Lecture 9 - Agenda Setting and Policy Change

Question 1

What are some factors that shape agenda-setting?

Answer 1

• who shapes the debate; who are the stakeholders, who has power/authority/legitimacy?
• how are issues defined?
• how are solutions judged?
• who controls access to the agenda?
• how are priorities determined?

Question 2

What are policy entrepreneurs?

Answer 2

People who are well placed in systems and can push items on and off the agenda

Question 3

How can the media influence what gets on the agenda?

Answer 3

Can frame narratives and draw attention to particular issues.

Can determine the way an issue/politician/policy/event is understood by the. The public can then take action by voting.

If there are regulatory standards in place about providing truthful information, the media can act like civil society.

When media is concentrated in a few number of countries it may not show public interest, only corporate interest

Human cognitive bias drives engagement with content reaffirming existing beliefs

Question 4

What are focusing events/tipping points?

Answer 4

Disasters, scandals and popular attention can generate shocks in the system, resulting in change

Question 5

How do ideas, interests and institutions influence the agenda of policies? (Fox and Reich, 2015)

Answer 5

Ideas: affect how the problem/solution is conveyed

Interests: influence which issues get on the agenda through strategic advocacy

Institution: Influence stakeholders’ perceptions of what is possible to achieve

Question 6

How do ideas, interests and institutions influence the design of policies? (Fox and Reich, 2015)

Answer 6

Ideas: determine what policy designs are socially acceptable

Interests: determine which designs are acceptable to different stakeholders

Institution: establish which designs are feasible given existing institutions

Question 7

How do ideas, interests and institutions influence the adoption of policies? (Fox and Reich, 2015)

Answer 7

Ideas: influence which policies are fashionable and are thus more likely to get adopted

Interests: influence decision makers through lobbying and other forms of influence

Institutions: influence whether legislation is passed or amendments are made through veto points/players

Question 8

How do ideas, interests and institutions influence the implementation of policies? (Fox and Reich, 2015)

Answer 8

Ideas: can influence implementers if the policy solution violates deeply held beliefs or undermines their power

Interests: creates new opportunities to oppose/shape reform during implementation

Institution: can foster support and government spending through specific institutions

Question 9

What are the 3 agenda setting processes?

Answer 9

1. Staged approach
2. Incrementalism
3. Dynamic models (e.g. John Kingdon’s policy streams)

Question 10

Explain the staged approach of policy change.

Answer 10

A staged approach is a simplified process of agenda setting.

First the problem is identified, then solutions are generated, and then a choice is made.

Question 11

What are the arguments against a staged approach?

Answer 11

• Critics argue that this approach is oversimplified as decision-making is a messy process, not a rational cost-benefit analysis.
• Agenda setting also does not have to follow these 3 steps from start to finish as issues can arise at any stage, for example solutions which chase problems.

Question 12

Explain the incrementalism approach to policy change.

Answer 12

• Emphasizes small, gradual changes to existing policies rather than large-scale comprehensive reform.
• Decisions are often based on past practices rather than starting from scratch.
• This approach is often associated with a pragmatic and realistic view of policy making.

Question 13

Apply the staged approach of policy change to the case study of reducing smoking via vaping.

Answer 13

Under a staged approach the government would identify smoking as having negative impacts on public health.

Various solutions are then brainstormed such as raising taxes, increasing the size of warning labels, public health campaigns, banning cigarettes or helping people transition to vaping (considered a safer alternative to smoking).

Finally, one intervention is chosen and implemented.

Question 14

What are some challenges associated with the incrementalism approach to agenda setting?

Answer 14

• While this may be a more pragmatic approach to agenda setting, large scale change is sometimes needed.
• This approach may also lead to perpetuation of historical issues or favour a powerful stakeholder group.

Question 15

Apply the incrementalism model of policy change to the case study of reducing smoking via vaping.

Answer 15

• The UK government has set a goal to make the UK “smoke free” by 2030. This means that adult smoking prevalence will be 5% or less.
• To do so, the government intends to establish numerous smaller interventions to reduce smoking in the UK population.
• Firstly, e-cigarettes will be promoted as a less-harmful alternative to smoking in public health campaigns.
• Secondly, local authorities will provide free e-cigarettes to smokers via their “Swap to Stop” initiative.
• Finally, the Tobacco and Related Products Regulations (TRPR) as well as the Committee of Advertising Practice (CAP) regulations to include government-approved inserts in cigarette packages which promote e-cigarettes.
• Through these smaller incremental initiatives which build on existing regulations, the government hopes to stop adults from smoking.

Question 16

What is the dynamic model(s) of policy change?

Answer 16

• Dynamic models of the policy process emphasise the complex and ever-changing nature of policy development and implementation.
• They recognise the dynamic nature of various factors which influence policy including social, economic and political changes.
• Policy change occurs over time from shifting processes.

