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Role of Theory and Research in Policy Development in Health Care System

Abdulaziz Mohsen Alsufyani

Taif Comprehensive Rehabilitation Center, Ministry of Human Resources and Social Development, Saudi Arabia

Abstract: The implementation of actions for health is only possible by adequate policy development. There is a need to review the nature and development of policy in health political science gaze. Therefore, the present study aims to conduct a review on theory and researches to develop adequate policies in health care system. It provides a comprehensive review about the important theories with empirical research evidences for promoting health. The review analysis shows that it is important to understand the theory and approach behind policy development to recognize the incremental nature of aspects involved in policy development. The health political science insights need to be embraced in the light of public health and promotion of health. The present study has provided deep understanding about the structuring and implementation of health policies in health care systems in the light of theory and research.

Keywords: development, health care system, policy, public health, research, stakeholders, theory

Received March 02, 2020; Revised April 12, 2020; Accepted April 19, 2020

Citation: Abdulaziz Mohsen Alsufyani, Role of Theory and Research in Policy Development in Health Care System. American Journal of Public Health Research, 8 (2). 61-66. January 2020. doi:10.12691/ajphr-8-2-4

1. Introduction

The research and practice agendas have been welcoming system perspectives on population health development since 1980s. This was followed with the emergence of two traditions; tradition by McLeroy et al. [1] and Ottawa Charter for Health Promotion. McLeroy et al. [1] provided justification about the change in healthcare behavior as the result of complex association between high level of environmental determinants and policy conditions. Moreover, societies are enabled to make healthier choices by emphasizing development of supportive environment, reorientation of health services, along with making health public policies in the light of Ottawa Charter for Health Promotion.

Policy is considered as verdicts taken by a responsible person for a specific policy area [2]. Policies are either made at central level or local government level, in hospital or school, and in a local business of multinational company. In addition to this, public policies are mainly concerned with policies of government agencies. According to Dye [3], whatever government choose to do or prohibit constitutes to be public policy. Public policies are also made as the result of failure to decide or act on an issue of concern. For instance, legislative actions are taken for using child seats for young children in vehicles. However, policies covering public and private policies regarding health are constituted as health policies. The health policies have significant impact on organizations, services, and funding arrangements within a health care system. These policies are made in government as well as private sectors. Health policy analysts are increasingly interested in organizational actions towards the health system as health is significantly affected by external determinants of health care system [3].

The health policy triangle shown in Figure 1, provides basic structure to explore the issues in health policies and collected relevant information in a systematic way. The intertwined actors and processors make it difficult to draw out the inter-relationships. The policy triangle includes common factors that either impede or enable interactions between different variables (including content, actors, processes as well as context);

• Content – promote (good quality research) or constraint (unrealistic recommendations) relationships.

• Actors – factors that impede (lack of technical background among policy makers) or enable (agreement on priority issues) relationships.

• Processes – involves events and other communication channels to intervene for either impeding or promoting the use of research.

• Context – constraints (centralizing information and power) or enables (state stability) the ability of research to influence policy.

However, there is appreciation for the capacity to develop and assess policy processes to promote health across jurisdictions. Policy competencies are defined as set of skills, awareness, and knowledge among the individuals regarding the processes of policy making that enable them to act effectively in a policy making situation. It helps in evaluating efficiency of public policies based on the economic situation and identify failures in the market place related to health care and other heath related activities. According to Australian Health Promotion Association’s Core Competencies for Health Promotion Practitioners [4];

“an entry level health promotion practitioner is able to demonstrate knowledge of: health promotion strategies to promote health—health education, advocacy, lobbying, media campaigns, community development processes, policy development, legislation.”

Figure 1. Health policy triangle

In a health care system, there are many decisions related to health that go beyond the provided treatment. For instance, there is significant impact of physical environment, poverty, and education in the health status of individuals. Therefore, it is believed that policies have significant impact on health of individuals, for instance, the increase in taxes on cigarette and sweetened beverages in Saudi Arabia might alter the behavior of individuals in Saudi community. It is important to understand the association between health and health policies to tackle the major health related problems. Therefore, the present study aims to explain the role of developing theory and research within the health care system.

