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Politics and health: policy design and implementation are even more neglected than political values?

Ken Judge
DOI: http://dx.doi.org/10.1093/eurpub/ckn043 355-356 First published online: 21 July 2008

It is surprising that political phenomena have not been more prominent in public-health research. But there can be no doubt that politics do matter. It is impossible, for example, to understand health inequalities policy in England in the past two decades without acknowledging the ideological differences between the Thatcher/Major and the Blair/Brown governments. Even within one party tradition there are also many examples of different Ministers wanting to try to put their personal imprint on policy. The recent change from a Blair to a Brown-led government in England helps in part to explain why health inequality policies there are now being refreshed.

But despite clear evidence that politics matter it is not difficult to see why many scholars shy away from an explicit focus on this. Much of politics is about values and these do not lend themselves easily to scientific examination. This is not to suggest that they should be ignored, but the dividing line between scholarly endeavour and personal politics is an uncertain one.

The constraints are less evident in cross-national work where a rich vein of studies, that have examined variations between nations in conventional population health outcomes such as infant mortality, has paid particular attention to those factors that might be seen as the outcomes of purposive political choices. Many of them suggest that more progressive tax systems and universal welfare cultures are associated with improved population health outcomes. For example, Chung and Muntaner1 report that ‘more protective types of welfare state regimes, namely the group of Social Democratic countries’ are associated with lower rates of infant mortality and low-birth weight. It is not easy to draw general inferences from such studies, though, because they use different samples of countries, outcome measures and methods of investigation.

Although there seems to be a growing consensus that discretionary characteristics of welfare states are associated with variations in population health outcomes it is less clear that this is as true of health inequalities. There are as yet only a small number of studies that try to investigate the links between classical welfare state models and health inequalities. Those that have been published, however, are beginning to cast doubt on widely held assumptions that Nordic welfare states, for example, do better than more liberal ones, at least in Europe.

But even these new areas of study are perhaps too narrowly based. Any serious consideration of the impact of political science on public health must cover a broad territory. The American Political Science Association defines political science in a way that should encourage as much interest in the practice of government as in politics per se (http://www.apsanet.org/section_517.cfm).

If politics can perhaps be represented as the art of making and marketing policy choices, then government is to a significant extent about designing and implementing policy proposals. From this perspective, and certainly in relation to the study of health inequalities, it is arguable that government is even more neglected than politics.

In most countries that have formally adopted policies in relation to health inequalities it is difficult to identify much that goes beyond rhetoric and aspirational targets. Even in England, where it is claimed that a strategic plan of action has been in place for several years, it is difficult to find evidence that policies, interventions and investments have been conceived, designed and implemented in purposeful ways that have any realistic prospect of achieving desired outcomes.2

It remains largely true that ‘policy making about health inequalities takes place in a fog of disagreement about goals, controversy about causes and uncertainty compounded by ignorance about means’.3 One of the relatively few studies to take this topic seriously reports that ‘implementation is hampered by deficiencies in performance management, insufficient integration between policy sectors, and contradictions between health inequalities and other policy imperatives’.4

Fortunately this situation is, somewhat belatedly, beginning to change. Perhaps the best example of a focused strategy with a clear action plan to achieve specified reductions in inequalities can be found in England where an important new report5 about the failure of the infant mortality target to make adequate progress illustrates the nature of the implementation failure that has occurred and shows the importance of audit and review, widening the scope of interventions (to include wider determinants of health) and supporting local implementation efforts—if the situation is to be improved in future. New plans start to address important questions of policy implementation and feasibility that increase the probability that desired outcomes will be achieved.

Politics and government do matter for public health. But it is time to focus more effort on the relatively unglamorous hard slog of improving service delivery and performance.

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