Question 17

What are the limtiations of dynamic models of policy change?

Answer 17

• limited predictive power due to the unpredictable nature of the political environment
• streams can be hard to define and analysis in isolation since they are so independent (e.g. political will can influence problemetisations)

Question 18

Explain John Kingdon’s ‘policy streams’

Answer 18

1984
A type of dynamic model of policy change

• Kingdon’s 3 streams approach proposes that problems, policies and politics change independently and policy change occurs when all three “streams” intersect (COUPLE) at a specific point in time.
• This intersection creates a “policy window” during which the likelihood of a particular issue gaining attention and being adopted as policy is significantly increased.
• In addition to the streams, Kingdon defines policy entrepreneurs as individuals or groups who actively work to promote specific policy ideas and solutions. They can open the window by moving streams such as convincing officials to see the problem they want it to be seen.

The problem stream
- Involves the recognition of a problem through evidence, focusing events, or new conceptualisations.
- Identifying the problem means that policymakers perceive the issue as requiring attention or action.
- Problems often gain attention and hence get on the agenda when they are framed in a way that resonates with policymakers and the public.

The policy stream
- Involves policy proposals to deal with the identified problems.
- Policymakers, think tanks, academics and advocacy groups generate ideas and proposals to solve or mitigate the problems identified in the problem stream.

The politics stream
- Focuses on the political climate and the factors that influence policymakers’ decisions.
- This includes the political context, public opinion and interest group activities.

Question 19

Using Kingdon’s 3 streams approach, explain why the mandatory HPV vaccination mandate was not taken up in California.

Answer 19

CALIFORNIA: HPV vaccination mandate legislation for girls entering middle school was proposed but not adopted

Problem:
1. Caught attention of policymakers and the public through a focusing event caused by the vaccine manufacturer’s (Merck) national television advertisement. Raised awareness among legislators and the public about the vaccine and the public health threat posed by HPV
2. Merck also financed a Women in Government conference that acted as a focusing event by drawing attention to cervical cancer prevention; California legislators attended the conference and reportedly became more engaged in the HPV issue

Politics
1. “Family values” groups argued that a vaccination mandate would ruin parental rights and prematurely force parents into conversations with their daughters about sex
2. Time the legislation was introduced, California was in a serious budget crisis so vaccines with even a moderate price tag stood little chance of adoption

Policy
1. Public health officials and medical professionals were satisfied with the vaccine’s safety but were aware of opposition by family values groups. They did not support the school entry mandate because they thought it would cause more opposition from antivaccine groups
2. Policymakers raised the issue of vaccine-related adverse effects more often than respondents from public health or medical groups, fuelled by media reports

Policy entrepreneurs
1. State medical professional associations, family values groups, antivaccine organisations, Merck

Problem was in line for policy change but the politics and policy streams did not align due to opposition from family values groups, cost, and media coverage of potential side effects

Question 20

Using Kingdon’s 3 streams approach, explain why the mandatory HPV vaccination mandate was taken up in Virginia.

Answer 20

VIRGINIA: HPV vaccination mandate legislation for girls entering middle school was adopted

Problem:
1. Reportedly, most stakeholders became aware of the HPV issues after hearing about Delegate Hamilton’s proposed legislation
2. No clear focusing event other than the introduction of the mandate legislation itself

Politics:
1. House and Senate versions of the bill were sponsored by members of different political parties (bipartisan support) which paved the way for all legislators to support it
2. Legislature was only in session for 45 days which didn’t give opposition groups enough time to organise

Policy:
1. HPV policy was set by efforts of elected officials who were in favour of enacting a policy to promote vaccine uptake
2. Merck lobbied policymakers in Virginia. This was seen as interference by non-governmental stakeholders but was seen as normal practice by those in government.

Policy entrepreneur
1. Delegate Hamilton (moved the problem stream by creating the legislation and engaging powerful stakeholders such as the School Nurses’ Association)

Question 21

What is the Advocacy Coalitions Framework?

Answer 21

• One of the most common models for policy change
• Policy change occurs through the interaction of competing adovacy coalitions
• Assumes that policymaking occurs among specialists within a policy subsystem
• Actors within a subsystem who have similar ideas and interests form coalitions
• Coalitions shop for vanues to press for policy change. They may exploit opportunities produced by external events/shocks
• Key actors have belief structures:
  o Deep core beliefs: deepest underlying ideas/beliefs, very hard to change e.g. core moral views, faith in a religion, belief in superiority of democracy or the market
  o Policy core beliefs: normative beliefs within a policy sub-system. Includes strategies or policy positions for achieving deep core beliefs
  o Secondary beliefs: empirical beliefs and policy positions. Easiest to change
• Coalitions may link groups with similar policy core beliefs but very different deep core beliefs
• Policy change occurs when coalitions shift or their beliefs change

Question 22

Provide a case study for a time when an adovacy coalition exploited external events/shocks.

