Three (3) Journal Article Summaries/Evaluations

Policy to tackle the social determinants of health: using conceptual models to understand the policy process Mark Exworthy

Accepted 22 June 2008

Like health equity, the social determinants of health (SDH) are becoming a key

focus for policy-makers in many low and middle income countries. Yet despite

accumulating evidence on the causes and manifestations of SDH, there is

relatively little understanding about how public policy can address such complex

and intractable issues. This paper aims to raise awareness of the ways in which

the policy processes addressing SDH may be better described, understood and

explained. It does so in three main sections. First, it summarizes the typical

account of the policy-making process and then adapts this to the specific

character of SDH. Second, it examines alternative models of the policy-making

process, with a specific application of the ‘policy streams’ and ‘networks’ models

to the SDH policy process. Third, methodological considerations of the preceding

two sections are assessed with a view to informing future research strategies.

The paper concludes that conceptual models can help policy-makers understand

and intervene better, despite significant obstacles.

Keywords Policy process, social determinants of health, health inequalities, research

methodology

‘What is striking is that there has been much written often

covering similar ground . . . but rigorous implementation of

identified solutions has often been sadly lacking.’ (Wanless

2004, p.3)

This quote was written about UK policy addressing the social

determinants of health (SDH) but is applicable to most high or

low and middle income countries. Despite mounting evidence

of the causes of health inequity, even in the latter countries,

attention on the policy process is a notable omission. This may

reflect the epidemiological emphasis on SDH research and/or a

lack of engagement between public health and policy analysts.

This article seeks to remedy that by closely examining the

nature of the SDH policy process, how it might be conceptua-

lized and researched.

Re-visiting the policy-making process The term ‘policy’ is so widely used that it often obscures

meaning. Searching for definitional clarity can be misleading.

Its various uses denote the significance attached to it by mult-

iple stakeholders (Hogwood and Gunn 1989; Buse et al. 2005)

KEY MESSAGES

� Social determinants of health (SDH) represent major challenges to health policy-makers in all countries.

� Models of the policy process are often ill-suited to local contexts and the nuances of SDH.

� A sensitive application of models such as ‘streams’ and ‘networks’ offers significant insights into the nature of SDH policy

and the opportunities/constraints facing policy-makers.

� Understanding and explaining SDH policy processes need to be undertaken sensitively, recognizing peculiar methodological

challenges.

School of Management, Royal Holloway-University of London, Egham, Surrey, TW20 0EX, UK. E-mail: [email protected]

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

� The Author 2008; all rights reserved. Health Policy and Planning 2008;23:318–327

doi:10.1093/heapol/czn022

318

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and/or the multiple levels at which it is developed. A useful way

of understanding ‘policy’ is in terms of context, content, process

and power (Walt 1994). First, context is the milieu within

which interventions are mediated; it therefore shapes and is

shaped by external stimuli like policy. Second, content refers to

the object of policy and policy analysis, and may be divided into

technical and institutional policies (Janovsky and Cassells

1996). Third, Wildavsky’s (1979) reminder that ‘policy is a

process, as well as a product’ is crucial because it draws

attention to the course of action over time. Finally, power

draws attention to the interplay of interests in negotiation and

compromise.

The ‘policy process’ is often presented as a linear, rational

process moving from formulation to implementation; for

example:

� ‘Politicians identify a priority and the broad outlines of a

solution . . .;

� Policy-makers . . . design a policy to put this into effect,

assembling the right collection of tools: legislation, funding,

incentives, new institutions, directives;

� The job of implementation is then handed over to a different

group of staff, an agency or local government;

� . . . the goal is (hopefully) achieved’ (UK Cabinet Office 2001,

p.5).

This is an over-simplistic view. The distinction between

formulation and implementation is rarely clear-cut; intentions

and action are often hard to distinguish. It may be more helpful

to view the ‘policy process’ as disjointed and ‘messy’. For

example, John (2000) argues that there is often no start or end

point, only a middle. Policies are developed within a pre-

existing context that effectively constrains new opportunities.

The legacy of former decisions creates conditions from which

policy-makers may find it difficult to diverge, a condition

known as ‘path dependency’ (Greener 2002). Most resource

decisions, for example, only consider marginal changes rather

than taking fundamental re-assessment of principles. Path

dependency limits the range or possibility of radical changes of

direction, at least in the short term—often called ‘increment-

alism’ (Lindblom 1959). This perspective also contends that the

policy process can often be static for relatively long periods,

only to be disturbed by moments of change—disjointed

incrementalism and punctuated equilibrium. As a result, the

policy process is characterized by (positive and negative)

feedback loops and rarely reaches completion. However, Clay

and Schaffer (1984), for example, demonstrate the ‘room for

manoeuvre’ that policy-makers can enjoy.

The health policy process is also characterized by other

features. First, policy decisions rarely take place at a single

point in time and can be protracted over months or even years.

It is therefore difficult to discern if/when a specific decision was

made. Policy decisions often reflect a broad direction (despite

conflict) so as to mollify stakeholders’ concerns or to denote

their power. Second, policy-making rarely occurs in public but

rather behind ‘closed doors’, despite some attempts to make it

more transparent. Third, policy-making often results in no

decisions or non-decisions. The lack of (observable) action or

outcome may actually signify a complex set of forces that have

stifled a decision or prevented proposals from being enacted

(Lukes 1974). Finally, much of the evidence on the policy process

originates from high income countries (HICs); there is thus an

empirical question as to whether typical approaches and under-

standing are valid in low and middle income countries (LMICs).