The research concerning the health policy and the systems is found to generally been descriptive rather than explanatory [5]. Various researches have emphasized that the recommendation on the health security policy generally lacks the theoretical foundation. This makes the provided suggestions incoherent, which are difficult to be integrated in to the health policy as well as strategies [5]. Likewise, some scholars argue that there lacks a theoretical foundation concerning the global health, which helps generate the durable as well as intellectual models to determine, evaluate and assess the problems of healthcare in different contexts, introduce different educational interventions for the practitioners, as well as predict future situations [6]. The understanding concerning such models is likely to help in the development of humanitarian and social sciences for developing interdisciplinary research that assesses the process of policy development focused on global health research and policy development [7].

The finding is likely to help improve reflexivity of the institutes and individuals concerning their present position in the global health discipline [8]. Earlier research has shown tremendous increase in the social-scientific research concerning the power and the politics in the global health [7,9,10,11]. Despite it, there continues to exist a gap related to the expanding of scope as well as profile of such inquiries. For instance, the research of Gomez [9] highlight that the political science discipline needs to seriously assess the global health issues, whereas the community of the global health needs to adapt similar strategy for the political science, particularly issues that concern the institutional design and governance. Thereby, the research concerning the power and the politics needs to be more integrated in the social science and health research communities, which is of substantial importance. The findings of this review are likely to assists in the deployment of the political science approach, and implementing collective decisions. The research findings are likely to depict how the interdisciplinary approaches add to the study of policy development, and identify the mechanism related to the policy development and system.

2. Policy Development

The understanding of the policy in the healthcare discipline requires the understanding of the development process related to policy development. This development process is significantly integral for the impact which the policy intends to have along with the health formulated objectives. The theoretical process application enables the appreciation for the range of stakeholders and policy choice determinants. The policy development, according to Mackenbach [12] study, is mainly related to further development of political epidemiology’ which help identify the political variables (structures, processes, outputs) and causal effects concerning population health. For the development of the policies, different political science tools have been introduced by the scholars which helps in the framing of the policy process as well as the political variables used [5]. Previously, the theories that have been deployed for its improvement include the policy stability in the long run, with some alternations and general shifts in the policy development perspective. The translation of decisions to government policies is carried on in 4 steps, i.e., setting agenda, legislating and regulating, implementation, and evaluation [13];

• Setting agenda – relates to identification of societal problem and presenting it to the government.

• Legislating and regulating – responsible for providing formal responses for a problem.

• Implementation – policy execution to achieve desired goals.

• Evaluation – providing appraisal to policy performance and adequate program outcomes.

In general, it can be stated that a problem is presented to the government after occurrence of series of activities that might result in direct action from the government to resolve the issue instantly. Considering the health care system, it is not necessary that the process of policy development is sequential or logical. The linear perspectives of the stages help in defining the purpose to organize the thoughts and concepts associated with policy development. The professionals in healthcare system need to understand the significance of being aware about the components and functions of process, even before the process itself is studied.

2.1 Process of Policy Development

The processing of policy is integral across the world. The relatedness of the policy process with the healthcare sector holds substantial significance given its impact on the health of the patients as well as the services provided by the professionals. Generally, this process can take several months to develop, test and implemented. Not only this, the process entails different procedures related to the practitioner to undergo substantial consultation, research, as well as writing. Similarly, this process must also be considerate to the individuals who are likely to perform this task. The questions such as what task is to be performed, who is likely to perform this task, and when it is to be performed.

Stage heuristic is known as the commonest approach towards understanding the policy development processes. Different stages involved in policy development are explained in Table 1 [2]. The table denotes the four stages, i.e., identifying problem and recognizing issues, formation of policy, implementation of policy, and evaluation of policy.

Table 1. Stages of policy development

Health policies play an important role in identifying courses of action to counter with the social problems, when the intent of public policy is to affect health care. The development of policies take place within a dynamic environment, along with complex policy making processes [14]. In general, there are few barriers for applying theories of policy process within health care system. One of the barriers is that training to healthcare professionals is provided in political science and they are not willing to get into the field of health education to promote health.

