annual meeting of the carmen observatory on chronic non-communicable disease policy: “mobilizing...

Annual Meeting of the Annual Meeting of the CARMEN Observatory on CARMEN Observatory on

Chronic Non-Communicable Disease Policy: “Mobilizing for Chronic Non-Communicable Disease Policy: “Mobilizing for Action” Action”

May 12-13, 2008May 12-13, 2008Hilton Montreal Bonaventure HotelHilton Montreal Bonaventure Hotel

Cristina Puentes-MarkidesCristina Puentes-MarkidesPublic Policy, Regulation and Health FinancingPublic Policy, Regulation and Health Financing

Area of Strengthening Health Systems and ServicesArea of Strengthening Health Systems and ServicesPAHPAHO/WHOO/WHO

MAKING THE CASE: The Power of Policy MAKING THE CASE: The Power of Policy ArgumentsArguments

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Policy Decisions ….Policy Decisions ….

• Policy requires decisionsPolicy requires decisions• Decisions require at least:Decisions require at least:

Facts and anticipated consequencesFacts and anticipated consequences About values, what matters, priorities and preferences.About values, what matters, priorities and preferences. A process to integrate facts and values in analysis and A process to integrate facts and values in analysis and

constructive deliberation. (NRC, 1996)constructive deliberation. (NRC, 1996) Yet,Yet,

Policy problems are “wicked” / “ ill-defined”Policy problems are “wicked” / “ ill-defined” Scientific evidence/data are insufficient to generate action.Scientific evidence/data are insufficient to generate action. Beliefs, ideology, interests often drive public policymaking.Beliefs, ideology, interests often drive public policymaking. Often too much data, too little wisdom. Often too much data, too little wisdom.


Argumentation in Public PolicyArgumentation in Public Policy

For individual positionsFor individual positionsIn public deliberationIn public deliberationIn practical politics.In practical politics.Can be useful at various stages of the policy processCan be useful at various stages of the policy process When positions are being taken or developedWhen positions are being taken or developed When positions are declared and agendas setWhen positions are declared and agendas set When a decision is being made.When a decision is being made.


Argumentation in Public PolicyArgumentation in Public Policy

Not equivalent to a quarrelNot equivalent to a quarrel Not equivalent to proofNot equivalent to proof Prominent role of communication, deliberation and dialogue Prominent role of communication, deliberation and dialogue Policy argumentPolicy argument

Not to prove or disproveNot to prove or disprove Not only to argue for or againstNot only to argue for or against To support a claim of what needs to be doneTo support a claim of what needs to be done

An effective policy argument must assume, assert the facts, An effective policy argument must assume, assert the facts,

definition, interpretations, assumptions, value, consequencesdefinition, interpretations, assumptions, value, consequences

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Knowledge Approaches Needed in Policymaking Knowledge Approaches Needed in Policymaking

Episteme: “what is objectively true” Episteme: “what is objectively true” Universals, objective, repeatable rules, codified, corresponds to modern Universals, objective, repeatable rules, codified, corresponds to modern scientific ideal, achieved with the aid of analytical rationality. scientific ideal, achieved with the aid of analytical rationality.

Techne: “what works in place.”Techne: “what works in place.”Concrete, pragmatic, variable and context dependent, arts/craft, capability, tacit Concrete, pragmatic, variable and context dependent, arts/craft, capability, tacit knowledge.knowledge.

Phronesis: Phronesis: “‘where are we going?; is it desirable?; what must be done? what“‘where are we going?; is it desirable?; what must be done? what should we do” should we do”

Pragmatic, variable, context dependent, requires consideration, judgment, Pragmatic, variable, context dependent, requires consideration, judgment, choice, experience, emotional intelligence. choice, experience, emotional intelligence.

Metis:Metis: savvy, cunning, street smart. Great politicians and leaders have it.savvy, cunning, street smart. Great politicians and leaders have it.

Tim Tenbensel . The role of evidence in policy: how the mix matters. School of Population Health Tim Tenbensel . The role of evidence in policy: how the mix matters. School of Population Health University of Auckland Panel Track: 4) Evidence Based Policy University of Auckland Panel Track: 4) Evidence Based Policy


Perceptions and FramingPerceptions and Framing

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Perceptions about chronic diseasesPerceptions about chronic diseases

Gerard F. Anderson. Physician, Public, and Policymaker Perspectives on Chronic Gerard F. Anderson. Physician, Public, and Policymaker Perspectives on Chronic Conditions. Conditions. Arch Intern MedArch Intern Med. 2003;163(4):437-442. . 2003;163(4):437-442.


