Unpacking the black box of policy, with a cube!

by Patrick Harris and Evelyne de Leeuw

One of the enduring myths among researchers is that policy-making is a black box of unknowable dark arts that is to be avoided at all costs. This myth is particularly pervasive in the field of Public Health. Public Health is a field that thinks it is enough to generate evidence to then give to policy makers to do something about.

At CHETRE, we do not subscribe to this myth. Our core interest is of course equity. We recognise that equity is largely determined by political decisions and policy institutions. And to improve health equity we have recognised that we need to know how the evidence of equity morphs into policy systems and decisions about what (not) to do. We require knowledge about what policy and political processes are. 

I (Patrick) have been thinking about what policy is for around a decade now. Over that time I have been systematically breaking down what public policy is, with the aim of better articulating how to then go about influencing public policy to be more equitable. Evelyne has been on a similar journey over the past 20 or so years. Both of us have built our understanding from the discipline of Political Science.

Very recently I was trying to explain what policy is to some colleagues who are undertaking a systematic review of the literature on intersectoral action (for health). At the same time, I was putting the finishing touches to a book on my research, the first part of which is a manifesto for how to research (healthy) public policy. I had also just published a bibliography of ‘healthy public policy’ as well as a glossary of how the concept of power plays out in policy (see sources). During that recent conversation I suddenly had a brainwave that the ‘black box’ of policy is actually a cube. So I went away and, with Evelyne, came up with the ‘Policy Cube’.

Figure 1 shows that the cube is made up of smaller cubes; they are not separate, of course, but this is a way of abstracting complex realities.

Figure 1. The Policy Cube

Each of the elements of the cube is based in the policy and political science literature, the knowledge about which can be found in the source references at the end of this blog. The essentials are as follows.

The ‘top’ of the cube corresponds to what policy-making is and what it is intending to achieve. Policy is in large part made up of processes (indeed there is a whole body of political science labelled ‘Theories of the Policy Process’). These processes are in place to influence decisions and choices, and their foundations. In turn, these processes, then choices, go on to influence ‘events’ or, what we are most interested in public health research, ‘outcomes’ – such as inequity or disease or so forth.

The left side corresponds to how political scientist break down the sub-systems that influence the processes of policy making. I tend to explain these sub-systems as ‘institutions’, although others, like Evelyne, think sub-systems is a better description. This is mostly a discourse about constructs and metaphors – but the key is that we can distinguish between different sorts of elements that influence, and operate, processes. The elements of these institutions or subsystems are essentially actors (the organisations and individuals involved in policy making), their ideas (largely based on interests and values) and structures (the rules and mandates that flow through systems).

Three other fundamentals of policy-making form the rest of the cube.

First of these is ‘Governance’, in the figure on the right side. The literature on governance is vast and sometimes confusing. A very brief definition goes ‘how we do things around here’.  Essentially it refers to the types and functions of networks of stakeholders involved in policy making. Importantly, especially in current times, these actors include but go beyond government. Government tends to facilitate governance networks to achieve various policy goals. Evelyne has written extensively on Governance for Healthy Public Policy and has helpfully divvied up three essential forms of Governance: constitutive, setting the principles; directive, providing guidance; operational, promoting individual actions.

Power is crucial to policy, and so this is the first of the through arrows in the figure. Power is a tricky and slippery concept, which is sometimes clearly visible but often needs to be explicitly brought out into view in research. Making power visible is actually achieved by clearly articulating the various other dimensions of the cube. But essentially policy is embodied by power.

Time is the final critical factor and is the second through arrow. Policy stays the same or changes (often quite suddenly) over time. Perhaps most importantly for public health researchers, the outcomes we so desperately want to observe from policy making processes and sub-systems often take a very long time to become apparent.

So there you have it! The Policy Cube. Before you go off and think you know it all, we have however a warning. The cube is what we call in academia a ‘heuristic’. It is merely a way of breaking up the black box to articulate the core dimensions of what policy making is. The reality of policy is much more messy and will be different for different policies and different contexts – figure 2! The cube should only be used to draw out core elements of what a particular policy or policy system is made up of.  

Figure 2. Heuristics are not reality
References
Cairney, P. (2011). Understanding public policy: theories and issues. Macmillan International Higher Education.
Clavier, C., & de Leeuw, E. (2013). Health promotion and the policy process. OUP Oxford.
de Leeuw, E. (2017). Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action. Annual Review of Public Health, 38(1), 329–349. https://doi.org/10.1146/annurev-publhealth-031816-044309
Harris, P., & Wise, M. (2020). Healthy Public Policy - Public Health - Oxford Bibliographies. https://www.oxfordbibliographies.com/view/document/obo-9780199756797/obo-9780199756797-0196.xml
Harris, P., Baum, F., Friel, S., Mackean, T., Schram, A., & Townsend, B. (2020). A glossary of theories for understanding power and policy for health equity. J Epidemiol Community Health, 74(6), 548–552. https://doi.org/10.1136/jech-2019-213692
Howlett, M., Perl, A., & Ramesh, M. (2009). Studying Public Policy: Policy Cycles & Policy Subsystems. Oxford University Press.
Peters, B. G. (2019). Institutional Theory in Political Science, Fourth Edition: The New Institutionalism. Edward Elgar Publishing.
Weible, C. M., & Sabatier, P. A. (2017). Theories of the policy process. Hachette UK.

