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An update on the power and politics of health policy – and a call for action on health equity

Introduction by Croakey: The third edition of the book, Making Health Policy – which has been described as “a must-read for those studying and working in global health” – hit the shelves recently.

Professor Kent Buse, one of the authors and Director of the Global Healthier Societies Program at the George Institute for Global Health, Imperial College London, shares some of the backstory below, including reflections on the changing landscape of global health policy.

He urges health policy wonks to go beyond ‘thinking politically’ to ‘acting politically’, writing that:

Too many well-intentioned people working to improve health seem reluctant to challenge the status quo, too much research remains apolitical and too little action is undertaken with wider coalitions for social justice.”


Kent Buse writes:

I remember it vividly; perhaps because the situation seemed surreal for someone coming from a small mining town in the north of Canada.

Twenty years ago, I was sitting on the long grass in a lovely meadow that is part of the Wimpole Manor Estate situated a few miles outside of Cambridge in the United Kingdom. I was surrounded by disinterested cows doing their thing. My laptop was open with a blank page.

I realised I had a huge opportunity but wasn’t sure where to start. I was frustrated that so little attention was given to the politics of health policy. Instead, the journals I read were full of apolitical analysis of health systems delivery and finance – most offering technical fixes to what I understood to be political challenges.

The opportunity before me was the chance to write a textbook on the power and politics of health policy for the course I had just been employed to teach at the London School of Hygiene and Tropical Medicine. But I didn’t quite know how to start.

This month the third edition of the same book – Making Health Policy – has been published by Open University Press.

A lot has happened in those two decades in terms of greater appreciation of and interest in the politics of health policy. Recently, for example, The Lancet ran a series on political science and health led by Professor Eduardo Gomez – this would have been almost unimaginable two decades back.

I like to think that all the students and readers of the first two editions of Making Health Policy had something to do with that change in appreciation of power and health.

Indeed, on learning of the publication of the third edition it was greatly satisfying to see Dr Constancia Mavodza of the Biomedical Research and Training Institute of Zimbabwe, post a tweet in which she said that as an MPH student: “This text was a guide, an anchor. I devoured it. I was never the same!”

So that blank page was eventually filled and many more pages were filled too. I was joined in the effort by my mentor, the sociologist Professor Gill Walt, who had published an influential book on Health Policy, and the knowledgeable and intellectually grounded Professor Nick Mays who brought insider experience from the UK NHS as well as the New Zealand Treasury.

Theory and practice

We aimed to deliver an accessible text that applied basic principles of political science and policy analysis to health.

In so doing, we sought to enable a better understanding and more appreciation of the art and science of policy analysis in the health space. But we also wanted readers to be able to use it as a guide to engage in political processes that would lead to better health for all.

To reach that goal, we figured that people needed know more about the theory as well as the practice (and challenges) of formulating and implementing evidence-informed, pro-equity policies.

The concluding chapter is the most important one for me: it builds on the concepts explained in previous chapters to enable readers to move on to ‘Doing Policy Analysis’.

The chapter leans heavily on the ground-breaking work of Professor Michael Reich, particularly his model of assessing players, power, positions and perceptions for policy influencing – but also draws on my own work on prospective policy management, including lessons learnt from 12 years in charge of strategic policy management at a UN health agency.

Those years certainly brought to life the challenges of putting theories (even from a great textbook!) into practice – not least seeking to ensure evidence-informed policy when negotiating with the Holy See and several countries that criminalise sex work, drug use or same-sex sex.

The book covers key theories and frameworks of policy analysis – and the constituent parts of such analysis – including actors, processes, context and content. It helps readers understand relevant concepts, ideas and institutions and how they influence policy and how they can be analysed. This includes how power is wielded by different actors and institutions, be they government, interest groups or the media, and how values inform and are reinforced by policy.

Chapters cover the stages of the policy process, including agenda setting, implementation and evaluation. The book also considers how national policy making is influenced and constrained by global policy and how global policy is developed.

There are scores of case studies ranging from the history of global agenda setting for drowning prevention, to US corporate lobbying to influence the World Health Organization, to scientific uncertainty (both real and manufactured) in relation to COVID-19 and public health policy making. It also includes many opportunities for self-directed reader assignments with feedback as well as an extensive glossary.

Three editions. Photo supplied.

