3.1 Politics and governance: achieving the co-benefits

The logic of co-benefits has two compelling advantages relative to other ways of approaching intersectoral health action:

• As health policy, the causal connections between health and health systems and other outcomes are important and make a convincing case for investments in health and health policies. It also allows for an increase in attunement to the other goals health policy can influence.

• As health politics, it focuses conversations on win-win outcomes. This permits broader coalitional politics, rather than relying on the generally unproven ability of health advocates to mobilize another set of actors.

Delivering these goals, though, depends on politics governance: the institutions and organizations that make and implement decisions that can bring together or force apart organizations, sectors and people.

Achieving co-benefits puts a spotlight on politics and governance, in particular for the policy-focused approaches. How can health policymakers and health care leaders work with others to produce safe, healthy, equitable and sustainable cities and economies? How can they seek positive-sum, win-win solutions that build political coalitions to support a policy’s passage, implement it, and sustain it? Such win-win approaches enhance policymakers’ ability to build necessary supporting coalitions for policy (Reference Greer, Lynch and ReevesGreer et al., 2021b, Reference Greer, Lynch and Reeves2022a).

In the previous chapter, we have identified where the impact of the co-benefits is likely. In this chapter, we address the reasons why potential win-win solutions are precluded, ignored or adopted but not implemented or sustained. Administrative history is littered with more and less successful efforts to promote “joined up government” and other such goals (Reference BogdanorBogdanor, 2005). Here we show how we can build on these concepts to formulate and answer a set of important theoretical and practical questions.

• How can evidence from research on co-benefits be most effectively used in different political situations and systems in order to develop policies that promote co-benefits?

• What kinds of arguments and knowledge translation approaches work in different countries and political situations?

• What governance approaches work in different situations to implement and sustain co-benefits approaches?

• How should policies for co-benefits address the challenges of multi-level governance and the need for a whole of government or whole of society approach?

In health, a sector often known for its comparative isolation from the rest of government, efforts to integrate a broader logic into this argument are not new. A focus on co-benefits is an extension of longstanding research and practical experience in intersectoral policies, notably Health in All Policies (HiAP) in recent decades. The intuitions behind it are, of course, much older. Claiming that a single policy achieves multiple goals – has many co-benefits – is a persuasive tactic as old as politics. Creating or holding together a political coalition by winning supporters with different priorities is often necessary.

Governance is how societies make and implement decisions (Reference Greer, Vasev and JarmanGreer et al., 2019) – the formal and informal institutions that manage conflict and turn it into policy. This chapter introduces the two governance frameworks used throughout the case chapters to identify opportunities for action to achieve goals when political action is required.

3.2 Getting to a win-win: identifying practical co-benefits

Achieving co-benefits places the focus on politics and governance. Without them, the best-evidenced study or most persuasive model is unlikely to lead to real change. The study of political systems is rightfully a field in its own right. Everything is ultimately political, for the implications of even the most technical and scientific determinations and questions will be decided in the broad arena of politics and government (and to make something technical and scientific is to successfully constrain the scope of conflict over that topic).

This chapter presents two basic frameworks for identifying opportunities to make successful policies for co-benefits. One is for addressing the problem of change within government, in the framework commonly used by advocates of intersectoral policy. We adopt a framework from Edward C. Page that can clearly identify key dynamics and opportunities for the construction of cross-cutting policies, as well as the areas in which, under current circumstances, progress is likely to be limited and advocates might find themselves frustrated or defending their achievements against attack. This approach is essentially internal to government and the sectors involved.

The second approach to analysing politics and the possibility of action is grounded in the analysis of agenda-setting (Reference Greer, Kingdon, Agendas, Balla, Lodge and PageGreer, 2015; Reference Herweg, Zahariadis, Zohlnhöfer and WeibleHerweg, Zahariadis & Zöhlnhofer, 2023; Reference Jones, Peterson and PierceJones et al., 2016; Reference KingdonKingdon, 2003; Reference Zahariadis and SabatierZahariadis, 2019), which has been profitably applied to the area of intersectoral policy for health (Reference Leppo, Ollila and PeñaLeppo et al., 2013). Well known in health policy research, the multiple-streams framework focuses on the separate interests and development of political and policy debates as well as problems that can erupt unpredictably. The interplay of these three streams can produce a political agenda – which is not the same thing as legislation or government agreement, but is usually a precondition for any successful legislation.