Questions about similar translations between demographic/

population and income groups may also be posed.

SDH offer an insightful case study of health policy processes

because they have in recent years assumed a more central place

in policy processes of many HICs and LMICs; previously, policy

analysis has tended to overlook the issue in favour of other

policy imperatives. It is, therefore, instructive to learn how the

specific nuances of these complex phenomena are articulated

in the content, context and process of health policy processes.

Such a case study is significant because, on the one hand,

SDH are more prominent in topical debates about MDGs and

poverty reduction, and on the other, SDH are illustrative of

increasingly complex developments in policy process (such as

governance and internationalization). However, each aspect

that public policy in each country seeks to address is, more or

less, a particular configuration of issues. Practically, these issues

need to be understood and explained by academics and by

policy-makers that they may assess the likely impact of SDH

policy.

Broadly, eight challenges to addressing SDH through public

policy can be identified. Defining clearly the features of SDH

helps to draw sharper implications for policy development and

implementation. First, SDH are multi-faceted phenomena with

multiple causes. Models of SDH are useful conceptual devices to

identify the causal pathways which have differential impacts on

health (see Figure 1).

However, SDH models rarely offer policy-makers a clear

direction for policy development (Graham 2004). First, some

policy-makers believe that the lack of a ‘simple problem’

hinders the development of ‘simple policy solutions’ or that

policy is ineffective in the face of wider social forces (such as

globalization). Others see SDH as ‘invisible’ (Dahlgren and

Whitehead 2006, p.15). As a result, there has often been no

policy response to ‘act upon SDH’ or, where there has been

some attempt, a diffuse approach. This has often been

hampered by the lack of consensus among academics and

policy-makers about the policy solutions required.

Second, the life-course perspective (Blane 1999) presents a

challenge to policy-making processes whose timescales are

rarely measured over such long periods. The life-course perspec-

tive posits that early life influences (say, upon diet or educa-

tion) have life-long impacts that will only be evident many

years hence. This perspective contrasts with the tenure of

elected and/or appointed officials (which is usually measured

in years, rather than decades), the electoral cycles in

parliamentary or presidential democracies (usually measured

from 5 to 7 years), and organizational reporting cycles (e.g. for

budgetary purposes usually measured annually). Moreover,

coalitions of interests in support of SDH policies may be

unsustainable over the time periods necessary to witness

significant change, thereby presenting a challenge to create

and sustain commitment to and involvement in the policy goals

and process. Partly as a result, attention of the public (often

supported by the media) and some practitioners has tended to

reinforce such short-term timescales. This second feature is

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thus a challenge to integrate long-term approaches with short-

term organizational/political imperatives.

Third, SDH necessitate policy action across different organiza-

tions and sectors (not least, the health care sector) (Hunter 2003;

Gilson et al. 2007). Often, policy responses are only disease-

specific rather than addressing SDH. Inter-organizational and

inter-sectoral partnerships are critical to formulating and

implementing policy towards SDH. However, evidence shows

that partnerships at all levels are hampered by cultural,

organizational and financial issues (Lee et al. 2002; Sullivan and

Skelcher 2002). Different values, different accountabilities and

performance measures/criteria, and different reasons for colla-

borating are among the challenges for partnerships. Moreover,

the ‘health’/SDH agenda may be marginal to collaborating

organizations, SDH being perceived as beyond their core purpose.

It can also be argued that action on SDH requires intervention

beyond state/government, by civil society organizations or even

private sector agencies. Such collaboration regarding SDH is likely

to be even more problematic.

Even within governments, inter-organizational collaboration

has often been poorly developed. Traditionally, government

agencies tend to be organized vertically (Ling 2002; Bogdanor

2005). For example, education ministries are largely focused on

running schools, health ministries on delivering health care

services, etc. Yet, such ‘silo’ or ‘chimney’ approaches are not

well suited to tackle cross-cutting issues. A strong coordination

role, say, across government or by an external (international)

agency might offset the ‘silo’ approach but the balance of power

usually remains with ministries.

Fourth, SDH are one of many competing priorities for policy-

makers’ attention and resources. Economic, foreign or devel-

opment policies might take precedence over SDH, inter alia.

More specifically, SDH may be over-shadowed in the policy

process by health care itself. As most states take a prominent

role in the financing and/or delivery of health care to its

population (Saltman 1997), it is perhaps inevitable that states

take a close interest in such matters. However, this health care

focus is often to the neglect of health and SDH per se (Gilson

et al. 2007). That said, other spheres of policy (such as

education or transport) can be informed by SDH.

Fifth, SDH are so complex that the cause-effect relationships

are not readily apparent. Moreover, some evidence is equivocal

about these associations. For example, statistical correlations

are common in epidemiological studies which inform policy-

making, but they rarely demonstrate causation. Knowing and

understanding causal pathways is a first step in devising

appropriate policies but many gaps in knowledge remain,

especially in LMIC contexts. Attributing policy mechanisms to

their impact upon health can often be obscured because:

‘Policy cannot be intelligently conducted without an under-

standing of mechanisms; correlations are not enough’

(Deaton 2002, p.15).

As a result, policy levers (such as legislation and resource

allocation) are seen as blunt instruments in tackling SDH,

whose consequences are not, and sometimes cannot be,

ascertained with sufficient clarity.