Additions and developments

For the third edition we added new authors who had used the text for their teaching and who brought helpful student perspectives to the revision.

For example, responding to changing terminologies and assumed hierarchies, such as developed versus emerging, introducing more current interest groups, such as Extinction Rebellion, proposing new sources of empirical data for policy analysis, such as social media, or providing more detailed explanations of concepts.

We also collaborated with Professor Mishal Khan who helped to identify case studies of policy change situated in and/or written by analysts from low- and middle-income countries (LMICs). For example, the work of Alex Osei-Kojo and colleagues analysing the application and relevance of the Advocacy Coalition Framework model in African countries or the work of Themrise Khan and colleagues on classification of people and countries in the practice of health policy.

Collectively we attempted to consider the implications of decolonising global health on doing policy analysis – in particular trying to get readers and budding policy analysts to consider their positionality.

Sadly, we didn’t find much theorising for policy analysis from LMICs – it might have been the case, as we state in the book, that globalising the understanding of health policy is still in its infancy. But it might equally be the case that we failed to look sufficiently hard at the political science writing coming out of the universities in the global south in non-English languages. Perhaps a task for the next edition.

There have been some major changes to both health policy making and how people understand it since the first edition of the book was published.

For example, the World Bank and a small number of bilateral donors had significant influence on health policy in many LMICs. Now such external influence is more likely to come from major (private) foundations.

Another change is that more people working in the health space have a better appreciation of the role that the for-profit sector has in influencing health policy making. And the content or focus of health policy has also changed – now one would expect to see more concern with climate co-benefits in health policy.

Of course, some things haven’t changed so much, or enough – for example, the continued gender-blind approach to health policy, including during COVID-19.

Satisfied readers

We hear positive feedback from those who use the textbook it in their training and teaching.

Health policy guru Professor Lucy Gilson, for example, who has played a key role in training health policy analysts, particularly in LMICs, over the past 20 years, and is editor of the journal Health Policy and Planning, calls it a “must have policy book” and contends that “Generations of students will continue to appreciate the book as a true eye-opener”.

Professor Vivian Lin, Executive Associate Dean of The University of Hong Kong, has written that “This is the ONE book not only for students but for all the policy practitioners who stum­bled into the field and need to make sense of what’s going on around them”.

Professor Jeremy Shiffman of Johns Hopkins University, who has played such an instrumental role in furthering understanding of agenda setting in health, considers the book as “essential reading for anyone wanting guidance on managing the politics of the health policy”.

Professor Rajat Khosla, Director of the International Institute on Global Health of the United Nations University in Kuala Lumpur, states that Making Health Policy has been a must read for researchers, academics and policymakers for almost two decades.

For her part, Professor Uta Lehmann, Director of the School of Public Health, University of Western Cape, South Africa, simply says: “This is the best textbook on health policy.”

No doubt the new edition will be on reading lists in schools of public health across the world in coming months. For me, I am excited to be using the textbook together with colleagues from the University of Colombo at the newly established Centre for Health Systems Policy and Innovation in Sri Lanka, which we hope to deliver with officials from the Ministry of Health and the World Health Organization.

Inciting action

Certainly, the odds are stacked against the kind of pro-equity health policy that Gill Walt, Nick Mays and I initially sought to support readers of Making Health Policy to bring about.

So much policy continues to focus on the development of health products and infrastructure for the elite, be it in high- or low-income countries. Simultaneously this focus of policy-making takes place against a backdrop on the one hand, the neglect of the much needed policy on the social determinants of health and, on the other, the commercial interests who keep health prevention and promotion largely off health policy agendas.

As I reflect back on my younger self sitting contemplating in the English countryside, I am more convinced than ever that a more sophisticated understanding of the politics of health policy making can assist those who are part of the struggle for Health for All.

But health policy wonks need to go beyond ‘thinking politically’ to ‘acting politically’.

Too many well-intentioned people working to improve health seem reluctant to challenge the status quo, too much research remains apolitical and too little action is undertaken with wider coalitions for social justice.

I hope that this edition of Making Health Policy not only informs but also incites action to deliver health equity.

• Professor Kent Buse, Director, Healthier Societies Program, The George Institute for Global Health, Imperial College London, UK


See previous #CroakeyREAD articles, about books and health

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