Abstract
Aims: The paper aims to contribute to our understanding of the policy process in health promotion by addressing the following questions: What are the characteristics of the policy process in health promotion? How do policy entrepreneurs influence project implementation? Methods: This is a qualitative study with an explorative case study design that uses three different data sources: qualitative interviews, written documents and observations. Results: The paper examines several factors (determinants) that influence the policy process and that, to a lesser extent, are addressed by current models in health policy research. Legitimacy, financial capacity, available structure and political timing are all important determinants that influence the policy process. Policy entrepreneurs, with established networks and knowledge of the environment and its procedures, create legitimacy and provide opportunities for action; however, indistinct organizational boundaries among roles and poorly defined individual responsibilities create policy process uncertainty. As a result, there are lengthy discussions and few decisions, both of which delay the progress of a project.
Keywords
Introduction
Most policy analysis in public health research (including health promotion) is largely concerned with measuring and evaluating policy outcomes, with little attention paid to the policy process [1]. A review of the theories on policy process in health promotion reveals that theoretical insights from political science are rarely applied [2]. When theories are applied, too often the analysis follows implicit linear models of policy-making. This linear and traditional perspective on the policy process follows clearly defined steps: From problem definition to alternative specifications, to resource allocation, to implementation [2]. As a consequence, public health researchers neglect the fact that converting scientific results into public health programs is a complex social process. To gain a better understanding of how public health policy is made, empirical results from public health projects should be examined by taking a political science approach [1].
Several parameters from political science theories pertain to policy-making processes. These parameters, which may create implementation difficulties, relate to how decisions are made, the discretionary power of street-level bureaucrats and the frequent gaps between talk and decision; and between decisions and actions [3–6]. Policy process is a dynamic process with poorly-defined boundaries and neither a clear beginning, nor a clear end [7]. Therefore, a theoretical framework is needed in the analysis of the policy process framework. One such framework is Kingdon’s Multiple Streams Theory (MST) [2,8,9].
Kingdon [9] proposed the basic outline of MST, following in the tradition of Cohen, March, and Olsen’s 1972 [10] “garbage can” model of organizational choice. This model, in contrast to models of individual choice and the sum of individual choices, views an organization as a collection of choices “looking for problems, issues and feelings looking for decision situations in which they might be aired, solutions looking for issues to which they might be the answer, and decision makers looking for work” [10].
MST addresses the entire system or a separate decision as the unit of analysis. Similar to system theory, MST views choice as collective decision-making, resulting from the push and pull of several factors. In taking its inspiration from organizational theory, MST yields insights into the dynamics of the entire policy process: agenda setting, decision-making and implementation. Thus MST, which is clearly broader than the “garbage can” model, allowed us to look at the policy process in a way that is useful in single-case or comparative-case applications across time, countries, issues, levels of governance and policy domains [11].
MST has five structural elements: problems, policies, politics, policy windows and policy entrepreneurs. The policy process was conceptualized as three largely unrelated streams: a problem stream, a policy stream and a politics stream. The problem stream consists of various conditions of interest that policymakers and citizens define as problems. Child or adolescent obesity would qualify as such a condition. The policy stream, which consists of a number of possible and competing solutions to conditions in the problem stream, is usually generated by specialists in policy communities: networks that include, for example, bureaucrats and academics; however, because of the challenges involving technical feasibility, value acceptability and resource adequacy, only a few of these solutions receive serious consideration. The politics stream consists of perceptions of the national mood and the results of pressure group campaigns, and administrative or legislative turnover. Because government officials and politicians are sensitive to citizens’ demands, in addition to the media’s focus on such demands, we find that various issues and questions appear on the political agenda [11].
Policy reforms result when an opportunity for joining of the three streams appears. The points at which the streams join are called policy windows or “windows of opportunity”. When these windows open, policy entrepreneurs must immediately take the opportunity to initiate action [11].
While we have no precise definition of policy entrepreneurs, they are generally regarded as public entrepreneurs whom perform several functions in the policy process. For example, they define and reframe problems, propose policy alternatives and help set the decision-making agenda [12].
With relevance to the case study of this paper, consider the following scenario: In response to a problem (e.g. child/adolescent obesity), the policy community prepares a proposal that is financially and technically feasible (physical activities are recommended). The politicians promote the proposal, because of the clear health benefits for children and adolescents [13]. However, the proposal may be set aside if other issues/problems seem more pressing. Therefore, policy entrepreneurs play an important role, by connecting the three streams as they search for these windows of opportunities [11]. Because of their established networks and familiarity with the organizational environment and its procedures, they are able to take action [14].
