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Schober Global Healthcare Consulting, Indianapolis, IN, USA
Keywords
TheorySocial policyHealthcare policyPolicy processA theory is often viewed as a hypothesis or system of ideas intended to explain and predict a phenomenon or justify a course of action. For the purpose of this publication, theory is also defined “generically to mean a range of approaches that specify the scope of inquiry, lay out assumptions, provide a shared vocabulary among members of a research team, and clearly define and relate concepts in the form of principles and testable hypotheses and propositions” (Weible 2014, pp. 3–4).
Theories of social and healthcare policy mean disparate things to different people. One perspective is that these policies are mostly concerned with content that includes the best method for considering financing services or service delivery. However, a look at policy requires an exploration into how policy is formulated and implemented as well as who or what influences policymaking. The theories selected for discussion in this chapter focus on policy as it relates to the processes of policy formulation and/or implementation and are considered to be classic illustrations of policy processes as referred to in additional publications (Klein 2014; O’Grady and Johnson 2014; Porche 2012; Schober et al. 2016; Walt 2006). The criterion for inclusion of a theory in this publication is not the newness of an article or reference but the quality of its insight, that is, its ability to explain some aspect of the policy process and/or policymaking. Finally, this chapter offers commentary on the relevance of social and healthcare theory to nursing.
3.1 Hall, Land, Parker, and Webb Agenda-Setting Framework
The Hall et al. agenda-setting framework (Hall et al. 1975) based on the theory of bounded pluralism suggests a compromise theory of power as it influences policymaking. The theoretical framework proposes that issues of high politics (e.g., economic issues) are decided by influential leaders but that most domestic or routine policies such as health and education are likely to be developed at a level that includes some participation of interest groups at different stages of the policy process. This theory proposes that government decision-makers may be open to influence from a variety of sources as long as the policymakers perceive the sources for the policy topic as legitimate. This idea lends itself to the notion of agenda setting as introduced in Chap. 2, Sect. 2.1.1.
The Hall et al. (1975) framework identifies three conditions that help to explain why policymakers might act on any particular concern or give precedence to a specific issue. The framework identifies the following concepts:
Legitimacy
Feasibility
Support
The suggestion is that only when an issue is high in relation to all three concepts does it become an item on the policymaking agenda. This provides a simple approach for assessing what issues might be considered by governments and key policymakers. Sections 3.1.1, 3.1.2, and 3.1.3 provide further discussion of these three concepts.
3.1.1 Legitimacy
Legitimacy refers to the issues that key policymakers/governments/organizations feel they should be concerned with and in which they have the right or authority to intervene. Conversely, these topics are issues where decision-makers feel people will accept, e.g., government intervention. Issues range from low to high legitimacy. The identification of legitimacy differs from country to country (Hall et al. 1975).
3.1.2 Feasibility
Feasibility refers to the potential for implementing the policy. Does the government/state/organization have the capacity to ensure implementation? Is the plan achievable? Implementation efforts face technological, financial, or personnel limitations that might, even in the early stages, suggest that a specific policy may be impossible to implement even if it is seen as legitimate (Hall et al. 1975).
3.1.3 Support
Support refers to the vague but important aspect of public support for or public trust in government or organization action. For certain issues, there may be strong support from interest groups or relatively weak visible support for a policy.
If support is lacking or dissatisfaction is high, it may be difficult to implement policy (Hall et al. 1975). For an example of this point, there is increasing evidence that the quality of care provided by APNs is positive. In addition, support for APN services in many healthcare environments is at a very high level. However, there is also evidence in various countries that factors such as opposition by medical associations can delay or totally block policies essential to support APN practice.
Findings from a study conducted in Singapore (Schober 2013) revealed that following years of formal and informal discussion, support was eventually established for the APN concept. In addition, there was an expectation that the government would develop policy and coordinate a strategic plan for further support and implementation. However, the ability to begin to move forward depended on action from three key decision-makers with power and authority to influence particularly the medical fraternity. Even though conditions of legitimacy and feasibility for ANP were met, further issues of support had to be addressed for the initiative to progress.
According to Hall et al. (1975), using these three conditions, governments and key decision-makers assess whether an issue falls high or low on a continuum. A position of high legitimacy (a view that they have the right to intervene), high feasibility (sufficient resources and infrastructure), and high support (significant interest groups are supportive or at least not opposed) suggests that the issue may likely come onto the policy agenda. However, there are times when representatives of governmental agencies will place an issue on the policy agenda to make a statement about it or to show they have a position on the topic, but they do not necessarily expect it to be put into practice. Thus, it remains policy on paper only (Walt 2006).
