By Jitse P. van Dijk -  Assoc. Prof. Jitse P. van Dijk is Senior Lecturer and Researcher in Public Health, Department of Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, the Netherlands and Fellow at the Global Health Law Groningen Research Center, Faculty of Law, Groningen, the Netherlands

Organizing health might seem to be an easy task. Universities or other research institutes produce epidemiological data on health-risk behaviour such as smoking or negligent driving regarding NCDs, or produce forecasts on the likely future burden of various diseases or disabilities. These data then can be used to organize a country’s health system in such a way that it decreases the prevalence of risk-taking behaviour or disease or mortality due to NCDs, or at least ensures that the related risk factors are directly addressed with the outcome being a decrease in risk-taking behaviour and disease.

The situation is not always that simple. The general question that must be considered is whether problems with adapting health structures to the health needs of the population reflects the norm, with such problems being found in most countries. If this is true, the question of what is behind these policies, which seems rather irrational and unpredictable from an epidemiological point of view, might also arise.

Answers to these questions must address other issues such as agenda building and the decision-making processes of governments regarding NCDs. Political scientists have studied these topics, and their findings are relevant for health researchers who wonder why the government is not simply implementing the evidence-based policy upon which it has been advised.

Bachrach and Baratz 2, who were interested in discovering why there was such an enormous degree of poverty in a society as prosperous as the USA, developed an analytical model which helped them to understand this situation 3. They depicted the policymaking process as a kind of pipeline or tube containing four valves or barriers. All valves should be open for an issue to pass the pipeline fully. The first valve concerns community values, which permit or hinder an issue from coming onto the agenda at all. When the issue has reached this stage, it has to pass through the second valve, which consists of many kinds of procedures, committees and institutions which need to modify the issue to make it acceptable within the decision-making arena. The third valve is the decision-making process itself, while the fourth valve leads to the implementation process. All four valves can be open or closed. If the latter is the case the attempt to change a certain policy cannot succeed. In other words, an issue has to pass through all four valves successfully before a new policy will be successful, with one closed valve being enough to derail the intended policy. The issue will not be on the agenda for years.

All the valves in the model are operated by groups of people who are in favour of preserving the status quo and thus want to keep the valves closed, while other groups in favour of change want the valves to be opened and try to use their influence to achieve this. Opening the valves is only possible for a coalition of groups who at a certain moment have the same interests and are prepared to cooperate throughout the process. Getting an issue such as the use of seat belts onto the agenda is not enough, as the issue also has to pass through the policy formulation valve with a law on this issue being drafted. Such a law must then be passed by parliament, acting as the third valve, while the fourth valve refers to the implementation of the law and the monitoring of it by the police. In this example, health experts occupied the position of those who want change, while the car industry was most probably in favour of preserving the status quo. To make things more complex, in different countries these groups looked for different partners in an attempt to influence the valves of the model.

At this point, an observation by Lindblom might be quoted: “… democracy plays a cruel joke. It gives power to the citizen, but it also gives power to all other citizens” 4. As a consequence, when a fairly small group of health experts wants to change something in society, it is likely that it will encounter other groups reacting against the intended change. It is due to the organization of society what we estimate as the “least worse” option.

In such a society, epidemiological facts are just one of the determinants of health policy. Together with other conditions such as financial restraints and public or political support they form the mix from which a healthy policy is made. When one has high expectations of policy based on expert knowledge, in other words, when one is a “policy optimist” in the sense that after having published epidemiological data, one expects that the government will formulate policy in line with the outcomes of the research. However, those who have more realistic expectations of policy are aware of the fact that after producing the data much still has to be done to influence the health agenda, such as marketing the data and forming coalitions with partners who have the same aim. If we consider such activities as “not belonging to research” then we should not wonder why our very important epidemiological data is not converted into health policy.

Correspondence

Assoc. Prof. Jitse P van Dijk MD, PhD, MPH, LLM, MSc

Dept. Community and Occupational Medicine

University Medical Center Groningen

University of Groningen

Ant. Deusinglaan 1

9713 AV Groningen

The Netherlands

j.p.van.dijk umcg.nl

References

1 Van Dijk JP, Public health facts – why don’t they lead to healthy public policy? Int J Public Health 53 (2008) 121–122; DOI: 10.1007/s00038-008-0241-x and Van Dijk JP, Roma health – do we know enough? Int J Public Health 64 (2019) 647-648; DOI: 10.1007/s00038-019-01247-8 (both similar publications)

2 Bachrach P, Baratz MS. Two Faces of Power. American Political Science Review 1962, 56:947–52.

3 Bachrach P, Baratz MS. Power & Poverty: Theory & Practice. New York London Toronto 1970.

4 Lindblom CE. The policy-making process. NJ, Englewood Cliffs 1963.