From Headline to Hard Grind: The Importance of Understanding Public Administration in Achieving Health Outcomes

Abstract

Many public policy programs fail to translate ambitious headlines to on-the-ground action. The reasons for this are many and varied, but for public administration and management scholars a large part of the gap between ambition and achievement is the challenge associated with the operation of the machinery of government itself, and how it relates to the other parties that it relies on to fulfill these outcomes. In their article, Carey and Friel set out key reasons why public health scholars should seek to better understand important ideas in public administration. In commenting on their contribution, I draw out two critical questions that are raised by this discussion: (i) what are boundaries and what forms do they take? and (ii) why work across boundaries? Expanding on these key questions extends the points made by Carey and Friel on the importance of understanding public administration and will better place public health scholars and practitioners to realise health outcomes.

Introduction

Governments around the world face a range of public policy challenges, many of them complicated, and some of them wicked.¹ In responding to these challenges, political actors place great stock in the ability of the public administration machine to take their headline policies and turn them into effective action on the ground. However, the hard grind of getting this complicated administrative system to work is often underestimated in the elegant design of policy interventions. In turn, governments often fail to achieve the policy outcomes that they seek, thereby creating a gap between aspirations and achievements. Developing a better understanding of the aspiration-achievement gap is important for a range of policy fields, both conceptually and practically.

In their article, Carey and Friel² argue that the scholarship of public health and public administration remain largely separate, despite the powerful potential for cross-pollination. This is surprising given that achieving public health outcomes relies so heavily on the ‘layered administrative systems composed of government and non-government entities.’² However, public health scholarship is not alone here; the boundary challenges that Carey and Friel illuminate in their article ring true across the disciplines that are focused on public policy challenges. As Bingham and O’Leary argued when exploring the topic of collaborative public management and the, somewhat ironic, lack of collaboration between scholars in different fields: ‘we tend to play cooperatively each with our own set of blocks…we do not generally pool our blocks to build a common structure collaboratively.’³ The strength of Carey and Friels’ article is its ability to mark out some of the key ideas that are important in understanding the field of public administration, and then to highlight three specific areas of intersection: joining up; boundary crossing; and partnerships. Each of these areas of intersection is important for developing understanding between disciplines and for advancing the connections between policy and action. The more that public administration scholars can work with their colleagues in specific areas of policy scholarship to explain the complex systems of administration, management and governance that they explore, the better both groups of scholars will be for it. Equally, public administration and management scholars have much to learn from scholars in other disciplines, especially those at the frontline of implementation studies such as public health.

Carey and Friels’ piece prompted two key questions that deserve more attention. Exploring each in a little more detail provides additional insight into the value that public administration and management scholarship can bring to bear on conceptual and practical challenges in the public health domain. The first is the boundary challenge itself; the second, the imperatives that drive the attention on joining up, partnering, and boundary crossing. These are both critical areas of public administration and management scholarship and practice and bring to the forefront ‘the most-discussed questions involving the performance of public institutions and achievement of public purposes.’⁴ Understanding the substance of boundaries and the imperative for working across them is important to public health scholars and practitioners, and extends Carey and Friels’ case for a deeper connection between these fields of scholarship and practice.

What Are Boundaries and What Forms Do They Take? The Boundary Challenge

Public administration and management scholars have placed the challenge of working across boundaries centrestage for some time. The first order issue of how to organize to achieve policy outcomes is not a new one. These choices are complex and public management and administration scholars know that organisational and relational design decisions will have an impact on the ability of governments to implement policy decisions. As is the case in public health scholarship and practice, implementation is a major theme. In public administration and management scholarship, it is well-recognised that organisational design choices always create boundaries. Regardless of whether the organising principle is based on function, place, or client group, different boundaries are created that will need to be crossed in some way in pursuit of governmental outcomes.⁵ Decades of practical experimentation with public administration reform shows us that restructuring does not remove boundaries; it simply reconfigures them.

In tackling this issue of boundaries, however, it is important to consider the type of boundaries that populate policy practice. As Carey and Friel note, governance structures, communication, accountability and administrative architectures have all featured in the discussions on addressing the challenge of working across boundaries. But the question arises of what is actually meant by the term boundaries and what types of boundaries are under consideration. It has been argued elsewhere that: ‘Boundaries separate and demarcate, and they are complex, constructed entities that we use to understand behavior and groupings’ (p. 12).⁶ Boundaries can be subjectives and ‘in the mind’ or more solid and ‘objective’⁷; others categorise boundaries as being either symbolic or social.⁸ In practice, the form that a particular boundary takes will matter for how implementation plans are devised for working across them. For instance, the challenge of crossing cultural or knowledge boundaries will be quite different to traversing formal jurisdictional ones and will require a quite different approach. Understanding boundary forms is an important part of devising effective implementation practice, not just in public health, but also across a range of policy areas. Detailed work undertaken by public administration and management scholars can provide practical guidance on which strategies are more effective for various boundary forms, thus addressing implementation challenges and helping turn headline policies into actual outcomes.⁹

When looking more deeply at the form of boundary public administration and management scholars have invested much in identifying the competencies required for practitioners working across them. This work shows clearly that the form of boundary, and the strategy developed for crossing it, will demand different competencies.⁹ Public administration scholars have not had the monopoly on mapping out these competencies but have drawn heavily on scholarship from the disciplines of management, organisation studies and organisational behavior. As Carey and Friel noted in their article, there is increasing interest in the so-called soft skills of those actors on the ground who are working to realise policy action. However, I would argue the bulk of the attention on these ‘soft skills’ has focused on collaborative forms of working. This reflects, perhaps, the preoccupation with collaboration and networks that has permeated the new public governance phase that Carey and Friel map out. It has been argued elsewhere⁹ that not all forms of boundary crossing will be collaborative, indeed some may be coercive, and a broader set of competencies, which are more fit for purpose, should be examined as scholars draw together areas such as public administration and public health to develop guidance for practice. The well-developed literature on co-production, especially by Alford encompasses a fuller spectrum of relationships from coercion to collaboration.¹⁰

