Timing is everything in health reform: Aligning policy, politics and maybe the planets

While writing this column, I’m looking slightly askance at a pile of assignments competing for my limited attention. I’ve asked my graduate class to use what they have learnt, to try and explain why health policy turns out the way it does.

They can pick a specific issue and identify what it is that they are trying to explain.

What happens in this brief window of opportunity is likely to shape health policy for the next generation or two

Given the momentous, and somewhat unexpected nature of the proposed changes to the health system announced in April, it makes sense to dip into the toolbox of theories about policy processes, to ask “why this set of reform proposals?” and “why now?”

One very popular framework for explaining why big changes do (or don’t) happen was developed by a US policy practitioner and academic, John Kingdon, in the early 1980s. Part of the inspiration for it came from looking at health policy changes that took place when Jimmy Carter was president.

At around that time, the big debate in the study of policy was about how policy change happens. The first generation of policy scholars in the postwar-US used rational analysis and planning, based on a clear problem definition, the development of a range of alternative solutions, and the adoption of the optimal alternative. If followed, such a process could lead to radical changes to the status quo.

In the opposing camp were the incrementalists – who argued that the “rationalist” approach was far too demanding, and required a central policy brain when one did not exist (particularly in the very decentralised US political system). This was why incremental change was the norm, and not necessarily a bad thing.

Stepping into this fray, Kingdon was among the first to suggest that actually, radical policy change occurs often enough, but that doesn’t mean that it is the result of a “rational”, orderly process. Instead, radical change is often random and unpredictable.

Kingdon’s suggestion was that there are three independent “streams” of activity in policy activity. The first stream concerns which problems are given most attention at a particular time. Governments – in common with any organisation, family or individual – have limited attention, and can only deal with a limited number of issues at any one time. Policy issues rise and fall in importance, and this process is cyclical.

Next there is the “policy stream” – the various solutions about what should and can be done.

Kingdon uses the evocative metaphor of the “policy primeval soup” to suggest that specific policy proposals are an evolutionary mish-mash of ideas, influences and pragmatic compromises.

Finally, there is the “political stream” which tracks the electoral fortunes of political parties, the balance of power between interest groups, and any major shifts in public opinion.

According to Kingdon, major policy change happens when events in the three streams align with each other, and that these conditions are rare and fleeting “windows of opportunity” for change (he had a penchant for mixed metaphors). There needs to be an imperative to address particular problems, a ready-to-hand set of solutions, and favourable political conditions – and all these need to be present at the same time.

Key individuals or groups (policy entrepreneurs) match available policy solutions to the problems of most concern when the window of opportunity opens, much like surfers lying in wait for the rare, perfect wave.

So how useful is this way of understanding policy change when applied to the current reform process?

Clearly, the window of opportunity idea applies to present conditions. The idea of a Māori Health Authority as a possible policy solution has been around for some time. The high salience in the problem stream of addressing Māori health inequities was strongly fuelled by the Wai 2575 claim.

As for the political stream, a government consisting of one party in an MMP system is an exceptionally rare event. While the case is compelling for this to be seen as the most important health system issue to address, activists are only too well aware that its prominence on the policy agenda is not guaranteed to last.

What about the creation of Health New Zealand and the abolition of DHBs?

Again, the political conditions are crucial, and this includes that the Association of Salaried Medical Specialists is no longer opposing the demise of DHBs. The idea of a central health authority with regional divisions, has again bubbled up to the surface of the policy primeval soup. In contrast with the 1990s, it has been matched to a somewhat different set of health system policy problems. Back then, the problems were “provider capture” and lack of competition. In 2021, they are more about workforce planning and management, integrated IT, and reduction of inter-organisational complexity.

So, it seems that Kingdon’s idea that health policy change is highly dependent on unpredictable conditions makes sense in the current New Zealand context. Some readers might take this as confirmation that the health sector is buffeted by random and unpredictable forces and there is no logic to what governments do or don’t do.

Acknowledging chance and unpredictability is important, but we shouldn’t over-emphasise it either. For one thing, major structural change is still very rare in health policy (although a little more common in New Zealand). The international and historical norm in the design of health systems is still minor, incremental change and “stuckness” over long periods of time.

Nevertheless, what is currently playing out is not simply a matter of pet solutions looking for fashionable problems to attach themselves to. Kingdon developed his ideas in a US context in which the separation of powers between the Presidency and Congress creates a more marked division of labour between those who identify problems, and those who develop solutions.

In New Zealand’s political system, that separation does not exist. There is considerable overlap between those defining the problems and the solutions, and the important details of the solutions are still to be designed.

But the main usefulness of Kingdon’s ideas for New Zealand health policy in 2021, is the emphasis on timing. This is a unique moment in history. It won’t last long. What happens in this brief window of opportunity is likely to shape health policy for the next generation or two. No pressure!

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