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Understanding Policy Change 95 Hall integrated aspects of historical institutionalism and the literature on scientific paradigms to explicate the roles played by ideas and knowledge in public decision making (Kuhn, 1970). Public policy discussion occurs within specific realms of discourse (Anderson, 1978). Policy-makers work within specific frameworks of ideas and standards that specify policy goals and the instruments or means by which these goals can be attained. These frameworks are grounded in the kind of language through which policy-makers convey and do their work. Th ere exist, therefore, infl uential systems of ideas that guide both policy development and the policy-makers themselves. Th is may be problematic “because so much of it is taken for granted and is not amenable to scrutiny as a whole” (Hall, 1993, p. 279). Th ese systems of ideas specify what types of problems will be defi ned as legitimate public problems requiring government action. Th ese systems also specify the tools that government may apply to address these problems (Hall, 1993). Hall refers to these interpretive frameworks as policy paradigms , which help to explain diff erent patterns of policy change by linking these paradigms to specifi c instances of social learning. Box 4.1: The Process of Social Learning Hall draws on Heclo’s work to formulate the concept of social learning. He argues that a key factor affecting policy at time-1 is policy at time-0. Previous policy is an important influence on current policy. In fact, Hall suggests that policy responds “less directly to social and economic conditions than it does to the consequences of past policy” (Hall, 1993, p. 277). Moreover, consistent with Weir and Skocpol (1985), he argues that the interests and ideals that policy-makers choose to follow are influenced largely by what are termed policy legacies (i.e., previous policy shapes future policy). In addition, experts in a policy field in which policy change is being considered tend to be very influential in the learning process. They may advise the state from a privileged and critical position at high-level meetings between the bureaucracy and intellectual leaders. Hall’s portrayal of the policy change process suggests a highly elitist activity from which some groups may be shut out. This suggests that policy changes reflect the interests of those attending such high-level meetings more than those who are likely to be adversely affected by policy changes. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

98 Health Policy in Canada paradigms to agree on a common body of knowledge on which to favour one paradigm over another. Yet sometimes paradigmatic change is a gradual process shaped by experiences accrued from policy experimentation and policy failure. Box 4.2: Advocacy Coalition Framework Like Hall’s policy paradigms, Sabatier’s advocacy coalition framework is a learning model of policy change. The advocacy coalition framework of policy change is a conceptual framework for examining policy change of a decade or more (Sabatier, 1993). This model attempts to explain the strategic interaction of political elites and policy experts in a policy community or subsystem. The policy subsystem consists of ideologically based advocacy coalitions that are involved in a particular policy area. Coalitions can include actors from both the public and private sectors, such as social scientists, senior civil servants, the media, politicians, and interest groups. The coalition can also include actors from local and regional governments involved in policy formulation and implementation. These actors can all play a role in the generation, dissemination, and evaluation of policy ideas (Dunleavy, 1981; Heclo, 1978; Milward & Wamsley, 1984). Consistent with Heclo, Sabatier argues that policy change occurs within a social, economic, and political context (Heclo, 1974). Policy change can also involve competition for power and conflicting activities within the community that emerge to address a policy problem. Sabatier is particularly interested in the role of technical information—or expert knowledge—and ideology throughout the policy process. Some key concepts require examination. Belief system : Subsystem members can come from different advocacy coalitions, and this shapes their activities (Sabatier, 1993). All share a set of normative and causal beliefs (ideology). Beliefs shape policy positions, instrumental decisions, and the information selected to support specific policy positions. The belief system consists of three structural categories. These categories are termed the deep (normative) core , which comprises fundamental normative and ontological beliefs; the near (policy) core , which are the coalition’s policy positions; and secondary aspects , which are instrumental decisions and information inquiries enlisted to support the policy core. The coalition’s strategies (policy core) and secondary aspects respond to perceptions about the adequacy of governmental decisions in relation to the perceived problem. Changes in strategy can include lobbying for major institutional revisions Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 101 infl uence institutions have to impede new ideas or help bring them into the policy discourse and public policy decisions (Fischer, 2003). Changes in the British economy, specifi