Scientific evaluations of policy in public health require less political naiveté about the policy process. Complex interactions at every stage of the policy process influence the relationship between public health problems, policy and politics. Evaluations of public health projects must therefore be more than just evidence in, and then policy out [15,16]. In our examination of a public health project, we focused on the policy process, with its complex interactions between the evidence and the policy outcome. Our aim was to develop a deeper understanding of the policy process and the influential factors (hereafter, called determinants) related to health promotion policy.
Our research questions were the following:
What are the characteristics of the policy process in health promotion?
How do policy entrepreneurs influence project implementation?
Context
A county council in Sweden initiated and conducted the public health project that this paper describes and analyses. The project, which was approved by the municipality and its districts, was run in the public sector. The project was designed to promote physical activity among children and adolescents. This study followed the initial policy phase, which lasted for 16 months. The project had financing for three years.
The 20 counties in Sweden provide and finance public welfare and healthcare, each within its geographic boundaries. Swedish municipalities, within these counties, are responsible for several key policy areas related to public welfare and healthcare. These areas include: childcare, eldercare, education and social services. Because the Swedish Constitution states that counties and municipalities are autonomous, the politicians make local decisions about taxes, organization structure and management control systems; however, the counties and municipalities are not entirely independent from the State, which controls their finances to some extent. Moreover, Sweden has a national public health policy that emphasizes that cooperation between local governments (the county and its municipalities) is essential for achieving efficiency in public health activities [17].
The county council in this study uses a provider-purchaser healthcare model. This model has three organizational units, each of which consists of politicians and civil servants, with different roles. Financiers or owners, purchasers and providers have these roles. The politicians have ultimate responsibility for all projects, because they make decisions and appoint the civil servants. The civil servants manage the projects’ daily activities. In this study’s project, the “Purchasing Board” buys a physical activities program from a provider, whom manages the project. The Purchasing Board also has agreements with the municipality, which specify the reimbursements to the municipality and its districts for certain public health activities.
Methods
This is a qualitative study with an explorative case study design that uses three different data sources in its study of policy process: qualitative interviews, written document and observation of meetings.
Sample and procedures
After consulting with officials at a local healthcare office, we chose a project that was in its conceptual stage. For our research, we interviewed various respondents involved in the project. These respondents came from different organizational levels: from the policy domain to the administrative and professional domains [18]. We also conducted a document analysis and made observations of meetings that focused on the project idea, the project decisions and the project’s initial implementation. By using three data sources, we gathered information and impressions from multiple perspectives [19].
Documents
We analyzed relevant documents, in order to identify political goals and plans for the realization and monitoring of the project. These documents dealt with the Purchasing Board’s decisions about the project. We identified these documents based on our discussions with the Health Planning Leader, as well as by our review of the Purchasing Board’s meeting agendas. The documents also provoked the formation of questions that we then asked in our interviews.
Interviews
We conducted interviews with the civil servants whom were responsible for the project implementation. After the local politicians on the Purchasing Board approved the project, we interviewed three politicians from the Purchasing Board. Once people were employed at the project organization, and had begun to establish and implement procedures that promoted more physical activity, we interviewed the project’s manager and employees. The interviews were with individuals and with groups. Table I presents data on the interviews.
Participants: Roles and interview times.
Before the interviews, we sent each respondent a letter that described the study and its purpose. We also repeated this information orally, when we scheduled the interviews. We also asked them to consent in writing to their participation in the study. Respondents could choose the interview locations where they were most comfortable [20].
Observations
We made observations of the study’s participants in their project meetings. Although the participants were mostly project members, public health officials from the municipality and its districts also attended. We also made observations of meetings of the politicians on the Purchasing Board.
Analysis and interpretation
Documents
We analyzed documents that related to the political decisions for the project. First, we used content analysis to identify relevant text for our research. As we read the documents, we asked ourselves: Do the documents comment on the policy process, in terms of project goals, actors and realization or monitoring? Second, we re-read the selected text closely, to establish the contribution to our research aim [21]. At this point, our question was: Are there any policy process gaps in the documents related to the project realization or monitoring? Table II presents an example of our document analysis procedure.
The document analysis.
Interviews
We digitally recorded and later transcribed the interviews. We used the qualitative computer software package Nvivo for processing and coding the interview data. We then analyzed these data using qualitative content analysis, taking an inductive approach. We conducted this analysis in several steps, to learn the politicians’ and officials’ experiences in the policy process [22,23]. First, we listened to the tapes and read the transcripts several times, to get a sense of the whole. This process included open coding, which means that we identified as many headings as needed from the transcribed text, and they were coded in Nvivo [22]. Using these main headings, we re-read the transcripts, focusing on our research questions. We then coded several headings to describe all aspects of the transcripts. Again, using these headings, we re-read the transcripts, focusing on the identification of meaning units, which we then condensed and sorted into sub-categories.
