The Role of The State in Public Health Research Paper

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This research paper explains the roles of state and its executive branch, the government, in public health policy. In contemporary complex societies, the state holds the political authority over the population of a given territory, and its diverse roles and functions (including policymaking) are executed by the government. This research paper describes how both roles have been evolving since the second half of the twentieth century.

Such evolution can be divided into three broad stages: the 1950s and 1960s; the 1970s and 1980s; and the 1990s to the present. Simultaneously, transformations have occurred in the following three dimensions. First, the responsibility of the state for ensuring public health has evolved. This has been accompanied by debate about the nature of the state’s responsibility in providing for public health. Second, the way in which governments have intervened in public health has also changed. Governments have now at their disposal new tools for influencing the lifestyles of citizens and organizations and for gathering information for promoting public health. Third, the process of making public health policies and the number and identity of actors and the arenas for policymaking have evolved. In this more complex scenario, governments are developing new approaches to the governance of public health and adopting new strategies for improving public health policymaking.

The Evolution Of The State’s Responsibility Over Public Health

Despite the intensification of state involvement in promoting public health in these last decades, public authorities since ancient civilizations such as the Incas, the Etruscans, and the Romans have been concerned with public health. In the Italian city-states of the middle ages, public infrastructures for providing safe water and sanitation (such as cisterns and sewers), cleaning streets, and fighting diseases and epidemics were developed and managed by public boards of health (Beaglehole and Bonita, 2004).

Gradually since the Middle Ages, first in Western Europe, states have become the preferred institutional configuration to collectively organize political societies. The nation-state replaced other political entities such as tribes, feudal societies, or city-states, monopolizing the legitimate use of physical force over a group of people, who shared a common identity as a nation, within a given territory. The state organizes through a number of institutions, including legislative assemblies, the executive or government, the judiciary, the civil bureaucracy, the police, and the armed forces.

The origins of the idea of state responsibility for the health and well-being of citizens can be traced back to the eighteenth century, but the idea was not translated into legislation and other central government interventions until the nineteenth century. The consequences of the industrial revolution forced states to intervene and regulate the working conditions in factories. This, however, was not without debate on whether the state had the right and duty to intervene in order to correct the shortcomings of capitalist development. In Britain, the first national health law was the British Public Health Act of 1848 (Beaglehole and Bonita, 2004) and a general board of health was set up. Public health actions were still, however, fragmented and usually undertaken by local authorities and religious organizations.

In the interwar years of the twentieth century, more comprehensive systems of health and health care developed across the world. Totalitarian regimes, such as the communists in the Soviet Union between the 1920s and the 1950s, or the Nazis in Germany in the 1930s, were very active in promoting public health, implementing programs such as promoting exercise among the population (especially among children and young people), combating smoking, and preventing infectious diseases.

The epitome of the state assuming responsibility for the welfare of the population was the establishment of national health systems following the end of the Second World War. These systems were funded by taxation and free at the point of use and were accompanied by comprehensive education, social care, and unemployment programs. William Beverage’s report Social Insurance and Allied Services in the United Kingdom (UK), published in 1942, is usually cited as the first systematization of such reform programs which came to be known as the welfare state. The British National Health Service (NHS) was subsequently created in 1948. However, the welfare state prioritized health care over public health. The welfare state marked the triumph of the ‘clinical care model,’ which emphasizes health care provided to individuals by specialized physicians in hospitals.

Following independence in the 1950s and 1960s, a number of newly independent former colonies in the developing world adopted socialist and Marxist ideologies. These ideologies advocated total state control over the economy through the use of public enterprises and huge bureaucracies. Soviet and Chinese socialism provided examples for many other countries. The state took full responsibility for public health and health care, even if this was limited in its delivery in practice.

In 1970s and 1980s, in the midst of a profound international economic crisis, the welfare state and, more widely, the idea of state responsibility for people’s welfare, was challenged. In the First World, a series of welfare reforms aimed to limit the exponential growth of the welfare state were introduced. For many, these reforms represented a ‘retrenchment’ (affecting less important areas of the welfare state such as employment policies or social care, not core services such as health and education), rather than a full ‘dismantling’ of the welfare state. In communist countries, the financial crisis also led to the cutting of public health and other welfare programs, with a resulting dramatic worsening of the health of the population as reflected in different health indicators.