Attribution of policy interventions to outcomes is problematic.

Such outcomes may not be evident for many years, if at all, as

indicated by the life-course perspective. Consequently, there is

often a reliance on ‘process’ measures as indicators of progress,

assuming that they are associated with outcomes. This may be

particularly problematic the higher the level of analysis, such as

macro-economic policy (Turrell et al. 1999), or as policy is

transferred from HICs to LMICS. Attribution may also pose

dilemmas for targets given the multi-faceted nature of policy

outcomes.

Sixth, the identification, monitoring and analysis of epide-

miological changes over time, is crucial to inform the policy-

making process. Yet, routine data are not always available, are

of poor quality or have been collected over insufficient periods

Figure 1 The main determinants of health. Source: Dahlgren and Whitehead (1991).

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to aid policy-making (Center for Global Development 2006;

Exworthy et al. 2006). Data categorization by population groups

(e.g. ethnicity, gender) or geographically is often poor.

However, whilst data are necessary, they alone are not

sufficient to secure policy implementation.

Seventh, globalization and multi-lateralism are significant

factors in delivering ‘global public goods’ such as health (Chen

et al. 1999) but such goods have been influenced by the

changing role of the nation state in policy-making (Lee et al.

2002; Labonte and Schrecker 2007). Powers have been re-

located to supra-national organizations such as the European

Union, World Trade Organization, International Monetary Fund

and World Bank. In particular, these supra-national institutions

tend to promote a neo-liberal agenda (Raphael 2003).

Governments’ ability to shape and mould the SDH with the

goal of improving their population’s health is becoming limited

as many of the ‘causes’ of poor health (Wilkinson and Marmot

2003) no longer fall within their responsibility. They, therefore,

need to rely on influence and leverage in multi-national

networks. By contrast, decentralization to regions and cities

has had a similar effect on the policy-making capacity of

governments. Decentralization in HICs and LMICs can be seen

as an attempt to make public services more responsive to local

needs (and in that sense, improve intra-area/population equity).

However, despite its popularity, decentralization in LMICs and

HICs is rarely achieved in full or within parameters defined by

central government (Bossert 1998; Atkinson et al. 2002). As

such, decentralization might be seen as less of a threat to

national policy-making than globalization, since the implemen-

tation of the former lies mainly within governments’ control

These seven challenges of the contemporary policy process as

applied to SDH are summarized in Table 1.

The challenges demonstrate that, despite the growing volume

of evidence on SDH, understanding of the particular demands

of the policy process around SDH in particular contexts has

been limited. In short, despite the growing attention on SDH,

understanding of the policy process in particular contexts has

been missing. Policy models and frameworks can help in

developing the theory and practice of policy development to

tackle SDH.

Policy models and their application to SDH Conceptual models can provide tools to describe, understand

and explain policy processes. Such models are important for

two reasons. First, much health policy practice has been

developed (and researched) in HICs and ‘transferred’, often

uncritically to LMICs. However, the variability of context and

nuances of individual policies make generalizability proble-

matic. Exporting policies within or between countries is often

discounted on the basis that the ‘context’ is different and hence

lessons from host countries cannot be learnt. However, a focus

on conceptual models can obviate some of these problems by

addressing key issues such as power and resistance. By applying

concepts of the policy process, it is thus possible to discern

meanings and motives, similarities and differences in patterns

and practices across context. Second, as SDH present specific

challenges to the policy process, the configuration of SDH and

policy context in each country demands that typical policy

frameworks are adapted to local contexts.

Despite the extensive literature on this topic and for sake of

brevity, this article focuses on selective models as illustrations

of the ways in which they contribute to improved under-

standings of how the SDH policy process, specifically, may be

approached by policy-makers. The three models do represent,

however, major approaches within the extensive literature,

though they do not provide, by any means, a comprehensive

assessment:

1. streams

2. networks, and

3. stages.

’Streams’ model

This model is concerned with how issues get onto the policy

agenda and how proposals are translated into policy. Kingdon

(1995) argues that ‘windows’ open (and close) by the coupling

(or de-coupling) of three ‘streams’: problems, policies and

politics. The model (and its variants) has been applied to

analysis of policy change around health inequalities and SDH

(e.g. Exworthy et al. 2002; Sihto et al. 2006). This model is

especially pertinent to SDH because, in many (HIC and LMIC)

countries, SDH have struggled to reach the policy agenda, let

alone become implemented. This is despite mounting (epide-

miological) evidence (Wilkinson and Marmot 2003) and policy

proposals.

Problem stream

Conditions or issues (such as SDH) only become defined as

‘problems’ when they are perceived as such. Often, only those

‘problems’ which are (potentially) amenable to policy remedies

Table 1 Link between features of social determinants of health (SDH) and the impact on policy-making

Features of SDH Impact on policy-making

Multi-faceted phenomena with multiple causes Coordinated strategies are difficult to achieve

Life-course perspective Long-term approach does not match policy timetables

Inter-sectoral collaboration and partnership Partnerships are problematic

Dominance of other priorities SDH often neglected

Cause-effect relationships are complex; attribution difficulties Attribution problems hamper policy; reliance on process measures

Data Routine data that is of high quality, timely and available, are often lacking

Globalization (and decentralization) Policy-making involves more stakeholders at multiple levels, hampering governmental action

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are recognized; many will remain unaddressed. The issues

might be brought to attention by:

1. Key events (such as crises or critical incidents) and/or

2. Publication of ‘evidence’ (such as research studies or

inquiries) and/or

3. Feedback from current policies (via the media or public

opinion).