The meaning units are groups of words or statements that relate to the same central idea. Condensing refers to the step in which we abbreviated the meaning units, while still preserving their core ideas [23]. Next, we created sub-categories from our interpretations and classifications of the condensed meaning units. In this step, our purpose was to further condense the meaning units, as well as to increase their relevance to our research questions [22]. The condensed meaning units and sub-categories can be seen as determinants that influence the policy process. Finally, we analyzed the sub-categories in the search for main categories that reflected the content of the meaning units [22]. Table III presents an example of the analytical procedure.
Examples of meaning units, condensed meaning units, sub-categories, and a main category; obtained from content analysis of the politicians’ and officials’ experiences with the policy process.
Observations
We took field notes by computer, at the observed meetings. As we read these notes several times, we conducted content analyses as a way of organizing the data. As in the document and interview analyses, we identified the determinants related to the policy process.
Results
We present our results in three sections: documents, interviews and observations. We then analyzed these data jointly.
Documents
The documents were analyzed with content analysis. Table IV presents the results of the document analyses.
Results from document analysis.
The politicians approved the project on 6 December 2012. The documents explain the rationale for the project and present the project’s general goals and objectives. The documents also described an initial plan for project implementation and a structure for subsequent operations. The documents emphasized the importance of collaboration among the parties. No details were presented about the realization and monitoring of the project.
Interviews
The interviews reveal several determinants, described below, that the respondents think may influence the policy process.
The incentives for the project vary, depending on roles in the organization
Table III presents an example of the analytical procedure, in which various determinants emerged from the meaning units and constructed the main category. The interviews revealed different incentives for the project’s initiation. The politicians on the Purchasing Board emphasized the importance of improving their legitimacy, by the demonstration of strong political leadership and by the presentation of the project as a pioneering role model. The politicians also emphasized the importance of sufficient financial capacity. The officials stressed the importance of the Purchasing Board’s history of projects (an available structure exists for the proposed project) and existing policy documents.
In summary, politicians and officials point to the determinants of adequate financial resources for the project, the timing of the project and the success of a similar, current project for adults. They admit these incentives do not guarantee the stability of the policy process. This uncertainty is revealed in another interview theme: The idea that doubts about project realization may lead to the expectation that “someone else” should take project responsibility.
Uncertainty about project realization may lead to the expectation that “someone else” should take project responsibility
The officials revealed uncertainty about the potential achievements of the project’s health promotion activities. Indistinct organizational boundaries among roles and poorly defined individual responsibilities create uncertainty, which was reflected in the comment that “someone else” was expected to take responsibility for the work. This theme appeared at all levels in the organization, which meant no one was taking responsibility. The result was a delay in the implementation of the health promotion activities. The following interview statements reflected this concern.
“Those who will work on the project will have to specify the activities for realization and monitoring of the project.” (Healthcare Planning Leader)
“The Health planning leader needs to push the local health officers. They are the people who need to do it. It’s impossible for us do it from here…” (Business developer for public health)
“At the general level, it’s very… well, it’s very hard to find something really. What are we supposed to… achieve? It is, and has been, very unclear.” (Coordinator for the project)
Because of their uncertainty, the officials stressed the importance of having “the right people” for the project whom could give the organization legitimacy. What “the right people” meant was revealed in another interview theme: The individual as the creator of legitimacy.
The individual as the creator of legitimacy
The individual characteristics of key personnel were highlighted as significant determinants in the policy process. The respondents thought it was essential that such people have extensive knowledge of organizational issues and an established network, both of which would help ensure the legitimacy of the project. If people from previous projects were involved in the current project, the politicians and officials were convinced of the project’s potential for success. One official stated:
“What you do and achieve is very person-dependent. Unfortunately, it is so. But since [sic] we have a developer who [sic] is an organizer, who has a broad vision of how to advance the organizational issues, I am not particularly concerned.” (Coordinator for the Purchasing Board)
“The right person” is someone, because of organizational familiarity and expertise, who can manage the uncertainty in the policy process.
Observations
We used content analysis with our field notes from the observed meetings. Table V summarizes these meetings and our observations.
Results from observations (type of meeting, length, participants and content).
HR: human resources (the people who hire new employees); IT: information technology (the people who set up or aid with computer-based work).
We made our observations of meetings over a period of 16 months. In the initial meetings, the main focus was the project infrastructure (e.g. planning, recruitment and actor participation). As the project planning progressed, we observed the uncertainty about the project that the respondents had described in the interviews. While there was considerable discussion about the project goals, few formal decisions for realization of the project were taken. The various responsibilities for the realization of the project activities were renegotiated as part of the policy process.