cally an unemployment crisis and high levels of infl ation, challenging the principles of Keynesianism, contributed to the paradigm shift to monetarism. Th ese changes therefore provided an opportunity for the application of new paradigmatic ideas from the Conservative Party (Fischer, 2003). Limitations of Policy Paradigms Hall provides a compelling explanation of the shift to monetarism and shows how institutions can structure outcomes. The focus on institutions, however, precludes other considerations. For example, his model fails to consider how structures and interests influence political, economic, and social change. He seems unconcerned about the close association between certain interests, such as social scientists and the political system. Moreover, Hall does not consider how the Thatcher government deliberately excluded particular groups from the political process. For example, after her election as prime minister, Th atcher undermined trade unions in the United Kingdom, thereby increasing class confl ict (Krieger, 1987; Towers, 1989). Th is increase in class confl ict distorted the policy change process by weakening the ability of information and knowledge supportive of the working class to infl uence policy change. More overtly, she also abolished the Greater London City Council, since it appeared to oppose her policies. Th ese actions represented clear exercise of raw political power that deliberately limited the ability of opposition groups to challenge these policy changes (Raphael, 2014). Hall identifies the influence of political elites on the policy change process, but does so in a manner that implies that this relationship and its impact on the policy change process is unproblematic. This close relationship between elites and policy-makers may be construed as policy development in the service of particular segments or interests of the population to the detriment of others. In addition, Hall articulates a single path to paradigmatic change. Paradigmatic change occurs in response to a series of policy failures, a shift in political power, or external shocks. But there is another trajectory for paradigmatic policy change. Paradigmatic policy change can also result from a series of incremental policy changes over several years (Coleman, Skogstad, & Atkinson, 1997). Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

104 Health Policy in Canada Civil society : Beginning at the top of the figure, civil society encapsulates the values and beliefs of the citizenry, as well as its institutions and traditions, thereby providing a context for the policy change process. Professional policy analysts and citizen activists : Civil society consists of many groups, including the market, trade unions, professional associations such as medical and nursing associations, other health professions’ associations, and faith communities, among others. The groups of interests identified in the figure are professional policy analysts, the experts in Hall’s policy paradigms, and citizen activists, because these are the groups that try to act on the political system to influence public policy. Some political actors constitute a hybrid. Th at is, they usually possess post- secondary degrees and specialized knowledge in a particular policy fi eld. Th ey may work as policy analysts for trade unions or social and health policy think tanks. Th ese aggregates are politically engaged groups of civil society and are not necessarily mutually exclusive, nor are they intended to be representative of all groups in civil society. Th ey represent diff erent political entities in the public policy process. An important element here is the inequality in the capacity of each group to influence the political process in terms of finances and other resources such as education. Both kinds of groups engage in knowledge creation and advocacy activities (see Box 4.3). Box 4.3: Editorial: Better Health, Lower Costs Toronto Star The case for a national pharmacare program, covering prescription drug costs for all Canadians, is now noticeably stronger. A persuasive new study analyzing the cost of such coverage has found it would save a great deal of money, especially for the private sector, with relatively little expense to government. “In many of the scenarios that we modelled, universal pharmacare was cost- neutral for governments,” said Dr. Danielle Martin, one of the study’s authors and a vice-president at Women’s College Hospital in Toronto. “This goes against current thinking that a universal program will cost more.” These findings, published on Monday in the Canadian Medical Association Journal , should be required reading for provincial and territorial politicians and especially in Ottawa, where federal determination to make pharmacare happen has been noticeably lacking. Universal public drug coverage could lower annual spending on prescription medicine in Canada by $7.3 billion, conclude the study’s authors. Several scenarios were developed on what such a program might cost government, Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 107 two groups. Did the experimental group improve their symptoms as a result of taking the medication? Or did the control group experience similar improvements in their symptoms? Interactive knowledge is created through exchanges or conversations with other people. People exchange information and actions supported