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The Quarterly 2011

Creating Political Will: Moving from the science to the art of health care reform

This article was derived from material presented by Prof. John Catford, Deputy Vice-Chancellor Deakin University and former Chief Health Officer for the Victorian Government at the RACMA 2011 Langford Oration, Melbourne.

Why is it so difficult to achieve change in health care policy? Why do Ministers and Governments not listen to our evidence-based advice and hard-earned experience? How can we be more effective at creating political will to achieve health care reform?

One of the reasons why progress has been less effective in the political arena of health care reform is that we have not placed as much attention on the process or method of policy making as we have on the content or shape of that policy. Health leadership requires a diverse set of skills and insights but political analysis and strategy has not been at the fore front. This needs to change if we are to be more effective at managing the decision making processes.

Deciding whether to embark on a new policy or programme goes far beyond considering the intrinsic merit or worth of the proposed intervention. A number of other criteria are equally important in a managerial and political sense to determine whether an intervention is 'able' for implementation, as illustrated in the figure below. To have any chance of support within the highly scrutinised and contentious realms of government, candidate interventions need to be shown to be reliable, valuable, acceptable, affordable, feasible and accountable.



Much effort is focused on the first two criteria of establishing efficacy and safety, and determining the potential health impact. Interventions need to show that they are reliable and valuable primarily through epidemiological, behavioural and clinical research which may include intervention studies. Increasingly attention is also being given to the cost and sustainability criteria in the decision making process.

Past experience of seeking change in health policy, however, suggests that, while evidence is important, it is not enough. The skills required today are more than those we learnt in our professional entry courses at university or health services. Health leaders need to be able to work within existing political and economic systems, to understand how decisions are made and then to know how to influence this decision making. This is the essence of political analysis and strategy and a major 'art' of health care reform.

The 'policy and political fit' criteria is often the area most neglected and the most poorly undertaken. To run the argument that a particular policy or programme is good for the public’s health and that it provides value for money is not enough. It does not answer the question of why government should be involved and why government should invest in this measure rather than any other. More is needed to create the necessary political will to act. From the perspective of one who has studied, published, managed and commissioned health care policies and programmes over two decades there are a number of key components for creating political will:

The Issue
In presenting a proposal to senior policy advisers, politicians or ministers it is vital that the intervention is seen to be responding to a perceived problem. If not, then the intervention should be 'reframed' to optimise the context. There needs to be a strong constituency of support both in and outside government advocating for the measure. The proponents should articulate clearly what is needed and present a simplified construct and set of achievable goals and manageable actions. This is important to give the confidence that the intervention is possible and realistic. Unclear, over complicated proposals which do not get to the heart of the matter are unlikely to win support. This is more so if there is no obvious backing for the intervention externally.

The Source
Advocates for a particular measure need to demonstrate their own credibility and status with community, politicians and government. Are they knowledgeable, legitimate, and trust worthy? To maximise the impact of such advocacy, alliances should be forged with a range of organisations – both within health and with other groups. This improves the authenticity of the proposal. It is also very important to provide unanimity of advice. Presenting a common front is challenging for health care leaders as there may be a range of options and alternatives, so try to agree the main ones and focus on those. If there is conflict, disagreement or indecisiveness over what should be done it is much easier for decision makers to do nothing or request further analysis or investigations. Convening a working party to consider and then report on an issue is a common delaying tactic. Often the problem has ‘gone off the boil’ when the committee reports some time later.

The Benefits
A key aspect is to focus on providing solutions rather than adding more problems. Politicians and senior government officials already have too many challenges to deal with – they want answers and help not more difficulties. Short term as well as long term 'pay offs' therefore need to be demonstrated. We need to get better at identifying and costing what the return will be on the investment or else it will lose out to the more 'urgent but not important' issues. Ideally the intervention should also create multiple 'wins' for different stakeholders so spreading the benefits to a broader base. Another useful approach is to emphasise that the consequences and risks from not acting are far worse.

The Timing
Often proposals fail because of poor timing. Ideally it is best to place issues on the political agenda before an election so that measures can be included in election manifestos, policy platforms and forward commitments. Seeking major funding support during the midterm of a government should normally be avoided; governments commonly are busy financing previous election commitments or holding back resources for pre-election initiatives. The exception is for policy measures which do not require significant resources and may be more acceptable if they are implemented well in advance of the next election. Wherever possible interventions should build on existing policies and political 'entry points' that have already been agreed.

The Methods
In negotiating with government it is important to develop supportive and constructive relationships. Show empathy and realism, mutual respect and trust with 'no surprises'. Government officials can be strong allies internally and you do not want them to turn hostile and negative. Proponents also need to demonstrate enthusiasm and commitment, and show in all they do that they are of high quality and performance. The media should be used creatively to highlight the need for action and the benefits that will arise. Messages need to be constantly reinforced from different angles. A positive climate for change needs to be transformed into an overt 'clamour for action'. Lobbying with influential 'figure heads', concerted press campaigns and peaceful protests can also play their part but always make sure that there is a clear and acceptable escape route for your opponents. If decision makers and politicians are backed into a corner they will go on the offensive which could be very counter productive.


Creating political will clearly take a great deal of time and resources. Persistence is essential; action almost certainly will need to be sustained over the long term. To take a public health example in Victoria, Dr Nigel Gray presented the case for a hypothecated tax on tobacco to eight health ministers before he found one who was sympathetic. Moreover Government ministers are unlikely to even notice policies that cannot demonstrate some kind of outcome within their political lifetime. If decision-makers know that you are not going away and are committed for the long haul then they may be more disposed to support you.

In generating public awareness an awkward kind of dance often goes on between the media and government where both accuse the other of failing to make more progress on debating public health issues. The media sees itself as reporting what the public wants to know, while government believes it is at the mercy of a press that will only report news that is headline grabbing. If there is no clearly identifiable victim to a health story then it is very hard to get any media coverage. This is particularly true concerning important but not glamorous aspects of health care reform.

These then are some of the avenues for creating political will and mastering the ‘art’ of health care reform. In terms of the key ingredients, these can be summed up by the five P’s:

Position    What are you seeking? When do you want action to happen?
Perception   How does this fit within the current context? What are the benefits?
Players    Who are you? What credibility do you have? How united are you?
Power     What resources and influence do you have to influence the agenda?
Persistence   How determined are you? Will you stay the course?

In conclusion, may I thank the Royal Australasian College of Medical Administrators for this great privilege in delivering the 2011 Langford Oration. Dr Sam Langford as the Foundation President of the College would have been a master of the art of creating political will. In 1968, to bring together such diverse opinions and vested interests needed to establish a new force for health care leadership in Australia would have been no mean achievement. He clearly drew on his military and hospital management experience in preparing himself for the charge! Would that others would follow in his footsteps at these times of great opportunity and challenge in health care.


Prof John Catford
MB BChir DM FRCP FAFPHM

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