Why is health improvement policy so difficult to secure?

Abstract

Many governments seek to improve the health of their populations, and some seek to reduce health inequalities. Yet, there remains a large gap between their policy statements, practices, and outcomes. It prompts perennial questions in public health research: why is this gap so large, why does it endure, and what can be done to close it? In that context, this essay uses political science and policy studies’ insights to explain the gap between rhetorical and substantive support for health improvement policies. On the one hand, the idea of ‘prevention’ has widespread appeal, particularly when governments think they can save money or reduce inequalities by preventing problems happening or worsening. While health protection inoculates populations against communicable diseases, health improvement strategies, including ‘Health in All Policies’ (HiAP), address non-communicable diseases (NCDs). Further, the coronavirus disease 2019 (COVID-19) pandemic highlighted the unequal spread of ill health, showing that preventive health ideas should be at the core of government responses. On the other hand, there is: a large gap between rhetorical commitment and actual practices, a continuous HiAP implementation gap, and a tendency for COVID-19 health protection to overshadow health improvement. Explaining each problem clearly should help public health researchers support solutions that are tethered to political reality. To that end, we identify the factors that always undermine prevention policies and those specific to HiAP and COVID-19. We go beyond a tendency to relate politics primarily to leadership or treat low ‘political will’ as the main policymaking problem. Instead, we identify the systemic policymaking dynamics that apply to even the most sincere, energetic policymakers. Health improvement policy is typically undermined by a lack of: clarity about what prevention means in practice; congruity between the radical aims of prevention and established policymaking routines and practices; and, capacity to overcome obstacles to policy change.