Discussion
The documents, interviews and observations revealed that several determinants, which to a lesser extent are addressed by current models in health policy research, influenced the policy process [2]. Legitimacy, financial capacity, available structure and political timing were all important determinants that affected the policy process. Furthermore, indistinct organizational boundaries among roles and poorly-defined individual responsibilities created uncertainty. This uncertainty delayed project progress, as much was discussed but little was decided. In addition, policy entrepreneurs, with established networks and knowledge of the organization and its procedures, were needed to give the project legitimacy and to provide opportunities for action.
The results of this case study indicate that the creation of a project is closely related to the policy entrepreneurs whom seize the chance to join the different streams in the policy process, such as financial resources, available structure and political timing. As shown in earlier studies, the chance that a policy will be adopted dramatically increased when the three streams were coupled in a single package. This required skill on the part of policy entrepreneurs, whom need to have close access to policymakers [11]. The policy entrepreneurs, who took action when they spotted an opportunity, used established networks and their expertise to create the project. Previous studies emphasize that such networks and knowledge build a platform for action [14].
In our study, the timely coincidence of elements in the three streams allowed the policy entrepreneurs to build a platform for action. Because of influences evident at the local, regional and national levels, it appeared that the streams crossed organizational boundaries. A condition in the problem stream was the fact of increasing child and adolescent obesity in society, which had been an agenda item for many years.
This condition, plus various elements in the politics stream (e.g. the pressure to allocate more resources to public health activities, and an agreed-on goal to improve the physical activity of children and adolescents), created an opportunity for the policy entrepreneurs to couple the idea for the project in the policy stream with elements in the problem and politics streams. As is also shown in earlier studies, resource adequacy and technical feasibility were also important selection criteria in the solution [11].
Our study also revealed the importance of policy entrepreneurs throughout policy processes, not only in joining the streams, but also in implementing the projects. Uncertainty and delay were created when policy entrepreneurs took a step backward and left implementation to the project group. When a policy process is vaguely outlined and not well understood at all organizational levels, projects are likely to be delayed or poorly implemented [3,6]. In our study, the policy makers sought the advice of the policy entrepreneurs, whom had in their professional networks a good understanding of, and access to, the organizational issues. Such knowledge and contacts could have helped support the legitimacy of the project; and thus, could have reduced the uncertainty in its implementation.
Public health researchers often neglect the fact that converting scientific results into public health programs is a complex, social process [1]. Our study showed that it was important to consider the interaction and negotiations between actors in the policy process, as well as the role of policy entrepreneurs throughout the policy process. These interactions and negotiations have implications for the design of projects and the time required for their implementation. A diversity of actors in the policy process, which is often the norm in public health, created a problem with managing multiple perspectives. The result often means time-consuming, unproductive delays in implementation [4].
Managing these perspectives often requires people with extensive networks and knowledge of the organization, which highlights the need for policy entre-preneurs throughout the policy process. Because public health activities, along with other sustainable development activities, are often implemented in projects [24], it is particularly important that policy entrepreneurs’ knowledge and experience, beginning at the initiation of projects, are transferred to the people whom work with the implementation of these activities.
Our use of a qualitative and explorative case study design allowed us to obtain data on interactions and processes in an actual project context. This design is suitable when the research object is dynamic, complex and impossible to control. Additionally, case studies offer a systematic way of handling data [25].
A possible limitation of this research was its time frame. A longer time frame would have increased our knowledge of the policy process; however, we only present our results and conclusions based on the research conducted in the initial phase of the policy process. We did not draw any conclusions about the ultimate success or failure of the project. The richness of the qualitative data, however, with its combination of three sources of empirical evidence, allowed us to explore the policy process in some depth.
Conclusions
This study showed that the characteristics of the policy process in health promotion are not linear. Converting scientific results into public health programs is a complex social process. Our study showed that it is important to consider the interaction and negotiations between actors in the policy process, both of which have implications for the design of projects and the time required for their implementation. Legitimacy, financial capacity, available structure and political timing are all important determinants that influence the policy process and which, to a lesser extent, are addressed by current models in health policy research.
This paper’s theoretical contribution was its analysis of the relationship of policy-making to linear models, via a discussion of policy entrepreneurs and their importance within the policy process. We conclude that we need to consider the influence of policy entrepreneurs, whom build legitimacy and seize action opportunities, by coupling the three streams in the policy process as they help bring projects to fruition. Furthermore, this study pointed to the importance of policy entrepreneurs throughout the policy process. Policy entrepreneurs, with their extensive knowledge of organizational issues and their established network, can help ensure project legitimacy and reduce uncertainty in project implementation. This paper has practical implications for practitioners whom work with the implementation of community policies.
Footnotes
Conflict of interest
None.
Funding statement
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.