Is local government better?

In the health field there has been a call — since the early 1980s — to make health policy development the responsibility of all sectors, not just the health care system’s. This echoes calls from administrative and political science, first voiced in the 1970s, to integrate or join up policy systems. There is a range of monikers for either, from Healthy Public Policy and Health in All Policy to Whole-of-Government and Integrated Governance. Whatever it is called, it remains what Peters has called ‘the holy grail of public administration’.

Our first feasibility study of such integrated health policy at the level of the nation-state was published in the late 1980s and early 1990s. We found that there are many parameters, intimately associated with the very nature of the nation-state and its governance systems, that do not bode well for the development and sustainable implementation of policy for health (rather than policies for, e.g., pharmaceuticals, health workforce development, practitioner accreditation, numbers of hospital beds, etc.). The emerging practice of Healthy Cities around the world from their official European WHO launch in 1986 turned out to be a ‘natural experiment’ (or rather multiple case study inquiry with an N>10,000) to see whether local contexts would provide different opportunities for evidence-based health policy.

Colloquially there have been convincing arguments that devolved governance to local systems is the ‘natural’ and more efficient thing to do. Benjamin Barber attractively argued (in his not entirely rigorously resourced book If Mayors Ruled the World: Dysfunctional Nations, Rising Cities) that ‘local government collects the garbage’ – and that local politics therefore would be more responsive to community needs and might well be more agile in its (health) policy response.

Based on three decades of Healthy Cities evaluations; a typology that has been developed to challenge the more traditional ‘knowledge translation’ paradigm (into an area of seven interlocking nexus theories); horizontal and vertical policy transfer theories; and an eclectic use of policy network and framing perspectives, this paper argues that although health policy making at the local level is relatively easier, its mobilisation and use of relevant evidence sources is often more convoluted. Rather than dealing with more abstract power and governance issues at the nation-state level, the fact that Council collects the garbage also requires it to shepherd a more conscientious and accountable way of generating, managing and applying the evidence to support responsive policy for health.

Read more in this new discussion paper by Evelyne de Leeuw here