3.2 Kingdon’s “Windows of Opportunity”
In offering a description of the policy environment, Kingdon (2003) indicates that policy starts with agenda setting and conceptualizes an open policy window or “window of opportunity” based on a three streams approach (see Fig. 3.1). This approach suggests that complex policy processes occur in three separate streams and only when they come together does an issue make the policy agenda. This concept suggests that policies are only considered when a major “window of opportunity” opens up in the three streams (problem stream, politics stream, policy stream) at the same time:
The problem or issue must come to the attention of the policymaker.
The issue must have a menu of possible policy solutions that have potential to actually solve the problem.
The right political circumstances have to be in place.
This perspective emphasizes that the three separate streams of problems, politics, and policies have lives of their own. When the streams are joined, it is when policy change occurs. As a result, Kingdon (2003) provides an interactive theory that aims to take into account the dynamic nature of policymaking. This convergence of three streams is viewed as often chaotic and unpredictable.
In contrast to the three conditions for policymaking proposed by Hall et al. (1975) (see Sect. 3.1) and incremental stages suggested by Lindblom (1979) (see Sect. 3.3), Kingdon (2003) proposes that policies are not made in stages, steps, or phases. What contributes to the three streams coming together may be due to individuals, media attention, a crises, or evidence of a problem. As a result, alternatives may be supported and promoted for long periods of time before the opportunity takes place for them to be accepted or placed on the policy agenda.
The streams as identified by Kingdon (2003) take place in parallel and somewhat independent streams until something happens to cause two or more of the streams to meet in a “window of opportunity.” This window is the possibility of change; however, the open window does not guarantee that policy change will occur. The origin can be a change in understanding of a problem, a change in the political environment that is favorable to change or increased focus on an issue that attracts attention to the topic (Birkland 2005).
In critiquing the Kingdon theory, Zahariadis (1993) proposes that the Kingdon approach can be applied to decision opportunities, not just for agenda setting. Therefore, a decision to make new or existing policy may be more likely when the streams come together. In addition, Sabatier (2007) suggests that the streams metaphor may be an incomplete description of policymaking as it does not describe the policy process beyond the opening of the windows of opportunity. The multiple streams theory supports the contention that policymaking is messy, complex, costly, and not necessarily logical but does try to make sense of an ambiguous process (Zahariadis 2014). In any case, the Kingdon theory provides a multilayered image of policymaking (see Fig. 3.1) from the early acceptance of new ideas about an issue to active consideration of actions by introducing the idea of focusing on events that can be examined for their influence on the policy agenda (Birkland 2005).
3.3 Lindblom’s Incrementalism and Disjointed Incrementalism
Lindblom is considered to be the creator and best-known proponent of the incrementalist policy theory (Lindblom 1959, 1979). In referring to the policy process as one of incrementalism or more realistically, disjointed incrementalism, Lindblom notes that policymaking is a process of negotiation, bargaining, and adjustment between different interest groups to influence policy. Lindblom’s emphasis is on what is happening rather than what ought to happen. As a result, it can be argued that what is feasible is only slightly different from existing policy. Beneficial points of the view of incremental change imply the following:
Policymakers focus on what is familiar based on their experience.
It reduces the number of possible alternatives to consider.
The number and complexity of factors policymakers need to analyze are reduced.
This description of the policy process is both a theory of how decisions are made and a description of how competing interests behave in policymaking (Birkland 2005).
Policy issues according to Lindblom (1959, 1979) are divided into two categories, ordinary questions of policy and grand issues pertaining to politico-economic life and structure. In situations of ordinary questions of policy, Lindblom sees many groups actively participating. However, on grand issues, Lindblom suggests that participation outside of key decision-makers may be ineffectual or nonexistent. Incrementalism can be seen as based on deliberate incomplete analysis of an issue; thus, this theory in turn proposes that policymakers make decisions in a political world which introduces many constraints to the process thus little policymaking is really revolutionary (Lindblom 1979).
Incrementalism views political change by small steps; thus, incrementalism varies by degree. As a result, the size of the step in policymaking can be arranged on a continuum from small to large. Lindblom (1979) distinguishes three meanings of incrementalism as policy analysis: simple incremental analysis, disjointed incrementalism, and strategic analysis. The next section explains disjointed incrementalism and proposes that it is a realistic view of some aspects of policymaking.
3.3.1 Disjointed Incrementalism
Disjointed incrementalism can be viewed as one form of strategic analysis, and simple incremental analysis is one element in disjointed incrementalism.
Stratagems considered to be descriptive of disjointed incrementalism include:
Limiting analysis to a few familiar policy alternatives
Linking analysis of policy goals with pragmatic aspects of the issue
Increased concern with problems to be resolved rather than only goals to be sought after
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