Obesity ExampleObesity ExampleGroupsGroups Obesity Obesity

FramesFramesMeaningMeaning Policy ArgumentPolicy Argument

Antiobesity Antiobesity researchersresearchers

As illnessAs illnessAs risky behaviorAs risky behaviorThreat Threat

• Obligation of the sick to seek Obligation of the sick to seek treatment.treatment.

• Fat people are too lazy or Fat people are too lazy or self-indulgent to manage self-indulgent to manage weight.weight.

• Risky behaviors (overeating Risky behaviors (overeating and inactivity) are immoral. and inactivity) are immoral.

• Fat bodies evidence Fat bodies evidence preventable illness and preventable illness and moral failings.moral failings.

• Epidemic (works an emotionally Epidemic (works an emotionally charged metaphor.)charged metaphor.)

• Eating disorders and weight Eating disorders and weight obsession concerns mostly upper-obsession concerns mostly upper-middle-class women and girls. middle-class women and girls. Neglecting obesity is a form of Neglecting obesity is a form of class bias.class bias.

Antiobesity Antiobesity activistsactivists

Fat Fat acceptance acceptance researchersresearchers

Body diversityBody diversityHuman rightsHuman rights

• Fatness is a natural and Fatness is a natural and largely inevitable form of largely inevitable form of diversity.diversity.

• Focus on weight is Focus on weight is counterproductive.counterproductive.

• Higher weights are as risky Higher weights are as risky as smokingas smoking

• Body weight is not a reliable Body weight is not a reliable indicator of one’s diet or physical indicator of one’s diet or physical activity.activity.

• Obsession with obesity stigmatizes Obsession with obesity stigmatizes fat bodies and neglects dangerous fat bodies and neglects dangerous weight loss and inadequate health weight loss and inadequate health care.care.

• Weight obsession is hazardous to Weight obsession is hazardous to your health.your health.

Fat Fat acceptance acceptance activistsactivists

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Framing: How to analyze who is blamed and burdened in Framing: How to analyze who is blamed and burdened in public debatepublic debate

Public DiscoursePublic Discourse

Individualizing FramesIndividualizing Frames Systemic FramesSystemic Frames

Burden to powerful groupsBurden to powerful groups

Involuntary, universal, Involuntary, universal, environmental, environmental, knowingly created riskknowingly created risk

BiologicalBiologicalBehavioral factorsBehavioral factors

Causes limited to particular individualsCauses limited to particular individualsLimits governmental responsibility for Limits governmental responsibility for addressing it.addressing it.

Responsibility falls on government., business, Responsibility falls on government., business, larger forces.larger forces.Invite governmental actionInvite governmental action

Interpreted from Lawrence, Regina G. Framing Obesity: The Evolution of News Discourse on a Public Health Issue. Interpreted from Lawrence, Regina G. Framing Obesity: The Evolution of News Discourse on a Public Health Issue. The The International Journal of Press/Politics International Journal of Press/Politics 2004; 9; 562004; 9; 56

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Agenda and Agenda-SettingAgenda and Agenda-Setting

• Political, conflictive, competitive among issue proponentsPolitical, conflictive, competitive among issue proponents• Contingent on ability to influence, power and position of groups, Contingent on ability to influence, power and position of groups,

preferences of decision-makers.preferences of decision-makers.• Almost unlimited number of issues, some don’t make it.Almost unlimited number of issues, some don’t make it.

AgendaAgenda““The list of subjects or problems to which government officials, The list of subjects or problems to which government officials,

and people outside of government closely associated with and people outside of government closely associated with those officials, are paying some serious attention at any those officials, are paying some serious attention at any given time … given time …

the agenda setting processthe agenda setting process narrows [a] set of conceivable narrows [a] set of conceivable subjects to the set that actually becomes the focus of subjects to the set that actually becomes the focus of attention.” attention.” Kingdon’s 1984:3Kingdon’s 1984:3

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PROBLEM STREAMPROBLEM STREAMIndicators, events, Indicators, events, definitions, values, definitions, values,

collective action. collective action. Policy Policy entrepreneursentrepreneurs aware of aware of

the problem.the problem.