The growing volume of research evidence has highlighted SDH

but many ‘policy-makers may even be unaware of the

magnitude and trends of existing inequities in health among

their people’ (Dahlgren and Whitehead 2006, p.16). This

underlines the fact that researchers are but one stakeholder

and evidence is just one source of information in policy

processes (Trostle et al. 1999). The lack of consensus about

evidence among the research community may hamper their

influence in defining the ‘problem’. The role of key events and

feedback (e.g. funding crises or negative public opinion) should

not be overlooked in accounting for the policy experience of

specific countries. Also, stakeholders or interest groups (e.g.

medical profession or community groups) might play a

prominent role in highlighting specific issues and bringing

them to the attention of policy-makers (often via the media).

The publication of a key research report [such as the UK

Acheson Inquiry (1998) on health inequalities or the World

Health Organization Commission on SDH] may be such a

prompt (Exworthy et al. 2003).

Policy stream

The multiple strategies and policies may be advanced not just

by civil servants or professionals but also by interest groups.

Some may be ‘kite-flying exercises’ (testing support for

particular strategies) or concrete proposals. However, for any

strategy to be enacted, it must meet a minimum threshold of:

1. Technical feasibility,

2. Congruence with dominant (socio-political) values, and

3. Anticipation of future constraints of the strategy being

proposed.

Many SDH policy proposals may fail to reach these thresholds

and so fail to offer coherent solutions. For example, policies

may not be technically feasible. Though desirable, policies may

not be (proven) effective. Moreover, addressing SDH or health

inequalities may run counter to dominant values and shifting

political values would also threaten further this criterion. The

paucity of evidence about cost-effectiveness of policy solutions

(e.g. Wanless 2002) illustrates this aspect as it might militate

against the relatively newly dominant paradigm of proving

impacts in this way (Davies et al. 2000). Future constraints may

include, for example, the (unintended) consequences of

tackling a particular condition (e.g. obesity).

Politics stream

This refers to the lobbying, negotiation, coalition building and

compromise of local, national and international interest groups

and power bases. In terms of SDH, such political debates can

be vociferous, as they often challenge the power of existing

social, economic and political systems or practices. For example,

in the UK during the 1980s and early 1990s, (right-wing)

governments rejected the notion of health inequalities (Berridge

and Blume 2002); this effectively stifled any policy development

towards SDH.

Coupling the streams

These three streams may be coupled by chance factors, political

(e.g. elections) or organizational cycles (e.g. staff turnover), or

by the actions of a policy entrepreneur. The ‘policy entrepre-

neur’ (such as a government minister, leading doctor, civil

servant or academic) facilitates the coupling process by

investing their own personal resources (namely, reputation,

status, time):

‘Policy entrepreneurs are people willing to invest their

resources in return for future policies they favour’ (Kingdon

1995, p. 204).

De-coupling may also occur if/when conditions in each stream

are not met. For example, the policy entrepreneur may move

position. Equally, there may be a change of government or

other issues assume greater importance. The ‘policy window’

will, therefore, close. The ability of policy-makers to ‘fix the

window open’ (by integrating SDH policy into ‘mainstream’

policy processes) will largely determine the long-term viability

of the policy.

Coupling the streams is not guaranteed; failure may be more

likely (Wolman 1981). Failure to join these streams can

result in disillusionment and claims that policies are purely

symbolic (Edelman 1971). For example, the inability to couple

‘streams’ (in terms of SDH) may be indicative of wider

constraints:

‘Many declarations to tackle inequities . . . appear to be

merely rhetorical, as they have not been followed by any

comprehensive policies and actions to address the problem’

(Dahlgren and Whitehead 2006, p.16).

Other policy models adopt a similar ‘streams’ approach,

involving the conjunction of separate dimensions. Webb and

Wistow (1986) and Challis et al. (1988) argue that three

streams (policy, process and resource) need to be conjoined to

complete the policy process.

1. The policy stream is concerned with policy aims and

objectives;

2. The process stream is concerned with policy means (the

instruments or mechanisms to achieve the policy ends);

3. The resource stream is concerned with the human, financial

and material resources needed to facilitate the process

stream.

A ‘successful’ policy will comprise clear objectives, mechanisms

that achieve those objectives and the resources to facilitate the

process (Powell and Exworthy 2001). However, aspects of

technical and political feasibility make the process stream

highly problematic for SDH policy. Moreover, SDH must

compete for resources (including staff time and finances)

among other priorities.

Another related model by Richmond and Kotelchuck (1991)

concerns the development of ‘health policy priorities’ by

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integrating the evidence base, social strategies and political will

which equates with a ‘public mandate for policy action’

(Nutbeam1998, p.31). Similarly, Nutbeam (2004) claims that

policy implementation is most likely when there is a synthesis

of plausible evidence, political vision and practical strategies

(see also Petticrew et al. 2006).

’Networks’ models

The policy process rarely operates in isolation but rather

through networks of stakeholders, each with their own

interests and motivation. These networks involve interactions

between communities of stakeholders (inside and beyond the

policy process):

‘Although decision-making bodies have some room for

manoeuvre, they usually depend on each other, and thus

form close relationships within a policy sector’ (John 2000,

p.83).

