Every action in human affairs has consequences. Also, every action is preceded by circumstances and forces that predetermine or are conducive to the action.
These rather trivial observations have important implications for public policy. First, it behoves every member of the policy community and every politician to consider carefully the consequences of every decision they make.
These consequences are sometimes easily foreseen, sometimes not; but the risk of adverse unforeseen consequences is less if decisions are made on the basis of reflective, consultative research and analysis protected from the passions of contemporary political disputation.
Second, to achieve an objective, leaders need to ensure that the preconditions for it are in place. For example, essential preconditions of hygiene in an operating theatre include disinfectant, equipment to sterilise instruments and staff with sufficient experience to utilise it. Then a successful operation requires a large number of other elements to mesh together at just the right times. Operations are postponed if even one of the essential elements is missing. Hospitals even have generators on standby in case a tree collapses across a powerline somewhere.
Sometimes the preconditions are essential, sometimes necessary (a less absolute form of ‘essential’), some simply desirable. For example, upbringing in a loving home is conducive to well-adjusted adulthood, though not essential, as people can rise above their circumstances.
Sometimes the preconditions are necessary but not sufficient by themselves, an example being that an infant requires nutritious food to be healthy, but also clean bedding and unpolluted air.
Differentiating between essential, necessary and desirable, then between necessary and sufficient is an essential skill for public policy analysts. It’s pivotal to understand that causes have many consequences, and consequences have many causes. In this series of articles on the preconditions of well-being, we will focus on some principles of effective policy-making and program implementation.
Five capacities
It is common to read Budget papers, government press releases or parties’ campaign announcements that proclaim some new project or initiative with worthy objectives but with no feasible pathway to allow them to be achieved.
This is an ingrained risk with short-term projects where the lead-up time needed to assemble the resources can consume a large proportion of the time before the funds or the time expire and the staff have to make a fresh submission to continue the initiative.
It’s also a risk factor for broad-scope strategies such as that outlined in National Preventive Health Strategy 2021-2030, a document to which we will return in a later column.
We can call the process of defining preconditions and consequences establishing a feasible path. We can call the components of a successful program elements, including infrastructure, materials and services. We can call the ability of a person or organisation to provide one or more of these elements a capacity.
Although committed functionaries will always try to make the best of their circumstances, the absence of any one or more of several necessary capacities renders much other capacity impotent.
Within the Australian public health sector, the separation of the frontline operatives who know about the deficient systems requiring remedy from those who make strategic decisions or control the budgets is chronic. Medicos and scholars who understand how human bodies function tend to shy away from involvement in politics.
Those who hold the power and the budgetary levers don’t necessarily understand public medicine and in any case are usually busy trying to cut costs – ‘budget discipline’, it’s called by the accountants, ‘penny-pinching’ by the operatives.
Superimposed on these disciplinary cleavages are the sectoral and jurisdictional ones: the health sector is populated with private, public, for-profit/non-profit, state and federal entities like no other.
In contemplating the sector, one is impressed by the number and earnestness of capable people labouring to manage frontline health services, but one commonly looks in vain to find any entity that is properly resourced with sufficient line command over an adequate number of elements of the health eco-system to deliver health services efficiently.
The elements of a feasible path can be classified into Passion, Powers, Personnel, Knowledge and Purses. The model applies to all fields of public policy. In this column, we will touch on just the first.
Passion
There is hardly a modern corporate or departmental strategy in existence that does not include a section entitled ‘Vision’ or ‘Mission’. Compilers argue that every organisation needs a clear statement of its purpose if it is to apply its capacities effectively. This reflects the ‘management by objectives’ philosophy that became popular in management circles during the late 1900s.
But a formalised corporate vision is not the primary launching pad for an effective strategy of health: it consists of just words on paper and can be regarded with deep cynicism when the organisation’s actions fall short of the words. Most public servants know the script: “Our staff are our most valuable resource” — but suffer repeated budget cuts, restructures and pay freezes.
Preceding any worthwhile vision is the passion that people within the system or the organisation hold for the functions that they are to discharge. Human progress is made by people who are committed to an ideal and have sufficient passion to overcome the institutional and other obstacles to achieving it.
Passion is overlooked in most rationalist metrics of how to run an organisation. It cannot be reduced to financial statistics. It is most often displayed by people who are knowledgeable about the field and it is played out in the vision that they articulate. Passion runs deep among researchers who are inspired by unsolved mysteries and by frontline medical and nursing staff who are inspired to relieve human suffering.
Passion is disparaged by economists who have been taught from their first lectures that human activity is motivated heavily or primarily by self-interest. Passion in research circles — notably in climate science — is disparaged by commentators who sneer that researchers are motivated primarily to secure grant funding as if the ambition to succeed in their chosen field is a character defect.
Passion can be expressed for the substance — e.g. health outcomes — or for the process — e.g. efficiently operated procedures in a hospital, but efficiency should be continually framed as a means to the health outcomes and not supplant it.
Passion itself has preconditions. It is grounded in an ethical framework that has metaphysical or professional antecedents, and these in turn are amenable to analysis.
Implications for policy
Teasing out the threads of past and potential causation in any issue in public policy requires meticulous research, thoughtful deliberation and wide consultation with those who know more about the subject than the analyst.
Every public authority should have staff personnel who are competent in policy and strategic planning to assist the organisation in sketching out a feasible path to achieve its mission. This will include anticipating the consequences of factors both within and beyond their control, as best they can.
Those personnel need to be allowed time to engage in research, deliberation and consultation — continuously. And Treasuries should make sure that they provide every authority with sufficient funding for this purpose. Staff competent in policy analysis are an essential precondition to successful policy.
Every public authority should have on its staff personnel who are passionate about the function they are delivering and have dedicated their careers to that field. Yes, there is a place for generalist managers who bring skills from other sectors and who can broaden the horizons of the frontline staff, but do so with respect for the deep insights that those passionate about their field commonly hold.
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