The economic crisis fuelled criticisms of the role of the state by a resurgent neoliberal ideology in the form of two connected arguments. The first argument challenged the notion that the government should be principally responsible for public service financing and provision and emphasized instead the role and duty of individuals to provide for themselves rather than to rely on the state. Governments, it was argued, should intervene less in social and economic affairs. For the neoliberal ideology, public health interventions are regarded as ‘nanny statist,’ and as ‘unnecessary intrusions into people’s lives’ ( Jochelson, 2006).

The second argument was that even if one accepted that government had a role to play, governments increasingly appeared to lack the capacity to intervene effectively and to deal with increasingly complex public matters. In the 1970s, the thesis of the ‘ungovernable state’ (also referred to as ‘overload’) grew from both neoliberal and neo-Marxist positions. For the overload thesis, the continuous growth of the state since the 1940s, increasing public expectations of what the state could deliver, and the demands of pressure groups had led to a situation of ‘ungovernability’ and financial crisis (Richards and Smith, 2002). Added to these domestic pressures, globalization and supranational integration (e.g., the European Union (EU)) challenged the way national states performed traditional functions. For example, as decision-making power was being increasingly transferred to the EU, many policies were not decided at the national level, although it was the responsibility of the member states to fully implement them.

Public health was affected by these wider changes. Overall, the economic and public sector reforms introduced during the 1970s and 1980s had a negative impact on public health by increasing poverty and inequality rates. Public sector reforms tended to target those policy areas, such as public health and social care, which were not supported by strong public constituencies and therefore were unlikely to have big political costs for the politicians responsible for the reforms.

Since the 1990s, a more pronounced role for the state in public health has again been advocated. Governments had articulated their commitment to public health in the 1978 Alma-Ata Declaration. The need for government action on public health was put forward by the worldwide People’s Health Movement in their 2000 People’s Charter for Health and the 2004 Mumbai Declaration. As a relative measure of the salience of public health and the responsibility of the state for promoting it, public spending on public health and disease prevention has been increasing over the last two decades in many countries (Allin et al., 2004).

In contemporary political thinking, those claiming that the state has (at least some) responsibility for promoting and protecting public health have suggested several images of the government as ‘catalyst,’ ‘enabler,’ ‘steward,’ and so forth. The ‘catalyst’ and ‘enabler’ categories are based on the idea that the role of the state is to help people to help themselves, that is, to enable individuals to make their own choices about their lifestyles rather than for the state to impose forms of behavior.

However, for others, the categorizations of the state as ‘enabler’ or ‘persuader’ still place too much emphasis on individual responsibility for public health. ‘Stewardship’ has been suggested as a better term to justify the state’s intervention in public health (Saltman and FerroussierDavis, 2000; Jochelson, 2006). ‘Stewardship implies government has a responsibility for protecting national health, and to serving in the public interest and for the public good’ (Jochelson, 2006: 1153). This renewed emphasis on the responsibility of the state does not, however, imply a traditional role for citizens as passive recipients of public services. In this new narrative, individuals have responsibility to play an active role in relation to public health. Stewardship does not necessarily imply that the state should be the provider of public health, but that the state should be responsible for ensuring that public interventions are funded, delivered, and effective.

All these images recognize that public health is a ‘public good’ (Bobak et al., 2004; Buse et al., 2005). Public goods benefit the entire population whether or not each individual has actively sought them, has explicitly paid a price for the cost of them, or even agrees with them being provided. For example, someone may be opposed to policies which ban smoking in public places, but he or she receives the benefit of cleaner air if such policies are implemented. In that sense, just as transport infrastructures, defense policy, and other public goods are nonexcludable, so is public health – ‘if provided to one, it is available to all’ (Hughes, 2003: 78; Buse et al., 2005). Even if the market could provide public health interventions, they are socially desirable so there are benefits to the whole society by some government involvement. For example, vaccination brings benefits for the entire population, despite the fact that it could be made available only to those who can afford to pay (Hughes, 2003: 78).