Kickert et al. (1997) argue that policy-making takes place in

‘networks consisting of various actors (individuals, coalitions,

bureaux, organizations), none of which possesses the power to

determine the strategies of other actors’ (p.9).

Whilst networks might develop high degrees of trust and

dependence, they can equally exclude others from the policy

process. Close network relations can also foster learning and

development as they are grounded in practical experience. As

such, networks can foster bottom-up policy developments.

These broad principles are illustrated by two main ‘network’

models: (1) policy and issue networks, and (2) the advocacy

coalition framework (Hudson and Lowe 2004).

(1) Policy and issue networks

The distinction between policy networks and issue networks

revolves around the degree to which stakeholders are involved

directly in the policy process. Four features characterize

networks:

� Membership (number and type of members),

� Integration (frequency, continuity and consensus),

� Resources (their distribution), and

� Power (balance between members) (Marsh and Rhodes

1992).

Policy networks comprise civil servants, politicians and co-opted

members (for example, academic experts). These networks

involve stable relationships among a limited group of stake-

holders with shared responsibility and high degree of integra-

tion. By contrast, issue networks are oriented around specific

‘issues’ and tend to comprise loose, open connections amongst

a shifting group of stakeholders. Heclo (1978) proposed that

issues are not defined by members’ interests but rather the

issues themselves become their interests (Nutley et al. 2007,

p.108).

Applied broadly to SDH, issue networks (relating, say, to

public health or community groups), which seek to raise

attention to the ‘problem’, promoting solutions and lobbying

policy-makers, have become commonplace. An ‘SDH policy

network’, by contrast, has traditionally been absent or poorly

developed, as it implies cross-departmental working (which has

typically not been the modus operandi of governments). There are

signs that such networks are becoming more established as

(some) governments begin to take action on SDH (e g. Judge

et al. 2005; Stahl et al. 2006), partly due to the influence of issue

networks and supra-national institutions (e.g. World Health

Organization and European Union). A schematic summary

indicates that ‘SDH policy networks’ tend to be small, weak and

poorly integrated (though the assessment is dynamic and

peculiar to each country) (Table 2).

Across any government, there are potentially several policy

networks relating to SDH. These networks will inevitably

involve trade-offs, say, between public health and health-care,

between ministries, between SDH policies and routine service

delivery, and between equity and other principles (such as

efficiency). In short, there are (greater or lesser) signs of an

uneasy integration of issue networks into policy networks, as

SDH become established as a legitimate sphere of government

competence in many countries. However, as this happens, new

patterns within policy networks are emerging, although the

SDH discourse has yet to fully permeate all corners of any

government (Exworthy et al. 2003).

(2) Advocacy Coalition Framework (ACF)

Sabatier (1991) (among others) has argued that the policy

process involves the formation and maintenance of complex

coalitions (networks) of interest as well as the top-down

prescription (for example, in terms of achieving ‘perfect

implementation’) (Hudson and Lowe 2004, p.212).

Sabatier’s ACF model views the policy process as a series of

networks which are composed of all the organizations and

Table 2 Assessment of policy networks and issue networks in relation to social determinants of health (SDH)

Network characteristic

Assessment criteria in relation to SDH Policy networks Issue networks

Membership 1) Number of participants 2) Types of interest

1) Low 2) Focused

1) High 2) Highly varied

Integration 1) Frequency 2) Continuity 3) Consensus

1) Low but growing 2) Low 3) Weak especially regarding interventions

1) High 2) High/medium 3) Weak

Resources Distribution Mainly hierarchical Loose affiliation

Power Balance of power Strong. Balance of power tilted towards government ministries and towards health-care

Weak but varied.

Source: Adapted from Marsh and Rhodes (1992).

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stakeholders (inside and beyond the policy process) with a

particular interest in that policy sphere.

‘Whatever the motivation for action, it is essential to find

potential allies and partners sharing common or converging

values and objectives, or to find acceptable trade-offs when

conflicting interests are unavoidable’ (Ritsatakis et al. 2006,

p.146).

These networks comprise a ‘coalition of advocates’ and are

termed ‘sub-systems’. They are defined by a set of core values

and beliefs which are resistant to changing ideas and new

policies. Although sub-systems are constantly involved in

examining and learning about their policy environment,

change is only likely to occur when a significant amount of

those values are challenged successfully.

It has become apparent that, over the last decade or so,

coalitions of advocates have been forming in many countries

around a set of core beliefs (relating to SDH) which are

challenging existing dominant values. Such beliefs have been

heavily shaped by the challenge of the SDH research paradigm,

as in the case of the UK’s Acheson report (1998). According to

Sabatier, the impact of such shifts in core beliefs upon policy

might only be apparent after a decade or more. Thus, for SDH

policy programmes which have only recently been established,

it is too early to judge their success. New coalitions may not

always be effective as resistance to new paradigms and

approaches might be expected from (coalitions of) interests

within and beyond the policy process.

’Stages’ models

Some commentators have sought to clarify and explain the

complexity of the policy process by developing models which

identify a linear progression through stages of policy develop-

ment. They offer a heuristic value in understanding the

evolution of policy and may help identify, for example,

potential points at which policy may falter through the use of

(negative) feedback loops (such as implementation failure,

leading to a re-formulation of the ‘problem’).

The most commonly applied example of ‘stages’ in relation to

SDH is by Dahlgren and Whitehead (2006) who identify seven

stages towards action (Figure 2).