Champion of adolescent health A/Prof Melissa Kang receives PHAA NSW Public Health Impact Award

PHAA NSW President Dr Patrick Harris presented the 2019 NSW Public Health Impact Award to Associate Professor Melissa Kang at UTS on 8 July 2020.

Photograph: Catriona Bonfiglioli

A/Professor Kang said she was thrilled to receive the award as it recognised the significance of adolescent health policy, access and innovation.

“I’m thrilled because it shines a light on youth health,” A/Professor Kang told PHAA NSW.  “I’ve been working with young people for almost 30 years and getting traction around young people for their health and well-being has been a struggle,” A/Professor Kang from UTS’s Faculty of Health said.

A/Prof Kang said New South Wales have been taking adolescent health very seriously with improvements in policy, funding, workforce development and accessibility especially for marginalised young people. “There’s a more to be done but compared to other jurisdictions, they’ve been taking it very seriously,” she said.

A/Prof Kang, MBBS (Sydney), MCH (UNSW) and PhD (Sydney), is most widely known as a champion of frank health and sex advice to young people during her long service as the Dolly Doctor (1993-2016) for the teenage girls’ magazine Dolly.

A/Prof Kang is the co-author of Welcome to Your Period, with media personality Yumi Stynes which won the 2020 Book of the Year for Older Children 13+ from the Australian Book Industry Awards.

She has published clinical resources, 100 academic reports, books and book chapters and articles for The Conversation.

A/Prof Kang is one of three UTS staff involved in the Centre for Research Excellence in Adolescent Health led by Prof Katharine Steinbeck at the University of Sydney. A/Prof Kang is working with UTS Faculty of Health Professors Lin Perry and Fiona Brooks and post-doctoral research fellow Daniel Waller.

https://researchdata.ands.org.au/centre-research-excellence-digital-age/1318192

A/Professor Kang is a Senior Career Medical Officer in Youth Health, Western Sydney Local Health District as well as an Honorary associate in the Department of General Practice, University of Sydney at Westmead.

Further information

A/Professor Kang who graduated in Medicine in 1986, trained in General Practice and has dedicated her career to improving and advocating for young people’s health wellbeing. Her major projects investigated youth access to health care, sexuality, sexual health as well as contributing to policy development, workforce training, research and research capacity building, in NSW, nationally and internationally.

In April 2020, A/Prof Kang and the manager of the Youth Health Service in WSLHD were invited to work on ways to help vulnerable populations during the COVID-19 pandemic.

In 1999 NSW Health developed its Youth Health policy and funded the NSW Centre for the Advancement of Adolescent Health (CAAH) A/Prof Kang, then at the Adolescent Medical Unit at CHW, was seconded into CAAH as the Education & Training Coordinator until to 2004.

A/Prof Kang founded the Youth Health Forum (YHF) at CAAH which continues today through the Youth Health and Wellbeing Team at the NSW Ministry of Health reaching several hundred youth health and related professionals across 30 regional and rural sites. In 2003, Melissa secured funding from the Transcultural Mental Health Centre to develop the GP Resource Kit, a resource to help GPs engage with young people.

Melissa has been the Chief Investigator on the NSW Health funded studies Access Phase 1 and Access Phase 2 which informed the 2011 – 2016 NSW Health Youth Health policy.

Access 3 involved young people and informed the NSW Youth Health Framework 2017 – 2024. A key finding was the value of dedicated ‘youth health navigators’ to help vulnerable or marginalised young people accessing health.

A/Prof Kang’s work has seen the number of Youth Health Coordinators rise from three across 17 Area Health Services to 15 across each of the fifteen Local Health Districts today.  Other projects have contributed to reduced presentations to emergency departments and used online interventions to improve chlamydia screening.

Melissa has contributed to curriculum development and teaching in adolescent health at the University of Melbourne, 2001-2004, the University of Sydney (2006-2015) and UTS (2019- present). She has supervised to completion several Honours, Masters and one PhD student and currently supervises seven PhD students and one MD student. She has been a Chief Investigator on research grants totally over $3M and Associate Investigator on grants totaling $11M+.

She is currently President of the Board of Directors of the Australian Association for Adolescent Health Ltd (AAAH) and a member of the International Association for Adolescent Health, the Society for Adolescent Health & Medicine (USA), and the Public Health Association of Australia.,

A/Prof Kang is a vocationally registered General Practitioner, an Associate of the Royal Australian College of General Practitioners (RACGP).

She has worked clinically at Cellblock Youth Health Centre (1994-95), in the Adolescent Medical Unit at The Children’s Hospital at Westmead (CHW, 1996-2004), Nepean Sexual Health Clinic (2011-12), and headspace Camperdown (2014-15).

In 2019 she was awarded the Sax Institute Research Action Award in 2019 and the Australasian Sexual Health Alliance Mid-Career Interdisciplinary Achiever Award.

https://www.uts.edu.au/staff/melissa.kang