Why Work Across Boundaries? The Imperatives for Joining Up

The imperatives for working together are varied and, sometimes, contradictory. Carey and Friel discuss how the social determinants of health are often situated outside the health sector itself, highlighting that the drivers for problems that appear in bounded policy areas originate elsewhere. Much of the focus in the newer phases or paradigms of public administration has been on more collaborative, partnership-style approaches to both policy development and implementation; although more critical scholars reject the notion that practice has moved very far.¹¹ Carey and Friel provide a useful summary of these phases as Traditional Public Administration, New Public Management, and New Public Governance, and they rightly recognise that these tend to layer on top of each other, rather than displace previous approaches. For public administration and management scholars that study these phases, it is clear that tensions are created for those implementing policies in practice because of this layering effect. For example, in the last decade (at least) it has often been the case that joined up, collaborative, partnership approaches accompany new policy declarations. However, this collaborative rhetoric commonly clashes with the Traditional Public Administration foundations which remain firmly in place. The focus on more joined up approaches has bought many of these practical tensions to the fore and highlighted the powerful hold of bureaucracy as the dominant organising principle in public sector organisations and systems, and control as the dominant principle in the relationships of government organisations with other parties they seek to join up with. Despite these tensions, the political and practitioner push for more joined up approaches that rely on boundary crossing action persist. This leads to the second question: what are the driving imperatives for this joined up action?

This question is explored in much more detail elsewhere⁶; here I point to the six dominant imperatives that were identified in a review of practitioner and scholarly literature. These six ‘stories’ of working across boundaries have come to dominate discussion in public administration and management. Whilst not all of these may resonate equally with public health scholars and practitioners, the emphasis that Carey and Friel place on joined up approaches, partnership and boundary crossing as the three critical intersections between these fields of scholarships, means it is important to include all six here. The first is the 21stC modus operandi story where governments and large consulting houses have made the case for more connected, collaborative approaches to governing to address the looming challenges of the 21stC. Here collaboration emerges as the way of operating for modern governments, with partnerships, networks, joining up and boundary crossing important parts of the rhetoric. The second story centres on coordination and reflects a perennial challenge of organising. Jurisdictional, sectoral, and functional demarcations have, and always will, create coordination issues. Thus, working across boundaries is nothing new; the imperative has always been such. The third story reflects a side effect of reforms from the New Public Management era which Carey and Friel discuss. More market-based and competitive, approaches exacerbated the perennial coordination problem and created more fragmented and disaggregated systems. This often occurred as a result of the movement towards single purpose agencies and more narrowly focused performance regimes. The imperative for working across boundaries emerged as a corrective to New Public Management era and has been most prominent in the New Public Governance ideas as discussed by Carey and Friel.

The fourth story centres on complexity and the idea that the problems that government confronts are increasingly complex and disrespectful of the organising principles we may adopt.¹² Therefore, the argument goes, governments require more joined up approaches which rest on cross-boundary working because neither the bureaucratic, siloed approaches of the Traditional Public Administration, nor the narrowly-focused fragmented New Public Management era can address these problems sufficiently. In extreme cases these are wicked problems, challenging traditional categorisation, and requiring concerted joint action.¹³

The fifth story is a strategic management one which focuses attention on the synergies that can be realised through tapping the capabilities of other actors. This involves, in various forms, working across boundaries to leverage these capabilities; for example through strategic alliances, networks or partnering arrangements. The sixth, and final, story relates to generating better value. Much of the public administration and management literature has been focused on how cross-boundary working can enable the creation of additional value. This is discussed in more detail elsewhere⁹; here it will suffice to say that the focus on efficiency and effectiveness emerge as key parts of the better value story. This is most often discussed in terms of joined up or integrated approaches to service delivery – reducing duplication and wrapping services around users to save money or enhance quality.

Conclusion

In their article, Carey and Friel put forward the argument that public administration scholars have developed in-depth knowledge of the complex machinery of government and that this knowledge is helpful to scholars of public health who focus much attention on implementation. It is also true that this learning should be a two-way process, with public administration and management scholars having much to learn from scholars of public health.

In this commentary, I have sought to extend key points from Carey and Freils’ argument to deepen this exchange. I have argued that understanding the driving imperatives for joined up working and the nature of boundaries is important to implementation, and that such knowledge is helpful in developing more effective practice. In relation to the six stories, I argue that together they provide an insight into the various imperatives that drive cross-boundary working. They capture the range of arguments that public administration scholars and practitioners have advanced; reflecting on them is useful in deepening the intersections between public health and public administration scholars. Looking in more detail at why we seek to work across boundaries, then exploring what types of boundaries we will confront in doing so can help us not only to develop the inter-disciplinary understanding that Carey and Friel advocate, but also help us to gain much more insight into how to make the hard grind of implementation better reflect the headline aspirations that policy-makers set out. In doing so the scholarship and practice of implementation, across fields, can be improved.

Acknowledgements

Thank you to the two anonymous reviewers for their helpful comments on earlier versions of this article.

Ethical issues

Not applicable.

Competing interests

Author declares that she has no competing interests.

Author’s contribution

JO is the single author of the paper.

Citation: O’Flynn J. From headline to hard grind: the importance of understanding public administration in achieving health outcomes: Comment on "Understanding the role of public administration in implementing action on the social determinants of health and health inequities." Int J Health Policy Manag. 2016;5(7):439–442. doi:10.15171/ijhpm.2016.49