Government And Its Tools For Promoting Public Health

The government is the state institution operating at the national level which embodies the formal authority of the state. In any political regime (i.e., democratic, authoritarian, totalitarian), in any state configuration (i.e., unitary, federal, parliamentary monarchy, presidential, etc.), at the federal/national level, there is a government which substantiates the formal exercise of power. Although there can be a legislative branch formed by two bodies (e.g., two houses, a senate and a congress), there can only be one national government. In non-democratic regimes, the power of government is even more pronounced.

The core functions of government are to make and implement policy. To carry out these functions, the government employs the resources of the state – principally, the civil service.

Governments have at their disposal various forms of organizations to develop and implement policy and to deliver services. These instruments include public corporations, private sector contractors, and public-private partnerships (Hood, 2006). In public health policy, these tools have evolved in response to the changing policy environment and the dominant ideology prevailing at any one time.

Another way of understanding the instruments available to government is by classifying them according to the objectives they seek. Thus, they can be broadly classified as tools for gathering information and tools for modifying the behavior of citizens and organizations (Hood, 2006). These instruments have been changing as a result of information-age technology, especially detecting tools for gathering information, to the extent that governments have now at their disposal new tools to obtain useful information for promoting public health, including the use of indicators, systematic screening of populations, cross-national data, surveys, and so forth.

In the 1950s, the paradigm for administering the state was the ‘bureaucratic’ model, which has been described by Max Weber as bearing the characteristics of centralization, formality, and hierarchy, supported by a politically neutral civil service. In the postwar bureaucratic state, public policies were formulated within central government and developed by the civil service. Ministries and departments were responsible for policy areas such as education, defense, foreign policy, and health, and ‘joined-up,’ cross-departmental work was rare.

Public health policy was placed under the remit of the ministries of health, which were established across the world in the 1950s (with the exception of some pioneering examples which came earlier (e.g., UK in 1919 or Costa Rica in 1927). State bureaucracies were responsible for the direct provision of health and health-care services. Responsibility for many public health programs was transferred to public corporations at the national or local level.

Banning alcohol consumption, taxing smoking, or subsidizing sanitation programs were typical behavior modifying tools employed by governments to promote public health. Tools for identifying population health needs or risks, however, were little developed.

Such a strong role for central executives and central bureaucracies in the financing and provision of services also characterized public administration in the colonies and, following independence, in the new countries (Hughes, 2003), and was even more marked in totalitarian and authoritarian regimes. In Botswana, for example, after independence in 1966, the government implemented a program of groundwater drilling and water network construction and provided incentives to rural households to build latrines by subsidizing them (Oxfam, 2006).

Under the influence of the neoliberal ideology, during the 1970s and 1980s, countries across the world embarked upon ambitious reforms of their public sector and the administrative structures of the state. Despite their differences, these reforms, which have been labeled as ‘new public management’ (NPM), reflected the neoliberal principles of a minimal state, a preference for market-based solutions rather than direct public sector provision, and the belief that the capacity of governments to intervene effectively is very limited. NPM advocated a new role for governments: ‘to steer rather than row’ and to oversee market competition.

For NPM advocates (among which the World Bank and the International Monetary Fund stood out), enabling private providers to compete in a marketplace was a more efficient way of providing services than direct public provision. The introduction of market mechanisms became a fashionable solution in the 1980s across the world. Many developed and developing countries such as the UK, New Zealand, South Africa, Chile, Thailand, and India adopted the NPM principles, undertaking major privatization reforms of their public sectors (Hughes, 2003).

As a result, NPM reforms across the world led to the cutting of public health programs, as happened with federal funding for public health in the United States and the decision by the UK Conservative Government to reduce the funding for the Health Education Authority for England (Beaglehole and Bonita, 2004). Many countries also introduced separate agencies to promote public health, thus leading to institutional fragmentation (Beaglehole and Bonita, 2004). Despite these reforms, many countries put in place national public health policies and strategies to promote collaborative work, especially between national and local governments and agencies, but institutional barriers made this aim very difficult to achieve.

As quality, equity, competition, and efficiency need to be guaranteed in the public sector, the state had to regulate the behavior of providers and the performance of markets. The most common regulatory mechanism has been establishing independent bodies at arm’s length from government – known as ‘quangos,’ nondepartmental public bodies, independent agencies, and so forth.