Ritsatakis and Jarvisalo (2006) offer a variation of the

Dahlgren and Whitehead ‘stages’ model:

1. Reaching policy-makers and the public (raising awareness);

2. Securing the information (such as international databases,

presentation and discussion, parliament);

3. Policy formulation and implementation (inter-sectoral com-

mittees, leadership, consensus conferences, formal consulta-

tions in drafting legislation, public referenda, informal

contacts);

4. Seeking partnerships and alliances; and

5. Provisions for implementation.

No single policy model offers a fully comprehensive description

or understanding of the policy process as each answers

somewhat different questions. The selection and appropriate

application of these models to health policy analysis is crucial

in understanding and explaining the ways in which SDH are

addressed in specific national contexts.

Conducting research on the SDH policy process Understanding better the policy process is a crucial step in

applying it to the SDH context. However, it is also important to

understand how such processes affect the conduct of research

about the policy process. Five considerations are noteworthy

(Table 3).

First, the long-term nature of policy development (arising

from the life-course perspective and engrained nature of SDH in

society) presents a challenge for research which is often funded

on a short-term basis in the hope of seeking quick answers and

remedial solutions. Tracing policy developments over the long-

term involves different methodologies too. For example, as

outcomes may not be observable for some time, intermediate

measures of progress are often sought.

Second, tracing causes and effects of policies presents attrib-

ution difficulties. Tracking the pathways from epidemiological

data to policy responses and their impact is complicated by the

‘open systems’ within which SDH operate. Counter-veiling

forces (such as the economic climate or globalization) might

Measurement

Recognition

Awareness raising

Concern Denial/indifference

Mental block Will to take action

Isolated initiatives

More structured developments

Comprehensive coordinated policy

Figure 2 Action spectrum on health. Source: Dahlgren and Whitehead (2006, p.95).

Table 3 Researching the social determinants of health (SDH) policy process

Features of SDH policy-making Impact upon researching the policy process

Long-term perspective � Long-term research � Search for process measures

Attribution � Programmes of research, examining range of issues

� Development of monitoring techniques

Non-decisions � Participant-observation � Policy ethnography

Multiple agencies and stakeholders

� Research into cultural, organizational and political practices

Multiple policy programmes

� Programmes of research, examining range of issues

� Long-term research

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undermine or counteract policy effects in unintended or

unobservable ways. Methodological responses to such dilemmas

might include research projects examining discrete interven-

tions but this loses the inter-connectedness of SDH (Milward

et al. 2003). Research programmes (with several projects) might

mitigate this, but doing so on an international scale is often

prohibitive.

Third, the opaqueness of policy-making (and especially non-

decisions) is problematic for researchers. Gaining access to

organizations is a perennial issue for researchers but it is

perhaps even more difficult to observe policy-making processes

in action. Moreover, the ways in which decisions ‘emerge’

(rather than taking place at a single moment and often

unobservable to the researcher) are particularly problematic.

Participant-observation is a strategy that is seemingly easy to

adopt but difficult in practice. There is perhaps understandably

a reliance on semi-structured interviews and documentary

analysis.

Policy ethnography is a developing methodology which

involves long-term immersion in a policy domain (Flynn et al.

1996; Exworthy et al. 2002). Nonetheless, it is difficult to

construct an authentic account of the policy-making process

that captures its nuances and complexity over the long-term.

Becoming too closely associated with policies can create a bias

as researchers can become apologists for the policy that they are

investigating. Decisions and non-decisions taken elsewhere may

thus become less apparent. Case studies and witness seminars

(involving stimulated recall of the key actors; Berridge and

Blume 2002) can also be useful techniques.

Fourth, capturing the views of multiple stakeholders and

tracing the influence of each organization’s practices and cul-

ture upon the policy process are complex tasks and time-

consuming. Studies of inter-organizational relationships have

a long lineage and researchers should draw on this extant

knowledge (Ferlie and McGivern 2003). However, the scale of

the task in terms of SDH should not be under-estimated given

the multiple agencies that could (potentially) be involved in

SDH policy (Nutbeam 1998).

Fifth, by its very nature, tackling SDH implies a multi-faceted

approach. Whilst much public policy tends to focus on single

strategies for particular population groups in specific circum-

stances, there is a need to examine the inter-connectedness of

components of SDH. The breadth of such research is daunting

and therefore requires large-scale, longitudinal research pro-

grammes (including policy research). This observation implies a

multi-disciplinary approach which is often antithetical to the

organization of universities, their criteria for appointments and

tenure, and the publication of research. Large-scale research

programmes may offer insights into the ways in which

international institutions are shaping the cross-national

causes of SDH; whether political action will be forthcoming

to address SDH globally is arguable.

Conclusion Partly as a result of methodological difficulties, there is often

a search for conceptual development and theoretical elabo-

ration in health policy research. The policy process has been

described as an exercise in ‘collective puzzlement’ (Heclo and

Wildavsky 1974, p.305). In puzzling about possible policy

options available to policy-makers, there is an implicit

imperative for making choices and for understanding the

ways in which policy-makers learn from themselves (e.g.

Freeman 2006; Marmor et al. forthcoming). Conceptual

models are useful techniques in such learning.

This paper has sought to raise awareness of the ways in

which policy towards SDH may be better described, understood

and explained. By identifying the components of the policy

process and the ways in which features of SDH require the

adaptation of traditional approaches, it is possible to apply

conceptual models which offer new insights about SDH policy-

making. Researchers must therefore adapt and apply exist-

ing methodologies to the specific nuances of SDH policy.

