Policy Capacity Meets Politics

Abstract

It is difficult to disagree with the general argument that successful health reform requires a significant degree of policy capacity or that all players in the policy game need to move beyond self-interested advocacy. However, an overly broad definition of policy capacity is a problem. More important perhaps, health reform inevitably requires not just policy capacity but political leadership and compromise

Large-scale, meaningful and durable policy and program change is very hard to achieve. Forest et al¹ seek to offer an explanation as to why. They argue that a lack of policy capacity, both inside and outside government, is a large part of the problem. They argue that this is an especially serious issue in health policy given that the vast range of factors that determine health. This leads them to suggest, inter alia, that the process by which policy is made needs to be better informed and more pluralistic.

While I agree with the overall thrust of their argument, there are three areas that I would like to focus on in this short commentary: the definition of policy capacity; the need for all players in the policy game to move beyond agenda setting and advocacy; and, something missing from the model – politics.

Forest et al¹ offer a very broad and sweeping definition of policy capacity: “Policy capacity is the sum of competencies, resources, and experience that governments and public agencies use to identify, formulate, implement, and evaluate solutions to public problems.” This definition, especially when linked to the idea that a diversity of players is needed to make good policy, has the merit of encouraging those who would seek to foster change to take into account the wider range of what is required to make good policy. To put it bluntly, I agree that reform requires more than good ideas; it requires an appreciation of the importance of adequate resources, both human and financial, well-designed organizations, and an appreciation of local context (ie, one size does not fit all). But this broad approach defines “policy capacity” to include most of what governments do. It expands beyond the usual focus on the formulation of new policies to extend the concept to their implementation (eg, programs; regulations; budgets) and their evaluation. If policy capacity becomes everything it risks becoming nothing. There is merit in distinguishing between the challenges associated with say, agenda setting, and those associated with program design or evaluation. Moreover, the authors are, in my view, too quick to suggest that the concept of policy capacity is not widely understood in academic policy analysis. This is arguably true for those who focus solely on health policy. It may also be true for those who, often trained in the United States, who privilege quantitative analysis to the exclusion of almost all else. Yet, there is a rich literature in political science that offers a more expansive and holistic account of policy change. For example, we now have a more sophisticated understanding of policy advisory systems and the role and function of a wide range of players inside and outside of government.²

One aspect of the vision of policy capacity articulated by Forest et al,¹ is the idea that all of the players in the policy game need to be more than mere advocates and must develop their own policy capacity and speak not only to what should be done but also to how it should be done with some sense of the tradeoffs that will, inevitably, be required. I could not agree more. This means, for example, that when the associations representing health professions, notably but not limited to physicians and nurses, engage in policy work and proffer policy advice, their contribution needs to advance the public interest and not just the self-interest of their profession.³ Similarly, there is a constant stream of public health research that identifies the factors that contribute to ill health and premature death. But true policy capacity, as Forest et al¹ conceive of it, requires that the public health community move well beyond trying to set the policy agenda by calling for things like less sugar in our diets, more walking and cycling in our daily commute, or a serious reduction in income inequality, to name but three. While these are noble and important goals, a more fulsome contribution to the policy debate would include some discussion of how to get there. There is some irony here insofar as the public health community broadly defined has the advantage of having experienced the long, difficult and as yet incomplete battle to reduce tobacco consumption. Yet, the sophistication of the public health arguments around tobacco control has not been replicated in a number of other areas of public health concern.

Forest et al are concerned, first and foremost with policy transformation. To do this they argue we need to “raise the level of policy conversation by making it better informed and more pluralistic.”¹ But there are limits as to what can be accomplished by making the policy process better informed. Yes, some efforts at policy and program change processes suffer from being dominated by voices that are insufficiently diverse or simply ill informed. But real change often requires difficult tradeoffs and/or the resolution of deep value conflicts. And this is the stuff of politics. Much can be accomplished by enhancing policy capacity. However, as the authors freely acknowledge, change also requires leadership. My fear is that in our efforts to improve our collective policy capacity we will lose sight of the fact that one of the most important competencies, resources and experience for policy and program change is political leadership. Enhanced policy capacity is essential but even the most well-informed and inclusive policy conversation has to be accompanied by the ability to identify and implement the compromises and tradeoffs that are inevitably required. As Richard French has put it, “The demands of politics are unpredictably diverse and protean and thus political reason is unusually resistant to generalisation and codification; it remains tacit and only obtusely articulable even for those who possess it. To some significant extent, the ability to deploy it effectively must be the product of nature and of the accidents and vicissitudes of life, rather than of any more intentional preparation.”⁴ Simply put, we elect representatives to make decisions on our collective behalf and then defend them against the inevitable critics. This is not and cannot be a purely analytical or managerial process. Enhanced policy capacity is both essential and desirable. But if the goal is sustained and sustainable policy and program change, a considerable amount of politics is required, and this in the best sense of the word.

Ethical issues

Not applicable.

Competing interests

Author declares that he has no competing interests.

Author’s contribution

PF is the single author of the manuscript.

Citation: Fafard P. Policy capacity meets politics: Comment on "Health reform requires policy capacity." Int J Health Policy Manag. 2015;4(10):707–708. doi:10.15171/ijhpm.2015.134