The NPM advocated practices such as the use of goals and targets for measuring performance and monitoring progress of public services. In 1980, the United States established quantifiable objectives to improve the health of the nation, reduce health risks, and improve services and protection (Allin et al., 2004). In 1985, the World

Health Organization (WHO) introduced regional targets, called the Health for All programe (Allin et al., 2004; Beaglehole and Bonita, 2004). Despite the fact that these targets reflected the narrow purpose of achieving improved efficiency and efficacy, they dramatically improved the detecting tools for governments and paved the way for better monitoring and evaluation.

Today, governments make use of many forms of organizations to provide services. Together with direct provision by public corporations and contracting out to private sector providers, public-private partnerships are being deployed in public health to promote, for example, antismoking initiatives, road safety, and alcohol misuse education campaigns or to undertake community renewal interventions. Partners typically include private sector or voluntary not-for-profit organizations, independent public agencies, governmental bodies such as ministerial departments, local authorities, universities, schools, and civil society groups, for example.

From the point of view of the tools used either to modify lifestyles or to gather information, both traditional and new policy instruments are being used. Traditional policy instruments for modifying behavior such as taxation, regulation, and government-led campaigns continue to prove effective. Taxation of alcohol or tobacco leads to a reduction in consumption and, therefore, to positive effects on health outcomes and, particularly in the case of alcohol, to better public safety (e.g., fewer motor vehicle fatalities, fewer homicides, less domestic violence and child abuse) (Jochelson, 2006). Examples of effective regulation to restrict the consumption of alcohol and tobacco include tougher licensing laws for pubs’ opening hours or the banning of smoking in public places and of tobacco advertising ( Jochelson, 2006). The ‘total sanitation campaign’ in India (Oxfam, 2006) and the ‘free school meals’ campaign in Sri Lanka (Oxfam, 2006) are examples of public health campaigns directly led by government which have met with variable success.

At the same time, governments throughout the world are exploring the use of new tools for influencing the lifestyles of citizens and organizations. Such tools include voluntary codes of conduct, financial incentives, benchmarking, performance league tables, the coproduction of policies and initiatives, and so on. For example, in Spain, voluntary codes of conduct have been adopted by the food industry, which has agreed to refrain from the aggressive advertising of ‘fast food’ to children, reduce fat and sugar levels through the food manufacturing process, and improve the information provided on food packaging.

As a result of information-age technology, governments can use new tools through which to gather useful information for promoting public health, including the use of indicators, systematic screening of populations, cross-national data, surveys, etc. The WHO provides a great deal of epidemiological and statistical information which is freely available online, including systems for managing information about disease outbreaks. With the support of the WHO and other international organizations such as the Organization for Economic Co-operation and Development (OECD) and the EU, countries are making efforts to standardize public health information data collection.

The Process Of Making Public Health Policy

The process of making public health policies since the 1950s has been evolving as well. The actors participating in the policy process, the venues or arenas where policies are formulated and implemented, and the way ideas enter the process and influence actors are now different from those of the mid-twentieth century (Richards and Smith, 2002; Buse et al., 2005). Today, governments do not seem to have the same level of autonomy and capacity to shape the policymaking process that they once enjoyed.

In the 1950s and 1960s, the process of formulating public health usually took place at the national government level and was led by politicians and senior civil servants within central executives and central bureaucracies. The civil service held the monopoly for policy advice to politicians and decision makers, thereby limiting the pluralism of ideas and policy solutions. At that time, only the medical profession, usually organized through formal corporatist bodies (such as medical councils or colleges), and powerful economic interests (such as the tobacco, food, and pharmaceutical industries) enjoyed any significant degree of leverage over the policymaking process.

Political parties, although crucially important in mobilizing people and channeling the selection and recruitment of political leaders and cadres, have always had a secondary role in formulating public policy (Buse et al., 2005). Parties do generate alternatives while in opposition or in the running up to an election, but once in office, it is the government which takes the lead in formulating and implementing policy.

The executive and the legislative branches were the arenas for public health policymaking. In unitary states, where hierarchical subordination exists between national central governments and lower units of government at the regional or local levels, public health laws were passed by the national executives and legislative branches and the lower levels of government were in charge of implementing them. In federal systems, where political power is shared by federal and subnational governments and legislatures, the latter have always had a major responsibility for formulating and implementing public health policies (Buse et al., 2005).