Answer 22

In the past 20 years, Switzerland has shifted its drug policy from being strict and against drug use to a more lenient approach focused on reducing harm. Kubler 2011 argue that the history of drug policy in Switzerland can be seen as a competition between different groups, or coalitions, each advocating for their beliefs about the issues and policies related to drugs. They point out that the AIDS epidemic played a significant role in this competition, acting as a key event that helped the coalition supporting harm reduction ideas to challenge the dominant coalition advocating for abstinence. Some people, concerned about the impact of harm reduction facilities on their neighbourhoods, opposed the establishment of such facilities, creating conflicts. However, this opposition led to learning opportunities for those supporting harm reduction policies.* In the past 20 years, Switzerland has shifted its drug policy from being strict and against drug use to a more lenient approach focused on reducing harm.
* Kubler 2011 argue that the history of drug policy in Switzerland can be seen as a competition between different groups, or coalitions, each advocating for their beliefs about the issues and policies related to drugs.
* They point out that the AIDS epidemic played a significant role in this competition, acting as a key event that helped the coalition supporting harm reduction ideas to challenge the dominant coalition advocating for abstinence.
* Some people, concerned about the impact of harm reduction facilities on their neighbourhoods, opposed the establishment of such facilities, creating conflicts.
* However, this opposition led to learning opportunities for those supporting harm reduction policies.

Question 23

Coalitions may demonise their opposition to undermine their position. Give an example of this.

Answer 23

Devil shifts: term coined by Sabatier et al 1987 which describes how political elites in high conflict situations perceive their opponents to be more evil and powerful than other actors in their policy community.

e.g. when Obamacare was created there was talk ot “death panels” (wording from Republican Sarah Palin) who would decide whether a patient would live or die. In reality this was not true as people were just required to buy health insurance.

Question 24

Why was cervical cancer given less attention on the global health policy agenda?

Answer 24

• • Cervical cancer and maternal mortality had about the same number of deaths per year and ~90% of cases for both were in low income countries. However, only maternal mortality was a global health priority
• Problems with:
  1) Actors power – poor coordination, disagreement on approaches etc.
  2) Ideas – challenge finding a resonating set of ideas
  3) Political contexts – mixed results in terms of actual funding allocated but did get into MDGs
  4) Issue characteristics – maternal deaths not very common, accurate measurement is technically difficult, interventions to avert are not as simple as others (e.g. vaccinations)
  Reasons behind the lack of attention
  1. Limited awareness and understanding: Cervical cancer may not receive sufficient attention due to limited awareness and understanding of the disease. This lack of awareness can result in a lower priority being given to cervical cancer compared to other health issues.
  2. Inadequate information: There is a lack of local, national, and sub-national information on cervical cancer, which hinders its recognition and prioritization on global health agendas. Without comprehensive data on the burden of the disease, it becomes challenging to advocate for its inclusion in policy agendas.
  3. Insufficient mobilization of affected civil society groups: The mobilization of civil society groups plays a crucial role in raising awareness and advocating for policy change. However, in the case of cervical cancer, there has been limited mobilization of affected groups, which can contribute to the lack of attention it receives on the global health agenda.
  4. Framing of cervical cancer debates: The way cervical cancer is framed in policy debates can also impact its prioritization. If the framing of the issue does not effectively communicate its significance and impact, it may struggle to gain attention and support from policymakers.
  5. Gender bias and disempowerment of women: Women’s health issues, including cervical cancer, have historically faced challenges in gaining priority on global health agendas. The disempowerment of women and the low emphasis placed on women’s health concerns contribute to the lack of attention given to cervical cancer.
  6. Competition with other health issues: Cervical cancer may be overshadowed by other health issues, particularly infectious diseases, which have received more attention and resources. This competition for resources and prioritization can limit the attention given to cervical cancer.
  What must change to get cervical cancer on the agenda
  o Better local data collection;
  o Increased civil society mobilization;
  o Reframing as an women’s rights/NCD issue;
  o Linking to well-funded services like HIV;
  o and identifying policy windows like emerging NCD discussions.

Question 25

Why is it hard to set global agendas?

Answer 25

• At the global level there is no one authority, lack of consistency in who changes the global health agenda. Different stakeholders to national policymaking
• Lack of clearly defined decision making institutions or formalised rules
• Lack of standardised accountability mechanisms
• Lack of consistency in shape and influence of institutional bodies
• Dominance of expert bodies and donor agencies
• Concentration of dominant ideas
• Electoral processes absent