POLICY STREAMPOLICY STREAMAlternativesAlternatives, solutions, , solutions, policy communities, policy communities, feasibilities. Hidden cluster feasibilities. Hidden cluster of participants dominate.of participants dominate.

POLITICAL POLITICAL STREAMSTREAM

National mood, public National mood, public opinion, electoral politics, opinion, electoral politics,

consensus building, consensus building, Visible cluster of Visible cluster of

participants dominate.participants dominate.

Streams Streams

are are

coupledcoupled

Window of OpportunityWindow of Opportunity(predictable, unpredictable)(predictable, unpredictable)

Kingdon’s Agenda Setting ModelKingdon’s Agenda Setting Model

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Policy EntrepreneurPolicy Entrepreneur

Analogy of a surfer, waiting on the board to catch the wave: Analogy of a surfer, waiting on the board to catch the wave:

“ “They bring several key resources They bring several key resources into the fray: their claims to a into the fray: their claims to a hearing, their political connection hearing, their political connection and negotiating skills, and their and negotiating skills, and their sheer persistence. Items’ chances sheer persistence. Items’ chances of moving up on an agenda are of moving up on an agenda are enhanced considerably by the enhanced considerably by the presence of a skilful presence of a skilful entrepreneur.” (Kingdon, 1995)entrepreneur.” (Kingdon, 1995)

Source: ODISource: ODI 1313

Policy entrepreneursPolicy entrepreneurs

StorytellersStorytellers

EngineersEngineers

NetworkersNetworkers

FixersFixers

Practitioners, bureaucrats Practitioners, bureaucrats and policy-makers often and policy-makers often articulate and make sense of articulate and make sense of complex realities through complex realities through simple stories. Sometimes simple stories. Sometimes misleading, yet their misleading, yet their narratives are very powerful.narratives are very powerful.

Policy-making usually takes place Policy-making usually takes place within communities of people who within communities of people who know each other and interact. If you know each other and interact. If you want to influence policymakers, you want to influence policymakers, you need to join their networks.need to join their networks.

Often, a huge gap between what Often, a huge gap between what politicians and policy-makers politicians and policy-makers say they are doing and what say they are doing and what actually happens. Researchers/ actually happens. Researchers/ analysts need to work not just analysts need to work not just with the senior level policy-with the senior level policy-makers, but also with the 'street-makers, but also with the 'street-level bureaucrats'.level bureaucrats'.

Policy making is essentially a political Policy making is essentially a political process. You don’t need to be a process. You don’t need to be a Machiavelli, but successful policy Machiavelli, but successful policy entrepreneurs need to know how to entrepreneurs need to know how to operate in a political environment - operate in a political environment - when to make your pitch, to whom when to make your pitch, to whom and how.and how.

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A successful argument depends partly onA successful argument depends partly on

Recognizing how the policy/political climate shapes effectiveness.Recognizing how the policy/political climate shapes effectiveness.Recognizing frames, perceptions.Recognizing frames, perceptions.Awareness of complexity and potential tensionsAwareness of complexity and potential tensionsRecognizing and taking advantage of policy windows.Recognizing and taking advantage of policy windows.A policy entrepreneur, someone willing to invest time and energy A policy entrepreneur, someone willing to invest time and energy for policy changefor policy changeAbility to integrate different types of knowledge (episteme, logos, Ability to integrate different types of knowledge (episteme, logos, techne) for policy relevance.techne) for policy relevance.Power, positionPower, positionReputation, prestige, political clout, credibility (ethos), ability to Reputation, prestige, political clout, credibility (ethos), ability to appeal to the emotions of the audience (pathos) and ability to appeal to the emotions of the audience (pathos) and ability to present good reasons/logic (logos).present good reasons/logic (logos).

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1.1. Currently, are chronic diseases (as a package Currently, are chronic diseases (as a package or specific diseases/conditions) issues in the or specific diseases/conditions) issues in the policy agenda of your government?policy agenda of your government?

2.2. Can you identify the policy frames used?Can you identify the policy frames used?3.3. What was the policy window (the coupling of What was the policy window (the coupling of

the problem, the solutions, the political climate) the problem, the solutions, the political climate) that made it possible?that made it possible?

4.4. If they are not in the policy agenda, in your view If they are not in the policy agenda, in your view what can you do as a policy entrepreneur to what can you do as a policy entrepreneur to help it happen?help it happen?

annual meeting of the carmen observatory on chronic non-communicable disease policy: “mobilizing...

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