The very human and somewhat untidy world of conjuring up new health policies

Lately I have developed an appetite for cryptic crosswords.

I love the way clues that, on first reading, look totally obscure and baffling, gradually make sense when you stick at it.

There has long been a view that developing health policy (or any type of public policy) is analogous to solving cryptics. Collectively, we start with a puzzle, a problem, and work our way diligently to a solution.

Sometimes we can see this ordered process in health policy, most obviously with outbreaks of infectious dis­eases, such as new strains of the meningococcal virus, or rheumatic fever.

However, in a classic book on public policy, US author John Kingdon suggests things generally work the other way round. People start with solutions, and go looking for problems to attach their solutions to.

Kingdon based his insight on detailed studies of US federal transport policy and health policy in the 1970s. He wanted to emphasise the importance of randomness and contingency, rather than rationality and predictabil­ity, in policy.

This probably confirms the worst fears of those who see health policy processes as fundamentally irrational. But it is worth exploring his idea a bit more, because it actually may have some advantages.

Kingdon observed an important division of labour between those whose job is to look for problems that need addressing, and those whose job is to develop work­able, feasible, implementable policy proposals. The time frames of these activities are very different.

Generally, it takes less time to identify problems than it does to devise concrete, implementable policy options. So perhaps it makes sense to give the policy wonks devising policy alternatives a head start, and to develop options that can be flexibly attached to a range of problems.

Let’s take capitation modes of payment as an exam­ple. It takes considerable time and analysis to develop a sophisticated capitation scheme.

For politicians on the right, capitation can be presented as a solution to problems of escalating costs. For politi­cians on the left, it can be a solution to the inequities of access that characterise fee-for-service schemes.

There are other reasons why policy processes are not like cryptic crosswords. For a start, there is no puzzle- master, no central brain, and no guarantee that all the pieces can fit together neatly.

Then there is the problem of our collective capacity to deal with complex problems where multiple objectives need to be balanced, and where there is often great un­certainty about the effects of different options.

Herbert Simon, a 20th century polymath who spanned economics, political science and psychology, argued that the informational requirements to solve policy problems rationally are monumental, and that “satisficing” – doing just enough to deal with a problem acceptably – is a more realistic aspiration.

Often, satisficing entails taking a tool or an approach that has been effective in other areas, and applying it to emergent problems, rather than attempting to devise an entirely new tool. This adaptive process is at the heart of biological and technological evolution.

Also, the word “solution” implies there is an end to the process: the puzzle is solved and we move on to some­thing else. But solutions are rarely as definitive as that. They need adjusting, they evolve, and/or they create new problems that need to be addressed.

Nevertheless, the division of labour between prob­lem-mongers and solution-mongers, as described by Kingdon, may arise in the US policy context. In the small­er policy community in New Zealand, this demarcation is not as clear.

Arguably, the more typical arrangement is that problems and solutions are defined simultaneously. In fact, this seems to be a fundamental skill of being a policy activist.

If I am part of an advocacy group arguing that rates of type 2 diabetes are a major problem, then part of my brief is to also define what needs to be done – whether a sugar tax, advertising restrictions, removal of junk food from school tuckshops, or all of the above.

One former health minister is reputed to have told officials not to come to him with problems unless they also offered solutions.

Now more than ever, policy debate seems to require participants to develop coherent stories that package together problems, diagnoses of causes and identifica­tion of solutions. But, typically, such solutions are mere sketches.

Someone else has to do the hard yards to fill out the picture, look for the fish hooks and internal contradic­tions, and work out how a proposed solution fits with the rest of the policy landscape.

We also need skilled policy analysts who are pre­pared to take a sceptical, or perhaps a “friendly critical”, approach to whether proposed solutions will successfully address problems and whether they will create unintend­ed consequences. In New Zealand, this policy capacity is patchy at best.

Sometimes, the nature of novel solutions in policy is that we just can’t predict their consequences. All the more reason to develop skilled policy practitioners who are prepared to ask the right questions.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland