In the latter, a former coalition Minister for Health, Senator Kay Patterson, introduced therapeutic cloning legislative changes also as a private member. Both bills were ultimately successful. Given the primacy of the party system in parliaments, successful bills by backbenchers are extremely rare, but this highlights how sensitive health policy can be (see also Ch 13).
WHO IS INVOLVED OR IS POLICY POLITICAL?
That policy is political is usually understood to mean that policy invariably involves competing interests with competing demands. Some analysts (Parsons 1995) who maintain that rationality and effectiveness are too often sacrificed to political expediency regret the intrusion of politics into the policy process. No process associated with conflicting interests can avoid the attempts by the individuals and groups involved to influence outcomes in favour of their own interests. Policy development, implementation and evaluation is therefore essentially a political process.
Federalism and health
This book is concerned with public policy in health, with those policies that have been developed within the wider governmental system. This system includes federal, state, territory and local governments, the public service departments serving them, as well as various semiautonomous public agencies charged with particular responsibilities. Constitutionally, the states and territories are responsible for health, but the federal government does supply most of the money and in reality this means that health is one of the most highly complex areas of policy. The federal system in Australia, which has a federal, or national, government and six state and two territory governments, often with different political parties in power, grafted on to a Westminster system of parliamentary government, allows for many problems of accountability. Despite the development of strategies to enhance ministerial control and increase public service accountability (see McCoppin 1995 and Ch 7), public servants inevitably exercise influence in the policy process by means of their expertise and advice.
There is much ‘buck-passing’ and accusations of blame between the state and the federal governments. A recent report of the parliamentary inquiry into health funding was actually titled The Blame Game (Parliament of Australia 2006). This occurs particularly in areas such as health where everyone has a personal stake in an effective system with, for example, efficient, clean hospitals staffed by expert and friendly staff in sufficient numbers, or expectations of the presence of general practitioners in rural areas. Hospital expenditure and crises of staffing in medicine or nursing are held to be the fault of the states and territories by the federal government, but the states respond that they are insufficiently funded by the federal government and that they need approval for more university places from the federal level (see Chs 4, 6, 9 & 10 for discussions of federal funding and health workforce problems).
Federalism, however, does not remain static. There are subtle changes and shifts in the balance of power quite apart from the few formal changes that have taken place. Generally, the shifts have been towards the federal or national level. In health and healthcare, the trend has been to an increased national, federal policy direction. We can see this as federal strategic policy development in areas such as control over the costs of pathology, control over the costs of general practice, control over the costs of radiology and over the costs of hospitals. There are frameworks for increased accountability and self-regulation through reporting mechanisms and an emphasis on outcome measures. At the level of the states and territories there is local decision making within federal policy guidelines. We can see this demonstrated, for example, in such wide-ranging areas as environmental health, rural health, illicit drugs, food safety policy (Ch 21), palliative care and mental health (Ch 18), all of which have detailed strategy documents.
In the same way that the development of policy is subject to economic and political influences, the process of implementation is constrained by a number of factors. If the policy is national, how can the federal government impose its will on the states and territories, which each have legislative and administrative responsibility for health and healthcare? If the state or territory government has the same political party in power as the federal level, this is more easily achievable, but by no means a fait accompli. State and territory governments have their own constraints, in particular perennial financial problems, which are often attributed to the federal government. State and territory governments, whatever their political persuasion, like to believe that they exercise power in their own right and should, therefore, be able to define their own policy priorities. This means that federal governments must work around these constraints. The Australian Health Care Agreements (formerly Medicare Agreements), which are negotiated every 5 years between the Australian government and the states and territories on federal government funding for public hospitals and related health services, make it attractive for states and territories to pursue particular health policies and unattractive to pursue others. No two states or territories have identical healthcare systems, the differences include variations in the provision of services, in health personnel registration systems (see Chs 6, 9 & 10), in the numbers of members of ethnic communities (see Ch 14) and Indigenous people (Ch 22), in rurality, and so on.
If the policy goals are shared between the federal, state and territory levels, implementation will be pursued more vigorously. There are, however, further implications for uniform national policies. In each state and territory, the relevant public service department, or health agency, or both, might interpret the process of implementation differently. Specific programs developed from the broad policy will be tailored to the specific needs of the community, as seen by the local decision makers. It can be argued that health policy which is informed by research, and which has included the major players in its development, has a greater likelihood of successful implementation, but it is still subject to economic, institutional and political constraints. Interest groups will be active at every stage of the process and their influence will modify initial goals. Australia’s federal system allows two tiers of government for such influence. The policy process is immensely subtle and complex, and while evaluations of health policies and programs will provide a great deal of useful information, they will not illuminate necessarily the whole series of activities and choices which have taken place.