Policy implementation, despite requiring participation from local authorities and ‘street-level bureaucrats’ (i.e., implementers), was understood as a top-down process directed by central government. Implementation failure would simply be seen as a problem of compliance by the lower administrative levels.

During the 1970s and 1980s, the emergence of a strong international public health movement allowed new actors to enter the public health policy process at both the international and national levels (Reich, 2002). International organizations such as the World Bank competed with the WHO to promote international health. Especially in developing countries, international donors and individual experts have been advising governments on public health. As NPM reforms were rolled out, the newly created executive agencies, local and national bodies, and independent providers of public services became new actors in formulating, but especially implementing, public health policies.

In the early twenty-first century, due to NPM reforms and to wider socioeconomic and political trends (globalization, processes of regional economic integration, etc.), the public health policy process is even more complex than ever. The trend of new actors entering the process has intensified. For example, in the health sector, the number of patient associations and health consumer groups has been growing in countries across the world, although their leverage over the policy process is still a matter of discussion.

The media is a powerful actor, capable of shaping the public agenda. For example, in 2002–03, the media coverage in the UK of the potential risk of autism associated with receiving the combined measles, mumps, and rubella (MMR) vaccination exemplifies how influential the media can be in bringing an issue to the forefront (Buse et al., 2005). Although in this particular example the government managed to resist the pressure to change its childhood immunization policy, on many occasions, high political costs incline governments to follow the flow of public opinion.

Not only have new participants now entered the policymaking process to develop public health policy, but the way old and new actors interact has been changing as well. Formal and informal contacts and relationships between state and nonstate actors, either from inside or outside government, take the form of ‘networks.’ The concept of policy networks reflect the existence of groups of people (politicians, civil servants, academics, interest groups, etc.) with common interests in the policy area to which the network is dedicated, who share common values over policy problems and solutions and who are keen to exchange resources (information, authority, legitimacy, nodality, etc.) to pursue common goals. For many scholars, policy networks are the quintessence of contemporary government.

Processes of regional economic integration and intergovernmental organizations across the world have brought about new arenas for policymaking (Reich, 2002). The EU has been developing a strong interest in public health. Treaties, such as the Maastricht Treaty of 1992 or the 1999 Treaty of Amsterdam envisage an important role for the European Community in contributing to the attainment of a high level of health protection for its citizens, therefore providing the EU with new competencies in public health. The Commonwealth, an association of 53 independent states, promotes cooperation between members on public health issues such as combating HIV/AIDS or promoting maternity and child health.

Another change to the venue of policymaking is a growing trend in countries across the world to devolve power to lower levels of government (Reich, 2002). Devolved administrations have been assuming more functions and roles to develop public health policy. Devolution in Scotland, for example, opened up a window of opportunity to develop more radical smoking control policies than in the rest of the UK. Groups advocating the banning of smoking in public places were able to influence policy through the Scottish Parliamentary procedures after devolution, whereas they had been unsuccessful in attempts to exert the same leverage at the UK policy process level (Cairney, 2007).

As a result of the increasing number of actors and arenas for policymaking and the effect of the information-age technology, ideas and policy solutions now flow more freely. Consequently the transfer of public health ideas and solutions across the world is more intense than ever before.

The multiplication of actors and arenas for policymaking also affects the process of implementing public health policies. Most of the time, policies are not implemented as originally intended by decision-makers, because many actors at the front line have some discretion to introduce changes, or various institutional factors impede or put obstacles in their path. This transformation of the policy process has been affecting both nondemocratic and democratic political regimes across the world. In democratic states, political power is exercised by the people, usually through systems of representation which require free elections. This implies that, at least formally, different economic, social, and political groups and individuals have the possibility to influence the policy process. In nondemocratic regimes, political power is concentrated upon a single individual or a group (such as a single political party or the military). The policy process is monopolized by a very limited number of actors, predominantly from within the regime. Intense popular mobilization makes it easy for a country to launch and implement public health programs successfully, as illustrated by the case of the quarantine policy for people with HIV infection, implemented by the Cuban communist regime between 1986 and 1993, which involved mass testing and the isolation of the infected in sanatoriums. Despite the fact that nondemocratic regimes have more capacity and autonomy to steer the policy process, globalization and wider socioeconomic and political trends shape their health policy agendas as well. Cuba’s health achievements with respect to nutrition and child survival, for example, are currently under threat from several causes, including the United States trade embargo, the collapse of the Soviet Union, and the effect of natural disasters (Beaglehole and Bonita, 2004). Other nondemocratic regimes have been forced to take on board demands for radical reforms imposed by external actors such as the World Bank and the International Monetary Fund.