Together, conceptual models and appropriate methodologies

may contribute to improved policy-making which may, in

turn, ameliorate conditions for many of the poorest across the

world.

Acknowledgements Research for this article was conducted by the author as a part

of the Measurement and Evidence Knowledge Network of the

WHO Commission on the Social Determinants of Health, of

which he is a member (http://www.who.int/social_determi-

nants/knowledge_networks/en/index.html). He is grateful to

members of the Knowledge Network, WHO representatives

and participants at the Health Policy Methodology Workshop

(sponsored by ODI in London in May 2007) for their

constructive comments. The views of this article do not neces-

sarily represent the M&E Knowledge Network, the Commission

or the WHO.

References Acheson D. 1998. Independent inquiry into inequalities in health. London:

HMSO.

Atkinson S, Medeiros RLR, Oliveira PH, de Almeida RD. 2000. Going

down to the local: incorporating social organisation and political

culture into assessments of decentralised health care. Social Science

and Medicine 51: 619–36.

Berridge V, Blume S (eds). 2002. Poor health: social inequality before and

after the Black Report. London: Frank Cass.

Blane D. 1999. The life-course, social gradient and health. Chapter 4. In:

Marmot MG, Wilkinson RG (eds). Social determinants of health.

Oxford: Oxford University Press, pp. 64–80.

Bogdanor V (ed.). 2005. Joined-up government. Oxford: Oxford University

Press.

Bossert TJ. 1998. Analyzing the decentralization of health systems in

developing countries: decision space, innovation, and performance.

Social Science and Medicine 47: 1513–27.

Buse K, Mays N, Walt G. 2005. Making health policy. Milton Keynes, UK:

Open University Press.

Cabinet Office. 2001. Better policy design and delivery. London: Performance

and Innovation Unit, Cabinet Office.

Center for Global Development. 2006. When we ever learn? Improved lives

through impact evaluation. Report of the Evaluation Gap Working Group.

Washington, DC: Center for Global Development.

POLICY TO TACKLE SOCIAL DETERMINANTS OF HEALTH 325

Downloaded from https://academic.oup.com/heapol/article-abstract/23/5/318/615803/Policy-to-tackle-the-social-determinants-of-health by guest on 24 September 2017

Challis L, Fuller S, Henwood M et al. 1988. Joint approaches to social policy.

Cambridge: Cambridge University Press.

Chen LC, Evans TG, Cash RA. 1999. Health as a global public good. In:

Kaul I, Grunberg I, Stern MA (eds). Global public goods: international

cooperation in the 21 st

century. Oxford: Oxford University Press,

pp. 284–304.

Clay EJ, Schaffer BR. 1984. Room for manoeuvre: an exploration of public

policy planning in agricultural and rural development. London:

Heinemann Educational Books.

Dahlgren G, Whitehead M. 1991. Policies and strategies to promote social

equity in health. Stockholm: Institute for Future Studies.

Dahlgren G, Whitehead M. 2006. Levelling up (part 2): a discussion paper

on European strategies for tackling social inequities in health.

Copenhagen: WHO Europe.

Davies HTO, Nutley S, Smith PC (eds). 2000. What works? Evidence-based

policy and practice in public services. Bristol: Policy Press.

Deaton A. 2002. Policy implications of the gradient of health and

wealth. Health Affairs 21: 13–30.

Edelman M. 1971. Politics as symbolic action. Chicago, IL: Markham

Publishing.

Exworthy M, Powell M. 2004. Big windows and little windows:

implementation in the congested state. Public Administration 82:

263–81.

Exworthy M, Berney L, Powell M. 2002. How great expectations

in Westminster may be dashed locally’: the local implementa-

tion of national policy on health inequalities. Policy and Politics 30:

79–96.

Exworthy M, Blane D, Marmot M. 2003. Tackling health inequalities in

the UK: progress and pitfalls of policy. Health Services Research 38:

1905–22.

Exworthy M, Bindman A, Davies HTO, Washington AE. 2006. Evidence

into policy and practice? Measuring the progress of policies to

tackle health disparities and inequalities in the US and UK.

Milbank Quarterly 84: 75–109.

Ferlie E, McGivern G. 2003. Studying health care organizations: relationships

between health care organizations. A critical overview of the literature and

a research agenda. Report for the NCC-SDO. London: NCC-SDO.

Online at: http://www.sdo.lshtm.ac.uk.

Flynn R, Williams G, Pickard S. 1996. Markets and hierarchies: con-

tracting in community health services. Buckingham: Open University

Press.

Freeman R. 2006. The work the document does: research, policy

and equity in health. Journal of Health Policy, Politics and Law 31:

51–70.

Graham H. 2004. Social determinants and their unequal distribution:

clarifying policy understandings. Milbank Quarterly 82: 101–24.

Gilson L, Doherty J, Loewensen R, Francis V. 2007. Challenging

inequity through health systems. Final report: Knowledge Network on

Health Systems, WHO Commission on Social Determinants of Health.

Online at: http://www.who.int/social_determinants/en/.

Greener I. 2002. Theorising path-dependency: how does history come to

matter in organisations? Management Decision 40: 614–9.

Heclo H. 1978. Issue networks and the executive establishment. In:

King A (ed.). The new American political system. Washington, DC:

American Enterprise Institute.

