Making sense of the global health crisis: policy narratives, conflict, and global health governance

Health has become a policy issue of global concern. Worried that the unstructured, polycentric, and pluralist nature of global health governance is undermining the ability to serve emergent global public health interests, some commentators are calling for a more systematic institutional response to the "global health crisis." Yet global health is a complex and uncertain policy issue. This article uses narrative analysis to explore how actors deal with these complexities and how uncertainties affect global health governance. By comparing three narratives in terms of their basic assumptions, the way they define problems as well as the solutions they propose, the analysis shows how the unstructured pluralism of global health policy making creates a wide scope of policy conflict over the global health crisis. This wide scope of conflict enables effective policy-oriented learning about global health issues. The article also shows how exclusionary patterns of cooperation and competition are emerging in health policy making at the global level. These patterns threaten effective learning by risking both polarization of the policy debate and unanticipated consequences of health policy. Avoiding these pitfalls, the analysis suggests, means creating global health governance regimes that promote openness and responsiveness in deliberation about the global health crisis.     

Nondecision making and inertia in Portuguese health policy

Despite there having been a positive context for initiating health care reforms in Portugal in the past fifteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have influenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy: clarifying the public-private mix in coverage and provision, creating financial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes, namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.     

Is the doctor in? The evolving role of organized medicine in health policy

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.     

The Role of Interest Groups in the European Union Decision-Making Process

Most of the economic models that analyse the behaviour of interest groups in the policy making process uphold the idea that there are many organized groups that compete, with the aim of achieving their individual goals. The adoption of decisions is the result of a complex system of strategic interactions, and since different groups have different resources at their disposal this makes it easier for one or more groups to influence whether or not a policy is adopted. This research demonstrates that an institutional system such as the European Union (EU) should be able to protect us from the potential manipulation, which accompanies these channels of influence.     

Tax administration as health policy: hospitals, the Internal Revenue Service, and the courts

Since 1969 federal tax policy has permitted nonprofit hospitals to turn away indigent patients or to transfer them to public hospitals. The Internal Revenue Service made health policy, but its officials remain convinced that they were not making policy at all. Convinced that it was reasoning from legal principles, the Revenue Service accepted the hospital industry's view of the history and purpose of hospitals. The federal courts further obscured the problem. Moreover, the Revenue Service took no interest in the effects of its ruling on the services provided by tax-exempt hospitals until 1989. We describe these events and seek to explain them by linking the recent history of health policy to the assumptions that govern the making of tax policy. We conclude that the making of health policy by tax officials who are not accountable for it and who believe that they are not making policy at all is not in the public interest.     

Risk,response, and mental health policy: learning from the experience of the United Kingdom

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.     

In Defense of Asbestos Tort Litigation: Rethinking Legal Process Analysis in a World of Uncertainty, Second Bests, and Shared Policy-Making Responsibility

A central question in American policy making is when should courts address complex policy issues, as opposed to defer to other forums? Legal process analysis offers a standard answer. It holds that judges should act when adjudication offers advantages over other modes of social ordering such as contracts, legislation, or agency rule making. From this vantage, the decision to use common law adjudication to address a sprawling public health crisis was a terrible mistake, as asbestos litigation has come to represent the very worst of mass tort litigation. This article questions this view, arguing that legal process analysis distorts the institutional choices underlying the American policy‐making process. Indeed, once one considers informational and political constraints, as well as how the branches of government can fruitfully share policy‐making functions, the asbestos litigation seems a reasonable and, in some ways, exemplary, use of judicial power.     

State legislative staff influence in health policy making

State legislative staff may influence health policy by gathering intelligence, setting the agenda, and shaping the legislative proposals. But they may also be stymied in their roles by such institutional constraints as hiring practices and by turnover in committee leadership in the legislature. The intervening variable of trust between legislators and their support staff is also key to understanding influence and helps explain how staff-legislator relationships play an important role in designing state health policy. This study of legislative fiscal and health policy committee staff uses data from interviews with key actors in five states to model the factors important in explaining variation in the influence of committee staff on health policy.     

Health policy and ERISA: interest groups and semipreemption

This paper is a history of the health policy results of the Employee Retirement and Income Security Act of 1974, particularly section 514, which preempts state laws "which relate to any employee benefit plan" but permits states to continue to regulate the business of insurance. This history exemplifies how health policy is often made outside conventional arenas. On the basis of published primary sources and interviews with a number of key participants, the paper describes how interest groups which rarely act together coalesced to create and sustain semipreemption and its effects on state and federal health policy. The paper concludes with an assessment of recent state legislative efforts to address the problems created by ERISA semipreemption. The ironical results of semipreemption occurred because of the absence of a coalition of interest groups that was sufficiently strong to resolve the fundamental questions raised by our commitment to linking health insurance to employment.     

Public values, health inequality, and alternative notions of a "fair" response

The fact that disadvantaged people generally die younger and suffer more disease than those with more resources is gaining ground as a major policy concern in the United States. Yet we know little about how public values inform public opinion about policy interventions to address these disparities. This article presents findings from an exploratory study of the public's values and priorities as they relate to social inequalities in health. Forty-three subjects were presented with a scenario depicting health inequalities by social class and were given the opportunity to alter the distribution of health outcomes. Participants' responses fell into one of three distributive preferences: (1) prioritize the disadvantaged, (2) equalize health outcomes between advantaged and disadvantaged groups, and (3) equalize health resources between advantaged and disadvantaged groups. These equality preferences were reflected in participants' responses to a second, more complex scenario in which trade-offs with other health-related values - maximizing health and prioritizing the sickest - were introduced. In most cases, participants moderated their distributive preferences to accommodate these other health goals, particularly to prioritize the allocation of resources to the very sick regardless of their socioeconomic status.     