How Can Governments Tackle Public Health Issues Today?

At the beginning of the twenty-first century, as a result of wider economic, political, social, technological, and cultural changes, public health problems appear to be now more difficult to tackle than before. The public policy literature coined the term ‘wicked problems’ to refer to complex, contested issues of interest to multiple policy actors which therefore require addressing them from different policy domains and deploying a multi-agency strategy (Blackman et al., 2006).

Public health issues are usually ‘contested’ issues. Their nature is subject to competing definitions, in other words, they are ‘political’ issues in their very nature. For example, policies to ban smoking in public places usually encounter the fierce opposition of the hospitality sector and the tobacco industry, which claim that such measures would affect their business negatively.

The term ‘wicked issues’ is also useful to understand how public health policy usually deals with cross-cutting issues, which transcend a single policy domain and fall under the responsibility of different authorities and state structures. For example, social, economic, and cultural factors constitute the major determinants of (ill) health, and this implies that ‘the policy response to improve health needs to be interdisciplinary and multisectoral’ (Bobak et al., 2004: 135). Also, global public health problems transcend state borders. In consequence, public health interventions require interagency collaboration and complex coordination between local, regional, national, and supranational levels of government.

Given the complexity of current public health issues, the pressures modern governments have to face ‘from above, from within, from below’ (Reich, 2002) as reflected in the increasingly complex policymaking process, and given that public health policy is inherently a political process, governments around the world have been trying new approaches to public health policymaking.

The Public Governance paradigm, it is argued, can provide a more fruitful approach for tackling wicked health issues than the traditional administration approach or new public management (NPM). For Bovaird and Lo¨ffler (2003), the public governance paradigm incorporates the NPM concerns for measuring results in terms of outputs and achieving efficiency and value for money, but stresses the distinctive nature of the public sector and the centrality of political processes. In the public sector, it is not all about how good policies are (in terms of efficiency, value for money, technical viability, outputs, etc.) but also how policies have been made. The processes by which different stakeholders interact are also seen to have a major importance in themselves. Ensuring that the public policy process is inclusive and democratic, that decision makers are accountable, and that equity and fairness informs policymaking as much as efficiency and value for money are key issues for public governance theorists.

International organizations have been attracted by the governance agenda. The 1999 Manila Declaration on Governance defined ‘good governance’ as a ‘system that is transparent, accountable, just, fair, democratic, participatory and responsive to people’s needs.’ The EU White Paper on governance proposed the following five principles of good governance: ‘openness, participation, accountability, effectiveness, and coherence.’ The UK Labour Government’s program for modernizing government incorporates many of the public governance concerns. The 1999 Cabinet Office White Paper, Modernising Government, and the subsequent documents and initiatives that followed, in particular the 1999 Cabinet Office report Professional Policy Making for the Twenty-first Century, suggested a model of ‘modern’ policymaking based upon nine ‘core competencies’: forward looking; outward looking; innovative, and creative; evidence-based; inclusive; joined up; uses evaluation; employs reviews; learns lessons (see http://www.policyhub.gov.uk).

As a result, there is now a growing concern among governments with using good evidence, developing crosscutting work among stakeholder organizations, opening up mechanisms for public participation, avoiding implementation failures, and using evaluations in policymaking.

Evidence-Based

When making public policy, especially when facing complicated problems, policymakers need to review the evidence of what works and how it works best. This includes an assessment of what impact different proposals will have on various situations. Research also helps identify and clarify the policy problems which require action.

Research should be conducted throughout the entire policy process, not only during the policy formulation and design stage, at which policymakers define what problems require action and search for how to solve them. Pilots are useful tools for testing whether a policy will work as planned. Process evaluations, conducted while the policy is being implemented, can help to quickly identify unforeseen obstacles and recommend immediate action.