The theory by Lewin [15] states that individuals’ behavior concentrating on factors such as; roles, norms, interaction, and socialization processes mainly focus on the changes and alterations. This is appropriate for organizations that are based on small units, with traditional top-down. The steps in cycle of policy development are rarely with feedback loops between sequential stages or sequential to counter either clockwise or counter-clockwise sections of the cycle. However, based on the theory by Lewin [15], we suggested a roadmap for developing a policy in health organization. This roadmap informs the policy maker where she/he are going and how to reach her/his ultimate change. It comprises ten sequential steps and two questions in between with feedback loops. These questions determine the advancement of the process. If one question is not well addressed, it is necessary to get back to revamp some steps. Figure 2 demonstrates all the steps involved in policy development roadmap as follows:

• Identify and analyze the problem.

• Identify policy actors and resources.

• Develop objectives & goals of policy making.

• Communicate the objective & goals with policy actors.

• Involve policy actors in writing or revising the policy.

• Communicate the policy clearly and widely.

• Implement the policy in several stages.

• Establish feedback system.

• Evaluate the policy regularly.

Celebrate successes and disseminate outcomes if policy is proved to be effective.

Figure 2. Framework for policy development

3. Role of Theory and Research in Policy Development

Adequate understanding about the development process is required while studying the policy making in health care systems to highlight its impact on the framed health objectives. Appreciation from the stakeholders and determinants of policy choice is enabled by applying theories of policy process. Further development of epidemiology of policy was done by Mackenbach [12] by classifying casual effects of political variables including; outputs, structures, and processes on the health of a population. These political variables are framed in the presence of powerful toolbox of theories to make policies that are developed by political sciences [16,17,18,19]. Some of the tried and tested theories associated with policy development are highlighted in Table 2. The name of the theories includes multiple streams theory, punctuated equilibrium framework, advocacy coalition framework, policy domains, and social movement theory.

Table 2. Theories associated with policy development

The relevance of political science theory to study public policy and change in public policy range between hybrid approaches and address specific processes like coalition structuring [20]. It is important to explore the body of theories associated with policy process to make in-roads with health education research and health promotion [3]. Birckmayer and Weiss [25] proposed Theory-Based Evaluation approach to extend the significance of rigorous application of theory to solve social problems. The theory also provides key principle to promote health, along with development and evaluation of health education. Gonzalez and Glantz [26] authored a policy issue, which was examined without adequate application policy process theories. The study by Gonzalez and Glantz [26] presented a case study about policy failure in Netherlands, which is cosigner of Framework Convention on Tobacco Control and has also passed comprehensive legislation that regulates all aspects of MPOWER strategy;

M - Monitor tobacco use and prevention policies

P - Protect people from tobacco smoke

O - Offer help to quit tobacco use

W - Warn about the dangers of tobacco

E - Enforce bans on tobacco advertising, promotion, and sponsorship

R - Raise taxes on tobacco

It is assumed that the phenomenon under study explicit and select an adequate theoretical framework in a theory-based policy evaluation approach. The authors and professional visualize that policies are made and implemented as a blame for an issue; while, application of political science theory claims for the identification of association between Mackenbach’s [12] policy implementation outputs, structures, and processes. The multi-level governance perspectives of Hill and Hupe [27] stated that implementation is observed as a failure due to breakdown of governance arrangements between different policy sectors and levels. Careful operationalization of variables, rather than random selection of informants and media expressions is possible based on the model proposed by Mazmanian and Sabatier (Figure 3) [28]. This helped in identifying and managing policy related problems to take measures for implementing and evaluating facilitators and barriers beyond the control of government. It is expected that carefully crafted methodology with quantitative and qualitative approaches would produce evidence-based courses of action for policy entrepreneurs.