In both cases, these are basic analytic frameworks for understanding which action is likely to be effective in improving the likelihood that proposals for achieving co-benefits do achieve their potential benefits. Notably, neither is a discussion of legislative adoption, a different topic that involves a wide range of institutional, partisan, economic and other factors studied by comparative politics. Nor is it a discussion of the policy design (governance of intersectoral action) and implementation after enactment. The chapter does not discuss the governance and implementation of the policies, a subject of considerable investigation and writing, which is discussed in the next chapter. Instead, the chapter focuses on two robust frameworks which can be useful in identifying opportunities to make coalitions and policies.

3.3 Salience and conflict: making policy in complex governments

Coordination is the “holy grail” of public administration (Reference Boin, Ansell and LodgeBoin et al., 2011; Reference PetersPeters, 2015) and the COVID-19 pandemic has clearly shown its importance (Reference Greer, Jarman and FalkenbachGreer et al., 2021a). Unfortunately, it is also a notoriously difficult political and administrative problem and an intractable concept for many researchers and policy thinkers. The basic problem is that the diversity of interests in any modern society means that government is pulled in many directions. While speaking of sectors or organizing around ministries and agencies gives some basic orientations to the conversation, a quick look at most health ministries shows how they often combine, or are combined with, quite diverse functions (Reference RoseRose, 1987). Furthermore, organizations and institutions have entrenched interests and ways of thinking. Even if there is an argument that they could do their jobs better were they to change approaches, the process of creating widespread acceptance and implementation of a change can be very prolonged and politically exhausting.

Consider health ministries (Reference BriatteBriatte, 2010; Reference GreerGreer, 2010; Reference MätzkeMätzke, 2010; Reference SheardSheard, 2010). Until the 1980s, most West European countries, Bismarck or Beveridge, folded health care into a ministry of labour or social security, packaging the delivery of health care with other areas of social insurance such as pensions and unemployment insurance. That gave health a certain kind of coherence, as a form of insurance against a social risk, but also made it hard for governments to treat health as a topic in its own right. As governments became increasingly engaged with health and health care management from the 1980s, they created freestanding health ministries along with arguments about what issues (youth? families? social care? sport?) should be packaged with and implicitly subordinated to the goals of health and health care.

Furthermore, a focus on intersectoral governance as a problem of public administration tends to direct our attention towards problems of administration when the greater challenges are often political. The recalcitrant ministry or sector will often reflect the interests of some well entrenched interest, party or faction rather than being mulish or inert. Analysts can go a long way by focusing on structural interests and politics of ministries and sectors such as transportation, health care, education or finance. However, those ministries’ actions often reflect deep political disagreement rather than a problem of bureaucratic politics. Just consider the resistance of health sectors to the austerity imposed in many European countries after the 2008 financial crisis – a failure of coordination in the eyes of many finance ministries and central banks but a laudable fight to maintain essential health services in the eyes of many in the health sector (Reference FierlbeckFierlbeck, 2021; Reference Greer and BrooksGreer & Brooks, 2020).

Hierarchy, meaning an attempt to subordinate one issue area to another, might look like a lasting solution. It is certainly a common one, with governments worldwide operating formal and informal hierarchies of departments and ministerial posts. That might be desirable, but it is unlikely to work if the underlying interests, political priorities and institutions do not support it. Instead, the solution will often lie in a more subtle politics of coalitions, identifying the particular mixtures of wins that will create a strong supportive coalition for enacting and implementing the policy. The creation of such a coalition will often depend on very specific policy compromises (for example, to do with who works or what kinds of companies provide a service) and sometimes side-deals in entirely separate areas, something generalist politicians and major interests will often do. Nonetheless, the basic social coalitions that can underpin a successful policy will often be explicable in terms of policies that unite their shared interests.

Many co-benefits can be attained by action within a single sector, ministry or organization. Improved school nutrition or reduced catastrophic health care costs can be achieved without intersectoral cooperation. They might not even require new resources if the money can be redeployed from elsewhere within the sector. This means, perhaps paradoxically, that some of the greatest co-benefits will come from sectoral, rather than intersectoral, actions. If reducing catastrophic health care costs is a route to reducing poverty and social risk, then a health care finance policy aimed at reducing it can receive support from across government. If better and more easily available school meals improve student health and education, that might be perfectly attainable within a normal education budget. Coordinating within a sector is by no means easy; it is easier to write about redeploying resources from elsewhere within the sector than to actually do it (consider the noteworthy failure of many efforts to redirect health care resources from hospitals into primary care and prevention).