Heclo H, Wildavsky A. 1974. The private government of public money.

Basingstoke, UK: Macmillan.

Hogwood BW, Gunn LA. 1989. Policy analysis for the real world. Oxford:

Oxford University Press.

Hudson J, Lowe P. 2004. Understanding the policy process: analysing welfare

policy and practice. Bristol: Policy Press.

Hunter D. 2003. Public health policy. Cambridge: Polity Press.

Janovsky K, Cassells A. 1996. Health policy and systems research:

issues, methods and priorities. In: Janovsky K (ed.). Health policy

and systems development. Geneva: WHO, pp. 11–24.

John P. 2000. Analysing public policy. London: Continuum.

Kickert W, Klijn E, Koppenjan J. 1997. Managing complex networks:

strategies for the public sector. London: Sage.

Kingdon J. 1995. Agendas, alternatives and public policy. Boston: Little

Brown.

Labonte R, Schrecker T. 2007. Towards health-equitable globalisation: rights,

regulation and redistribution. Final Report to the Commission on

Social Determinants of Health, Globalization Knowledge Network.

Online at: http://www.who.int/social_determinants/en/.

Lee K, Buse K, Fustukian S (eds). 2002. Health policy in a globalising

world. Cambridge: Cambridge University Press.

Lindblom C. 1959. The science of muddling through. Public

Administration Review 19: 79–88.

Ling T. 2002. Delivering joined-up government in the UK: dimensions,

issues and problems. Public Administration 80: 615–42.

Lukes S. 1974. Power: a radical view. London: Macmillan.

Marmor TR, Freeman R, Okma KGH (eds). 2008. Learning from

comparison in health policy. New Haven, CT: Yale University Press.

Forthcoming.

Marsh D, Rhodes RAW. 1992. Policy networks in British government.

Oxford: Clarendon Press.

Millward LM, Kelly MP, Nutbeam D. 2003. Public health intervention

research—the evidence. London: Health Development Agency.

Nutbeam D. 1998. Evaluating health promotion – progress, problems

and solutions. Health Promotion International 13: 27–44.

Nutbeam D. 2004. Getting evidence into policy and practice

to address health inequalities. Health Promotion International 19:

137–40.

Nutley S, Walter I, Davies HTO. 2007. Using evidence: how research can

inform public services. Bristol: Policy Press.

Petticrew M, Whitehead M, Macintyre S, Graham H, Egan M. 2006.

Evidence for public health policy on inequalities – 1: the reality

according to policy-makers. Journal of Epidemiology and Community

Health 58: 811–6.

Powell M, Exworthy M. 2001. Joined-up solutions to address health

inequalities: analysing policy, process and resource streams. Public

Money and Management 21: 21–6.

Raphael D. 2003. Addressing the social determinants of health in

Canada: bridging the gap between research findings and public

policy. Policy Options, March: 35–40.

Richmond JB, Kotelchuck M. 1991. Coordination and development of

strategies and policy for public health promotion in the US. In:

Holland WW, Detels R, Knox G (eds). Oxford textbook of public health.

Oxford: Oxford Medical Publications.

Ritsatakis A, Jarvisalo J. 2006. Opportunities and challenges for

including health components in the policy-making process.

Chapter 8. In: Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K

(eds). Health in all policies: prospects and potentials. Helsinki: Ministry

of Health and Social Affairs, pp. 145–67.

Sabatier P. 1991. Towards better theories of the policy process. Political

science and politics 24: 147–56.

Saltman R. 1997. Equity and distributive justice in European health-care

reform. International Journal of Health Services 27: 443–53.

326 HEALTH POLICY AND PLANNING

Downloaded from https://academic.oup.com/heapol/article-abstract/23/5/318/615803/Policy-to-tackle-the-social-determinants-of-health by guest on 24 September 2017

Sihto M, Ollila E, Koivusalo M. 2006. Principles and challenges

of Health in All policies. Chapter 1. In: Stahl T, Wismar M,

Ollila E, Lahtinen E, Leppo K (eds). Health in all policies: prospects

and potentials. Helsinki: Ministry of Health and Social Affairs,

pp. 3–20.

Stahl T, Wismar M, Ollila E, Lahtinen E, Leppo K (eds). 2006. Health in

all policies: prospects and potentials. Helsinki: Ministry of Health and

Social Affairs.

Sullivan H, Skelcher C. 2002. Working across boundaries. Basingstoke:

Palgrave.

Turrell G, Oldenburg B, McGuffog I, Dent R. 1999. Socio-economic

determinants of health: towards a national research program and a policy

and intervention agenda. Canberra, Australia: Commonwealth

Department of Health and Aged Care.

Wanless D. 2004. Securing good health for the whole population: population

health trends. London: HM Treasury.

Walt G. 1994. Health policy: an introduction to process and power. London:

Zed Books.

Webb A, Wistow G. 1986. Planning, need and scarcity. London: Allen and

Unwin.

Wilkinson RG, Marmot MG (eds). 2003. The solid facts. Second edition.

Copenhagen: WHO Europe.

Wolman H. 1981. The determinants of program success and failure.

Journal of Public Policy 1: 433–64.

POLICY TO TACKLE SOCIAL DETERMINANTS OF HEALTH 327

Downloaded from https://academic.oup.com/heapol/article-abstract/23/5/318/615803/Policy-to-tackle-the-social-determinants-of-health by guest on 24 September 2017