Figure 3. Policy implementation framework

However, there is crossing between specification of policy alternatives and selection of policy interventions. Policy implementation may be considered as a real-life example. There are a wide range of contextual factors (such as shifting power relations) to drive the process of policy implementation. The stakeholders within the system are aware about the development of implementation strategies; although, the policy related problems are highly debated. Only certain interventions are favored, no matter how analytical and planned the policy processes are in its earlier stages. A rule named ‘least coercion rule’ was formulated by Bemelmans-Videc et al. [29] in which policy makers had to select an intervention that is least invasive in the choices made by individuals within a specific population. Therefore, the outcome of implementing terms favors communicative intervention over facilitative intervention, despite of following policy planning process meticulously.

4. Conclusion

There is need to apply a systematic and theory driven approach to determine the effectiveness of policy development in health care systems. The present study has provided profound insights about the theories associated with the process of policy development. The failure of success of policy initiatives are described in the light of various perspectives that transcends the current tradition followed. The process involved in policy development need to be negotiable between the stakeholders. However, in reality, the process should be based on theories from social sciences, specifically political science. Development of a policy relates with health-related problem or issue. The capacity to bring about far-reaching change is considered an effective option, as the policy is not a panacea for all the problems prevailing within a community. Policy development involves people and ownership is given to them over the issues affecting them, despite of the inherent challenges. Power to act on the health-related issues depends on people having strong commitment towards improving quality of life, rather than just the decision makers. Further development of health care system demands conscientious and transparent approach to determine what policy is. However, this approach is possible as decision makers themselves are intentionally ambiguous about what they pursue. The study suggests that public health policy analysts are responsible for exposing efforts to obscure he strictures of policy development.

5. Recommendation

Based on the findings of this study, it is presented that practitioners should invest their time to evaluate and research different policies to derive the one which ensures the best results. Similarly, the practitioners who are likely to follow these must be made aware of its significance, and importance concerning their operations. Not only this, the health-related laws should be considered along with the regulations that are followed at the place, where these are being delayed. The practices should also be based on the evidence-based research.

Initially, health promotion experts and scholars would have to discard the models that are used for conceptualizing the developmental phase, precisely at the micro level. However, they must fully embrace the challenges and the complexity involved in the policy change process as well as the procedural requirements that follow it. Secondly, there is a need to provide training platforms in health promotion and public health that are more precisely based on the comprehensive policy viewpoints for training and credentials. The accreditation bodies have a major role to play in embracing and implementing such viewpoints. Third, there is a need to fix the funding framework for effective health policy studies. For example in Australia, the Nutbeam Review of the funding criteria for health research concluded that ‘existing arrangements do not provide adaptability in response to the prospects to examine and/or asses the amendments made to government policy’ and a need for research that ‘supports partnerships between researchers and health agencies, especially in the development of intervention research, and the development and evaluation of health policy’ [30].

Undoubtedly this challenge is simply not exceptional for Australia and must be tackled around the globe by the other research bodies as well. Fourthly, to represent the wide variety of political systems experienced across the globe, new theories of the policy procedure need to be constructed. With no exclusion, the authoritative principles that are listed here, most of them were demonstrated by the democratic governance structure in the Western style. Therefore, it may convey a little logical connection to the important parts of the world population. There is a crucial need that attempts should be made for modelling other democratic systems and to recognize the change in policy made under strict establishments is far more strenuous.

Fifth and even more significantly, the political theoreticians have a role to perform which is to communicate the importance and benefits of their work in a better way to apprentices, researchers, legislators and bureaucrats. Commonly, detestation can be seen due to the theory being mainly suppositious, hard to understand and unvaried. Based on the findings of the research, it is suggested that future studies must focus on the theory-driven examination outcomes, which help in drawing concrete conclusions for policy reform. If these improvements are not made health promotion policy research would not be sufficient enough to provide much aid to the researchers that are working to make a change in the policy procedure. Also, this would restrict the advancement of the recent models in the healthcare sector. Thereby, based on the review presented, health promotion needs to be practical and must initiate plans to turn words into actions and start taking initiatives — which more often than not means addressing the shocking and great discrepancy in health and wealth at the political level. Thus, it is absurd to believe that this can be done without a proper analytical approach

Acknowledgements

The author is thankful to all the associated personnel, who contributed for this study by any means. Moreover, the author declares no competing interest, and the study is not funded through any source.

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