Australian politicians and policy makers still struggle to understand how to translate growing evidence around the social determinants of health into policy action. Researchers Dr Gemma Carey and Brad Crammond have interviewed a range of politicians, senior past and present bureaucrats, government advisors and lobbyists to explore why and how that can be shifted. Their report, to be released next week, looks at how current SDOH advocacy is out of step with the ‘structural and discursive’ dimensions of the policy process and where better opportunities might be, including not shying away from engaging in more and ideological debate.
Dr Gemma Carey and Brad Crammond write:
When it comes to the social determinants of health, scientists say the evidence is in: the distribution of social goods like income, education and occupation are key drivers of health and health inequalities. The challenge for social determinants of health researchers and advocates is no longer collecting evidence, it’s translating this evidence into policy change.
However, as Carole Claiver and Evelyne de Leeuw have argued in their recent book on health promotion and policy change, the “complex and shifting rationalities of public policy-making still largely elude (us)”.
Getting to grips with the policy process, it seems, is the next crucial step for those concerned with the social determinants of health.
Recently, we took up this challenge, interviewing a range of politicians, senior past and present bureaucrats, government advisors and lobbyists. We viewed these individuals as practitioners of ‘the art of government’, who could explain the policy process and how they traverse and negotiate it. From this, we built a picture of the policy process, as it relates to the social determinants of health, from a range of different vantage points, giving us insight into how to further action on the social determinants of health.
The findings form the basis of our report Taking action on the social determinants of health: Insights from politicians, policymakers and lobbyists, to be launched at the Social Determinants of Health Alliance Research Forum, in Canberra on July 14.
The report draws attention to the ways in which current policies and advocacy efforts to equalise the distribution of the social determinants of health are out of step with what we call the ‘structural and discursive’ dimensions of the policy process.
Put simply, governments are ‘structured’ in particular ways that help them to do the essential job of ‘governing’ the population. Government is broken down into departments, which manage different aspects of our lives. These departments are presided over by ministers, who are elected on a four-term basis to represent our interests. These structures make the enormous task of governing a population possible.
While necessary, these structures create certain conventions for how social problems (and potential solutions) are described and explained (the ‘discursive dimensions’ of policymaking). In short, they need to be amenable to resolution by and within these structures. This means that problems like the ‘social determinants of health’ that are diffuse, complex and cross over many – if not all – departments of government, are unlikely to gain traction. Instead, they are dismissed as too difficult and risky for governments to tackle.
For the social determinants of health, these structures of government mean that advocates must break down problems and solutions into more manageable initiatives, which can be tackled by one or two departments.
While bodies like the World Health Organisation have argued for more widespread ‘whole-of-government change’, this type of change was described by participants in our research as beyond government’s sense of its own capacity.
Although we recognise that widespread change is necessary, based on our findings, securing such change requires a more strategic approach: an approach that begins with small-scale, solutions-focused interventions that can secure early success. This, in turn, will open doors for researchers and advocates and provide them with a more influential seat within policy agenda setting and decision-making processes.
We also found that advocates and researchers should not shy away from engaging in more and ideological debate. While objective ‘evidence-based’ approaches have been all the rage in recent years, they are (again) out of step with the discursive conventions of policymaking. Moral, ethical and ideological arguments sit at the core of political debate and public policy. For example, winning an election requires politicians to present a vision of the future. To do this, they engage in moral and ethical reasoning. Lets take an excerpt from the Prime Minister’s book, A strong Australia: the values, directions and policy priorities of the next Coalition Government:
You cannot have stronger communities without a stronger economy to sustain them and you cannot have a stronger economy without stronger, more profitable businesses. My basic message to Australians today is that securing our future depends more on strong citizens than on big government.
Here, Tony Abbott paints a picture of ‘reality’, where small government and free markets create happy and prosperous communities. The policy response to this is to do away with government structures and policies that ‘get in the way’ of communities.
These moral arguments over what is needed to create a stronger future for Australia, used to persuade us of a particular course of policy action, are part of the context of policymaking. To disengage with these is to disengage with the basis upon which political and policy arguments are fought and won.
In our report, we provide guidelines for researchers and advocates interested in securing up-stream change, to help negotiate the structural realities and discursive conventions of policymaking.
Work within the political and policy structures
- Scale of the problem needs to fit within the remit of specific departments.
- Political commitment is often best gained through building community demand for change.
Pay closer attention to discursive traditions
- Linear evidence-based policy approaches should be abandoned in favour of a more dialogic approach that embraces philosophical and moral reasoning (alongside evidence).
- The scale of the proposed solutions cannot greatly exceed government’s sense of its capacity to act. Larger, structural reform requires slow and strategic introduction via community building and trusted advisors.
Dr Gemma Carey is a Research Fellow at the National Centre for Epidemiology and Population Health at the Australian National University.
Brad Crammond Brad is a lecturer and PhD student at the Centre for Epidemiology and Preventive Medicine at Monash University.