The political development of the Hill-Burton program: a case study in distributive policy

The Hill-Burton program offers a rare opportunity to study a distributive health policy from its adoption to its elimination. This study reveals that the political dynamics of the policy changed over time. It concludes by observing that interest group influence on distributive health policies may only be decisive when circumstances permit. Those circumstances include the involvement of powerful elected officials and the degree of consensus among policy experts about the need for the policy and the appropriateness of its objectives.     

Private Representation in Washington: Surveying the Structure of Influence

Despite the significance of interest representation to theories of law and politics, the social organization of interest representation has not received systematic empirical analysis. Based on interviews with 776 individuals engaged in the representation of private interests concerning national policies on agriculture, energy, health, and labor, this article reports some findings concerning the social and political characteristics of representatives, the nature of their work and their relationships with client organizations. Three models of the social organization of interest representation are developed and examined: a model based on substantive expertise, an institutional targets model, and a client-based model. The findings indicate that representation is predominately organized around client interests Although lawyers constitute a significant and distinctive group among representatives, they are neither as numerous nor as active in policy making as is commonly assumed. The analysis suggests that representatives are not likely to exercise influence in the policy-making process that is autonomous from client organizations.     

Congress and criminal justice policy making: The impact of interest groups and symbolic politics

This article explores the congressional criminal justice policy-making process in the United States, using efforts toward federal criminal-code revision and capital punishment as case examples. It examines how interest groups and symbolic politics affect criminal justice policy and thereby attempts to enhance understanding of the political realities of criminal justice policy making. Based on the findings reported here, an approach to criminal justice policy making is recommended. This approach builds on the disjointed incremental model found in the political science literature and should facilitate criminal justice policy makers in becoming more effective participants in the legislative process.     

Regulatory Agencies and Interest Groups in Occupational Health and Safety in Great Britain and West Germany: A Perspective from West Germany*

In this paper, results are introduced of an empirical study which investigated the practice of occupational health and safety regulation in two countries, Great Britain and West Germany. The analysis concentrates on the specific relationship that regulatory agencies and the concerned interest groups, employers and trade unions, develop in the two stages of policy formulation and implementation of health and safety regulation. Results show that interest groups actively participate in the regulation-making systems in both countries. Their policy pursued in this process is influenced and mediated by their actual resources as well as by individual views and assessments of each side's representatives. In Germany, a strong fragmentation with numerous private and quasi-governmental bodies entitled to formulate standards makes it difficult for the interest groups to concentrate on the competent and important committees. In contrast, we find a clearer responsibility of bodies and committees in the case of Britain. In both countries, enforcement policy prefers an advisory and persuasive style even though the legal backgrounds are quite different.     

Who shall lead: is there a future for population health?

Despite renewed interest in population health concerns, elevation of this field in policy considerations faces many challenges. At present there is much concern about disparities and meeting improved population health objectives, but interest waxes and wanes with scientific developments and especially with dominant political alignments and ideologies. If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability. Population health faces many issues in seeking to become legitimized as both a unique field of study and as a significant force in public policy. Among these are a clear definition of the boundaries of the field, a continuing flow of resources for development, and attractive career structures for new recruits and future leaders.     

The evolution of health-policy making in Italy

An analysis of the dynamics of health care policy in Italy suggests that in recent years the pace of change in the health care system has accelerated. Although the basic features of universalism, comprehensiveness, and funding from general taxation have remained remarkably constant, the capacity to innovate policy tools and their settings and to take account of domestic and international experience seems to have increased. The political will and capacity to combat entrenched interests may also have increased, although implementation is still weak. The imperative to contain public expenditure has heavily conditioned health policy and will continue to do so. This has occurred mainly at the national level, but as the principal locus of health-policy making progressively shifts to the regions, so too will the constraining effect of this imperative move downward. If the decentralization process continues, problems could arise due to interregional differences in capacities to formulate and implement appropriate policies and to tackle special interest groups.     

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.     

Weighing both sides: morality, mortality, and framing contests over obesity

Despite recent and growing media attention surrounding obesity in the United States, the so-called obesity epidemic remains a highly contested scientific and social fact. This article examines the contemporary obesity debate through systematic examination of the claims and claimants involved in the controversy. We argue that four primary groups-antiobesity researchers, antiobesity activists, fat acceptance researchers, and fat acceptance activists-are at the forefront of this controversy and that these groups are fundamentally engaged in framing contests over the nature and consequences of excess body weight. While members of the fat acceptance groups embrace a body diversity frame, presenting fatness as a natural and largely inevitable form of diversity, members of the antiobesity camp frame higher weights as risky behavior akin to smoking, implying that body weight is under personal control and that people have a moral and medical responsibility to manage their weight. Both groups sometimes frame obesity as an illness, which limits blame by suggesting that weight is biologically or genetically determined but simultaneously stigmatizes fat bodies as diseased. While the antiobesity camp frames obesity as an epidemic to increase public attention, fat acceptance activists argue that concern over obesity is distracting attention from a host of more important health issues for fat Americans. We examine the strategies claimants use to establish their own credibility or discredit their opponents, and explain how the fat acceptance movement has exploited structural opportunities and cultural resources created by AIDS activism and feminism to wield some influence over U.S. public health approaches. We conclude that notions of morality play a central role in the controversy over obesity, as in many medical disputes, and illustrate how medical arguments about body weight can be used to stymie rights claims and justify morality-based fears.