It is often then harder when multiple sectors are involved, if nothing else because people within a different sector, however much they disagree, will often have a shared interest in avoiding intervention by outsiders. Understanding routes to effective action requires understanding the particular political system and government constraints involved. Fortunately, there are useful middle-range social scientific tools for this (Reference Greer, Fafard, de Leeuw and CassolaGreer, 2022; Reference Greer, Vasev and WismarGreer et al., 2017a, Reference 53Greer, Bekker and Azzopardi-Muscat2018). These can include understanding agenda-setting dynamics, which are useful for policy entrepreneurship and advocacy (Reference Greer, Kingdon, Agendas, Balla, Lodge and PageGreer, 2015; Reference KingdonKingdon, 2003; Reference Leppo, Ollila and PeñaLeppo et al., 2013; Reference Moran, Rein and GoodinPage, 2006) as well as understanding the particular institutional and political landscape of a given country.

In terms of identifying prospects for effective action, intersectoral or within a sector, Edward C. Page developed a simple four-cell that is very useful for understanding the prospects of a proposal for action, shown in Fig. 3.1 (Reference BogdanorPage, 2005). Two questions arise when considering a proposal for action: 1) Is the proposal contentious between one or more powerful actors? 2) Is the proposal salient to high level political generalists whose intervention can force a resolution to a dispute?

Fig. 3.1 A high salience, low conflict problem has the highest potential of being resolved

In the abstract, the ideal situation for policy change is a high-salience, low-conflict policy. The second best is a low-conflict, low-salience area where patience can often achieve good outcomes. A high-conflict, low-salience issue has a bad prognosis since it is unlikely to attract the attention of more powerful actors who can decide an outcome. In contrast, a high-conflict, high-salience issue is likely to get a resolution because the top of government cannot avoid it. Note that both salience and conflict are partly rooted in the public administration and legal structures that preoccupy literature on intersectoral governance and HiAP. Still, both reflect broader politics which manifest in the creation, operation and leadership of different ministries and organizations.

The usefulness of this framework is twofold. Not only does it help to determine where a given proposal currently finds itself in terms of political importance and conflict, as previously mentioned, but it also helps us understand how the proposal can gain political importance while simultaneously becoming less conflictual. Thus, focusing on co-benefits has two potential rhetorical advantages in understanding and acting within this type of situation. First of all, it can increase the salience of the issue by offering more, or by documenting greater harms from a policy than were previously understood. For example, let’s consider the impact of catastrophic health care costs as a problem of both immiseration – poverty creation – and health access. There might be a bigger constituency to address them than if we only focus on health care access. Second, focusing on co-benefits also allows us to consider ways to redirect the conversation to reduce conflict. Identifying win-win solutions can release us from win-lose (or lose-lose) policy debates that have often gone on for a very long time and are often framed entirely within the constraints of very crude budgeting logic (Reference WhiteWhite, 2013). Win-win solutions are often attractive, in particular, to powerful generalist policymakers at the top, who are naturally reluctant to make tradeoffs.

3.4 Governance: overcoming challenges of implementation and sustainability

Implementation is famously one of the most theoretically and empirically challenging topics in social sciences. It is not for want of attention by researchers in fields as diverse as public administration, political science, economics, change management, organizational behaviour and psychology. There are powerful reasons why something that has been decided might be ignored at the level where it must be implemented – from habit to complexity to inadequate resources to poor communications to interest group resistance to corruption to well founded disagreement with the policy. It appears that, for all the effort, there is no one good theory of implementation or how it works which can be adopted across different contexts (a sign of this is the burgeoning new field of implementation science).

A second question is how to sustain, or entrench, a policy over time. Sustainability is a second question of great interest to political science researchers but often receives less attention in public health and health policy literatures (Reference Greer and LillvisGreer & Lillvis, 2014). Put simply, most officials, ministers and governments are not in position long enough to assume that even the policies they implement will be sustained. New officials, ministers and governments will have their own agendas, might be actively hostile to their predecessor’s activities, and are often unlikely to invest too much energy in the previous agenda. Interest groups and others who lost out on the original decision and resisted implementation will have additional opportunities to undermine the policy. We can see this in some of the most dramatic policies the EU has adopted in the twenty-first century as well as endless examples in government.