Many areas of policy are not entirely within the control of governments. In terms of health policy this has meant that governments do not solely determine its final shape. In other words, the formation of public policy is the function of both government and of ostensibly private interests and organisations. For example, pharmaceutical corporations (many of which are transnational) can influence policy by their own research and pricing policies. Non-government organisations (NGOs) have recently played a more important role in not only development of health policy and advocacy but also in implementation; for example, Diabetes Australia and the Salvation Army. Voluntary organisations contribute some millions of dollars to the health and welfare sectors, and the private health sector, while it is subsidised by governments, also contributes (Ch 4). In 2004–05 the contribution of all governments to the funding of total health expenditure was 68.2% and of non-government was 31.8% (AIHW 2006a p 22). The federal government basically contributes twice as much as do state governments. The public–private split in healthcare similarly confuses policy. It is, for example, relatively unusual for new developments in surgery to be introduced in the private sector, but Chapter 19 provides a detailed analysis of just such an innovation in cancer surgery. So policy is essentially a political process almost invariably characterised by competing interests. Not surprisingly there are differing views about how such competition is reconciled and which interests prevail.
In some areas of policy, the policy of a national government may be affected by the actions of international agencies due to treaty provisions or the moral authority of such agencies. For example, since Australia is a member of the World Trade Organization, a decision to prohibit certain food imports on quarantine grounds might be challenged by other nations and the decision put before a dispute resolution panel. Dissatisfaction with the actions of Australian governments (both national, state and territory) can sometimes lead to Australian activists approaching United Nations committees, seeking redress for their grievances. Although the findings of such committees cannot be imposed on Australian governments, they sometimes carry significant moral weight.
Swerissen (1998), however, makes a passionate plea for the primacy of political decision making, subject as it is to elections, the media, parliamentary oppositions and the parliament itself. He believes it is a myth to believe that policy decisions are as opaque as the cynics appear to think. Certainly, cynicism is a problem in modern democratic systems. It is important that people are not so cynical that they are turned away from the political system to the extent that they see it as not worth supporting. It is then that what is a fairly fragile system can face its worst threats. Political parties are different, they have different ideologies, and when in government they do different things. The health system is subject to these changing emphases, which often take the form of a focus on the private health system when the Coalition is in power, and a concern for the public system when the ALP is in government (Gardner 1995a).
Political parties and the policy process
Political parties play an essential role in the policy process, a role commonly determined by their relative degree of electoral support and the nature of their parliamentary participation. Parties are at the centre of the Australian system of government, competing for electoral support and, at least in the case of the major parties, seeking to form governments. Ideally, they should offer alternative policy visions, giving voters choices. Parties not in office have an important role in scrutinising and criticising the policies and performance of governments. Parties with smaller electoral support might participate in coalitions or operate in a similar manner to interest groups.
From a policy perspective, political parties often articulate major themes or ideas, leaving the detailed planning for implementation to a later stage in the process. Not surprisingly, parties not in power frequently identify policy problems and proffer solutions. This is often done through such devices as parliamentary question time and through the mass media. Where governments lack a majority in the upper house, or Senate, it is not uncommon for enquiries to be established by opposition parties with the aim of probing policy problems in the formulation and implementation of government policy. Parliamentary enquiries initiated by either of the main party groupings can produce major policy critiques (see above and Ch 18).
The articulation of policy might result from the annual conferences of parties or in the carefully considered process of developing formal platforms, manifestos and policy statements. Often, political parties refrain from publishing details of their policies on particular issues until closer to the time of a general election. Policies are then successively ‘launched’ so as to attract greater public and mass media attention. The larger parties are able to make use of their own ‘think tanks’ for policy development. It should be noted that governments, although usually formed on a majority party basis, are not necessarily bound to follow their previously stated policies. Parties also continually respond to the cut and thrust of political contestation, a process that often leads to policy statements and commitments.
The ideal of parties offering alternative policies in an effort to solve major policy problems is often tempered by the realities of electoral politics. As Gardner has noted:
Political parties are caught in a dilemma. On the one hand, they need to stress the differences between them and argue for their superior policies; on the other, the want to gain the most votes, so there is a need to obscure the differences.Stay updated, free articles. Join our Telegram channel
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