Pushing for health policy change demands resilience in electoral merry-go-round

You soon realise electoral agendas are crowded, and there is no guarantee health policy issues will be pivotal in the election

Picture yourself for a moment as an activist whose single most important priority is to ensure that people have better access to primary care services in your local area. What are your options? Where in our health system, and broader democratic system, might you have the best chance to make a difference?

You have good community networks and you have a clear understanding of why people are not getting the primary care they need. So you stand for election to your local DHB and are duly elected. Within a year or two, you realise there are clear limits on what you can achieve as an elected DHB member.

The DHB is in perpetual deficit. Most decisions are constrained by government directives and historical budgetary patterns. There are no levers to redirect spending from other areas of DHB activity. You realise the key to improving access for your people lies at the national level and to influence national health policy you need to get involved in national politics.

How do you do this? You could join a political party and get involved in the local branch. After a few years of putting your nose to the grindstone in your party, you achieve preselection for your electorate. But you need to be across all issues, not just health. You soon realise electoral agendas are crowded, and there is no guarantee health policy issues will be pivotal in the election.

Your party’s focus groups give a clear message that voters are most concerned about elective surgery waiting lists, so you have to talk about that. In contrast, access to primary care is not a big issue for the majority of citizens. Even as an elected MP, you are a small cog in a very large mechanism. The chances that you will even end up with a role relevant to health policy are fairly slim. After one term in Parliament you decide to explore other options.

How about joining (or forming) an interest group? Perhaps that might speed things up a bit. Now you can have a laser-like focus on access to primary care. The game here is different. In the 1950s, some political theorists, known as “pluralists”, thought this was how democracy was really achieved in practice. Governments act more like referees, deciding between the claims of competing interest groups. Not every group will get everything they want – in fact, no group is likely to get the exact outcome it wants, but the system comes up with a “satisficing” result nonetheless.

As long as there is a relatively even distribution of power between groups (no group gets its way all the time), pluralists argued this was a very neat and sophisticated realisation of democracy. Pluralists were heavily criticised for ignoring the imbalances of power between groups. Some groups consistently get (most of) what they want in policy, and others consistently get much less.

Your vision for primary care has implications for other interests and interest groups in the health sector. That caveat about the distribution of power turns out to be pivotal. As you develop concrete proposals designed to reduce access barriers, other groups and interests in the primary care patch are highly likely to lose out in some way.

You discover that your interest group (and your interest in reducing access barriers) is on the losing side more often than not. Nevertheless, you make some headway and manage to convince the Government to introduce new initiatives to improve access. After a few years, an evaluation of these initiatives finds they have not been implemented as intended in some parts of the country, including yours.

The evaluation report concludes this is mostly because players at the local level are able to ensure they are not adversely affected. You realise the importance of influencing these players at the local level. How do you do this? Well, you could always stand for election to the local DHB...
Policy activists are more important than ever. If you think you are up for it, then check out the job description provided by Max Weber, one of the most important sociologists in the early 20th century. Weber wrote an extended essay entitled “Politics as a Vocation”, from which the most famous line is “(p)olitics is a strong and slow boring of hard boards”.

He went on to say that “even those who are neither leaders nor heroes must arm themselves with that steadfastness of heart which can brave even the crumbling of all hopes”. Weber’s aim in his essay was to celebrate those who were willing to put themselves through all this, because without such people, most of the significant gains that have been achieved would never have happened.

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