There is a variety of solutions that governments can adopt in trying to address the sustainability problem and entrench their programmes. They include entrenching them in legislation or even constitutional law, the effectiveness of which varies with political institutions. The more difficult it is to legislate, the more value politicians will see in legislation since the difficulty of legislating will deter or defeat successors who do not value the policy. They also can include mandatory requirements of various sorts, which expand the scope of conflict and thereby make it harder for governments to renege on commitments. This can mean, for example, mandatory submission of reports on progress to the legislature, publication of regular and relevant data, and public consultation processes which allow allies in civil society to follow policy closely and argue for continued policy implementation. They include public visibility and “traceability” of benefits, allowing voters to know who, and what policy, is responsible for something good they received. They can also include the legal system’s use, for example, in the form of rights of action that can be enforced through lawsuits. This is partly achieved through simple policy design, which makes it clear where benefits and co-benefits come from.

Progress and sustainability require governance, which is the set of processes by which decisions are made and implemented (Reference Greer, Wismar, Figueras, Greer, Wismar and FiguerasGreer et al., 2016, Reference Greer, Vasev and Jarman2019). To some extent governance in a country is usually a given; there are legal, bureaucratic, political, cultural and other limits to how much any particular policy area or programme is likely to diverge from how things are generally done in a country. But governance is constantly changing, being reshaped by political and institutional evolution as well as the policies themselves, whose organization changes “the way things are done” for the future.

The TAPIC framework (Box 3.1) is a useful analytical tool for identifying problems in governance (Reference Greer, Wismar and FiguerasGreer, Wismar & Figueras, 2015). The framework first determines whether a problem can be attributed to governance (as against, for example, inadequate resources) and then identifies the particular governance problem: transparency, accountability, participation, integrity and policy capacity.

If we assume that the case for a particular programme with co-benefits has been made, then the question is what mechanisms will promote the necessary level of intersectoral governance. Longer discussions can be found in Reference Greer, Wismar, Figueras, Greer, Wismar and FiguerasGreer, Wismar and Figueras (2016), and especially Reference Lillvis, Greer, Greer, Wismar and FiguerasLillvis and Greer (2016) and Reference 54McQueen, Wismar, Lin, McQueen, Wismar and LinMcQueen and colleagues (2012). Table 3.1 is a schematic presentation of the below described approaches, drawing on and expanding the more structural (organizational and budgetary) approach developed in earlier work (Reference McQueen, Wismar and LinMcQueen et al., 2012).

3.5 Conclusion

Governance and politics in the abstract are not always interesting or productive topics, but figuring out the political coalitions’ governance arrangements that will create and sustain intersectoral co-benefits is complex and vitally important. How do the law and organization of each sector contribute to or impede intersectoral action? What policy tools might help to change that?

In particular, intersectoral action faces the twin challenges of implementation and sustainability. Implementation challenges receive much of the attention in policy debates and literature, since it is clear that many statements of intersectoral good intentions, like many policies of all kind, do not turn into real changes. There are many ways policymakers approach the implementation problem, as shown in Table 3.1, which can include budget, procedural and other changes to the way policy is made, substantive plans and targets, and appointments of key people.

But politicians and policymakers also must focus on the sustainability of their approaches. Enactment of a policy creates new challenges and might give opponents new opportunities to delay or reverse changes, while also creating the possibility of policy that can win supporters as it is implemented. Policymakers meet the sustainability challenge by identifying ways to entrench intersectorality through techniques as different as reporting to the legislature, creating legal rights, and developing internal review processes within government. Entrenching policy is urgent because otherwise bureaucratic entropy combines with political opposition to undermine that policy. It is also a kind of political thinking, because it involves anticipating potential supporters who can defend and extend the policy once the ministers are long out of office, and identifying ways to empower them.

Governance for co-benefits, in particular, is often going to be about supporting coalitions of different interests which can support each other even after a government decides it is time to go back to basics (for example, not focusing on win-win solutions and instead focusing on a few targets), changes ideological orientation, or simply loses interest. Fortunately, the vocabulary and range of international experience means that there is a great deal of writing and thought in this area, and it shows the importance of creating and entrenching coalitions. That, of course, is best done with a win-win approach.