April 10, 2014
I highly recommend this exemplary book to others interested in public policy (related to health or not). If you are interested in understanding why the intersection between ‘problem, policy and political streams’ (Kingdon) are important to policy change, or figuring out whether or not health reform in Canada (even in the U.S.) can be characterized as ‘rigid’, ‘stable’, ‘in stasis’ (Redden), ‘frozen’, ‘comprehensive’, ‘significant’ or ‘incremental’, then this is the book for you. If you are only interested in finding out “What motivates healthcare reform or change?” you will be equally satisfied.
A former professor once said, “Try to find the answer, and you will seldom find it; ask yourself the right questions, and you will find the answer”. Reading Paradigm Freeze reminded me of the wisdom caught up in these words. Every chapter, without exception, in this edited volume astutely invites the reader to consider a number of pivotal questions, usually within the first 2 or 3 pages, sometimes as a segue to future chapters, as well as at opportune moments within each chapter. This rhetorical device allowed me to enter into the rightly curious minds of each author who wanted to truly understand the psychology of public policy decision-making, and (given the framework they developed) share these observations with a wider-audience. On both counts, they have succeeded.
Their approach was a benefit to me, as it allowed me to temporarily forget the complexity of answering the main (big) question (also the subtitle) of this book, “Why is it so hard to reform health-care policy in Canada?” so that I could concentrate on the various factors (presented in a highly structured way) that influenced “change” in healthcare over time.
People who know me know that I am critical by nature, and rarely use superlatives. In a word, I am not easily impressed. So, it will be odd for these same people to read my impressions of Paradigm Freeze, because what I have to say sounds too positive, and is so unlike me. What can I say, other than “I am impressed.”
I was quite impressed with the work of Harvey Lazar when he first presented preliminary results to a small gathering in the offices of the Canadian Health Services Research Foundation (now Canadian Foundation for Healthcare Improvement) in 2012. I was impressed, then, with the framework developed to describe when, how and under what circumstances (i.e. who’s involved, who resists change, etc.) healthcare reform took place in Canada. I was thankful for his description of the case studies, which provided essential context for understanding not only the decisions that were made, but the interests that were involved in setting agendas, considering options, and ultimately leading to the reform decisions (between 1990 and 2003, and between 2004 and 2011). I was also taken-aback by the sensitivity analysis employed, which compared observations and analysis related to reforms between 1990 and 2003 with previous reforms to healthcare in Canada between 1945 and 1989.
I more impressed now after reading Paradigm Freeze.
I would be doing a huge disservice to the authors if I were to attempt to describe in my own words precisely how they have managed to ‘embrace complexity without accepting’ it in this book. Suffice it to say that level of organization and discernment that was applied to analyzing various factors that influenced decision-making is breathtaking. They have managed to come much closer to recognizing how things work in “real life” with this book; only the people involved in decision-making related to the 30 case studies examined (who may or may not have participated in the interviews conducted) could possibly quibble with the observations and conclusions drawn from any of these cases.
Truly, I have seldom heard or seen such clear analysis of what really motivates people involved in health care change in Canada, or the “factors” that truly influence change. Sure, we have all read articles on issue competition, agenda-setting in public policy, sociological and political literature. We have also read wonderful work by Flood, Stabile, Tuohy, Daniels and Sabin on the importance of transparency and accountability in health decision-making. But, how many articles or books have you read that causes you to intimately, completely and honestly reflect on what motivates people to support (or resist) change? In many ways, this book has few peers (in my view peers include Kingdon, Cairney, Massardier, Maioni, Boothe, Cartwright and Hardie, and some other authors who routinely adopt a multi-disciplinary approach to understanding the complexity and psychology of public policy decision-making). Yes, it is complex, but the presentation is far from being complicated.
Aside from outlining and describing the factors that matter at different times when one is looking to bring about large scale change in health reform in Canada (including, for example, the role of opposition parties, when to engage them from an advocacy perspective, why the first two years of a newly elected government is important to ‘change’, knowing who the opponents to change are, and the role of the public, health professionals, hospitals, other public institutions and private interests), Lazar and numerous contributors to this edited manuscript provide the reader with a rigorous analytical framework that does a wonderful job of reflecting real-life agenda setting and decision making.
Authors advance very honest appraisals of what their observations mean and what their analyses can tell us about why change did and did not occur. They equally steer clear of making (too many) predictions based on their review of 313 influencers (of which 105 were characterized as “major influences”) in 30 case studies. Authors routinely resisted the temptation of drawing firm conclusions in all cases, stating very clearly in some instances that readers may have a different interpretation of the applicability of certain theories to the Canadian healthcare context, or a different interpretation of the similarities or differences they observed between opposing views / theories on an issue. Authors did the same when it came to explaining what their observations and analyses mean for future reform in later chapters; yes, there are some definite conclusions (and even predictions), but they are always measured and supported. The past does not always predict the future, however the authors of this book believe there are some inescapable features (i.e. influences) regarding health reform in Canada that we need to take serious note of. Thankfully, authors also spend time explaining various paradoxes that exist in health reform itself, as well as in research related to health reform. Both types of insight are valuable, as they get the reader closer and closer to understanding the motivations of decision-makers and influencers, as well as to understanding the challenges and limitations of researching health reform itself. In this way, and for other reasons, the Editors and co-authors have created a volume that is invaluable to practitioners of public policy, influencers, decision-makers as well as researchers.
I hesitate to provide examples for each my observations above because the authors of this work deserve to be read, not poorly summarized by me.
That said, there are few real gems that stand out in this edited volume:
1) It focuses on an aspect few Canadian commentators speak about (with evidence to support their views) when talking about health reform: the psychology of decision-makers. The authors did not overstate their observations about this psychology, however, their insights into the factors that influence agenda setting and decision-making are a welcome addition to the routinely historical, legislative or political readings that sometimes downplay the psychology involved in policy-making.
2) The economy of the text. This is health reform. Authors could have published this work in volumes, or written a text book. They did neither. Each author appears to have received great guidance from the Editors; from my perspective, I see explanatory text, analysis and punctual historical context woven throughout each chapter. I see public, civil society organizations, media, professional interests and politics being described as a complex-whole, rather than artificially separated for the purposes of analysis and presentation. We must believe that this separation and analysis was required to conduct the analyses, but thankfully, like a good suit, I can’t see the seams. With regard to historical references, notably to past Commissions or political decisions, the balance struck was appropriate, in my view, as I did not feel I was “in for a history lesson” or was going to be drowned by “legislative debate”. Annexes 3 and 1, like a great footnote, complement the main text by providing the reader with the key references in their historical context, and then some. Given the amount of ink that has been spilled on healthcare reform in Canada, that the authors were able to produce a book under 400 pages is admirable.
This book should be required reading for not only students of health public policy, but for all students of public policy, public administration, sociology and politics.
Rigorous quantitative and qualitative methodologies (transferable to other disciplines), a well thought-out organization, surgical presentation of insights gleaned from informant interviews, rich references, analysis of case-studies, and thoughtful updates to “what has happened since the study period in this book ended”, have given us a highly believable set of measured interpretations about what the past can tell us about current and even future reforms to healthcare in Canada.
Moreover, from a strictly research-perspective, can this book be the (true) beginning of a new sub-discipline of decision-making science concerned with health and health care reform and, more broadly, public policy? In a word, “Yes”. Was it worth the wait? “Yes”.