To tackle wicked public health issues, it is especially important to improve the quality of health data. Health reporting is a crucial tool for identifying population needs and risks (Allin et al., 2004). The WHO has been promoting consistent approaches to collecting and analyzing noncommunicable disease risk factors to enable countries to set up compatible surveillance systems (WHO, 2002).

Although many governmental departments conduct research in-house, most of the time evidence comes from a variety of sources, ranging from different public organizations and private stakeholders to national and international groups. Researchers and policymakers need to evaluate the quality of the evidence they gather. This requires developing the analytical capacity of governments. To achieve this, governments have been setting up analytical units across departments and sharing information among local, national, and international organizations.

Cross-Cutting Work

Public health policy requires cross-sectoral interventions in areas such as housing, transport, education, and, of course, health care. To address this, governments are creating horizontal structures such as task forces, cross departmental bodies, and central–local partnerships to overcome institutional obstacles in order to better tackle cross-cutting issues.

In the UK, the Cabinet Office Social Exclusion Task Force, previously the Social Exclusion Unit, coordinates policy against social exclusion. Recognizing that health is often linked to other forms of exclusion, much of the task force work on critical health issues such as teenage pregnancy and health inequalities has sought to promote multi-agency, cross-departmental work.

The Public Health Agency of Canada has the same remit of providing leadership and promoting collaboration with provinces and territories on public health. The agency coordinates the efforts of federal and provincial governments, academia, and nongovernmental organizations to prevent chronic diseases; identify, prevent, and reduce public health risks; and respond to health crises.

At the same time, national governments also need to coordinate efforts with local authorities and other governments at the international level. Sweden provides a good example of how to promote synergies between the national and local levels of government in public health (Beaglehole and Bonita, 2004). Another example of good practice is the Australian National Public Health Partnership, set up in 1996 to coordinate public health initiatives between all levels of government in Australia (Allin et al., 2004). For Beaglehole and Bonita, ‘an ideal approach would combine strong and progressive national guidelines, appropriate legislation and inter-sectoral support, with local initiatives and responsibilities’ (Beaglehole and Bonita, 2004: 215–216).

Inclusive Policymaking

Citizens are no longer passive users of public services. They are increasingly aware of their rights to express their own views and needs, participate in the design of services, choose services according to their interests, and demand accountability over the quality of services. Policies should be developed in consultation with stakeholders who have a particular interest in them.

Democratic governance, especially at the local level, is crucial for health development. Best practice relevant for public health policy can be found in Uganda and in the Indian state of Kerala. The Ugandan Participatory Poverty Assessment Project brought together government and civil society groups in developing a comprehensive health plan (Oxfam, 2006). The 1996–2001 Kerala People’s Campaign for Decentralized Planning encouraged local democratic participation in producing projects according to the health needs of the people (Elamon et al., 2004).

Implementation

Good policy design has to consider whether the policy is workable, sufficient resources are at the disposal of implementers, and the timing is right, as well as how the success or failure of the policy is going to be measured. Consulting those with responsibility for implementing the policy during its design and development increases the chances of getting the policy content right and, therefore, making the policy successful.

Evaluation

Policymakers are increasingly acknowledging the usefulness of conducting evaluations of past public health interventions to inform policymaking. Traditionally, evaluation was considered to be the last and least important stage of the policy process to the extent that it was not considered part of it at all. Evaluation, however, is a key element, comprising early assessments, pilots, informal ‘feedback loops,’ and formal and systematic reviews of past or ongoing policies. This implies that provisions for evaluation need to be included at early stages of the policy process, ideally during policy formulation and design.

Australia provides an example of good practice of the use of economic evaluations of public health interventions, although, according to Allin et al. (2004), their outcomes are not systematically used for decision making.

Conclusion

Since the 1950s, both the responsibility of the state over public health and the way government has intervened in public health have been changing, and the policymaking process has become increasingly complex. Presently, most states retain an important role in promoting public health. The foreseeable future is that, facing continuous pressures ‘from above, from within, from below,’ the state and its executive branch will need to continue searching for tools for governing public health effectively and to develop new approaches for improving public health policymaking.

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