by common experience, tradition, history, and culture. This knowledge builds connections among members of a community and enables the formation of community. An example of interactive knowledge would be a lived experience such as asking people what they would do for their children if they were unable to find a child care space, or understanding the culture of nurses working in a particular ward of a hospital. What is the nurses’ informal understanding of their work, and their relationships with each other, physicians, other health professions, and patients? Critical knowledge is derived from reflection and action. Citizens acquire critical knowledge by questioning or challenging their life conditions and identifying what they wish to achieve as self-determining social beings. Through critical knowledge, they can mobilize others to challenge existing public policies and programs that govern their lives. Thus, critical knowledge has a transformative element. An example of critical knowledge would be the relative power of nurses and doctors and how this developed. Nurses would acquire a critical understanding of why they are subordinate to doctors and hence undervalued for their contribution to patient care. Source: Park, P. (1993). What is participatory research? A theoretical and methodological perspective. In P. Park, M. Brydon-Miller, B. Hall, & T. Jackson (Eds.), Voices of change: Participatory research in the United States and Canada (pp. 1–19). Toronto: Ontario Institute for Studies in Education. Instrumental knowledge represents a positivist-rationalist approach to problem solving, as exemplified by the biomedical approach defined in chapter 2. It is usually associated with experts such as epidemiologists, social scientists, physicians, or others in the health field, for example, with specialized knowledge perceived as objective and value-free. Interactive knowledge develops from people’s daily interactions with one another or their perceptions and understandings of a health condition, for example. This type of knowledge can be stories or concepts that people create Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

110 Health Policy in Canada registered nurses aff ected the quality of care they received when they were in hospital. Fewer nurses means that patients may not have their needs addressed as quickly as may be necessary. All of these approaches are about how to present information to government in order to influence public policy decisions. They are therefore informed by political considerations and questions of how advocates can effectively make their case on proposed policy changes and draw media attention to their efforts. Knowledge dissemination and issue promotion are also inherently political activities. Civil society actors present their policy ideas to government offi cials and opposition parties to achieve particular policy change outcomes. They also attempt to influence other civil society actors. They may form new alliances to enhance their political power. Media presence can help groups enhance their political power by increasing their visibility. This may help increase their visibility and generate public sympathy for their cause. The state: The state consists of the government of the day and state institutions responsible for a policy domain. In Canada, state institutions consist of legislative bodies, including Parliament, the Senate, legislative committees, law-making institutions such as the courts, and ministries or government departments run by civil servants (Ham & Hill, 1984). These different components of the state exist at different levels. In Canada, for example, there are municipal, provincial/territorial, and federal levels of government, with varying degrees of responsibility for enacting and enforcing laws in public policy. The state represents the legitimate use of force to achieve certain objectives and outcomes (Ham & Hill, 1984). In most jurisdictions, the state is led by a political party that is elected by citizens every four years. The state is not always well conceptualized in models of public policy. It is often presented as one-dimensional—as an essentially neutral or apolitical organization that mediates among competing interests. In this way, it is consistent with the pluralist view of policymaking presented in chapter 3. The state has numerous roles within the many areas that constitute health policy in modern capitalist societies such as Canada, the United States, and the United Kingdom. The economic system is integrally related to the political system, and state roles are often contradictory. The state must promote economic development while at the same time ensuring social order and solidarity among different social classes and other groups in society (Teeple, 2000). Thus, in addition to identifying the institutions that make up the state, the links between the state and the social system—including hierarchies of class, gender, ability/disability, immigrant status, and race, among others— must be clearly articulated. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 113 Of all the Toronto hospitals facing closure, Women’s College Hospital presents an interesting case. Women’s College Hospital grew out of the Ontario Women’s Medical College, established in 1911 (Kendrick & Slade, 1993). The founding of the college was a response to the refusal of the University of Toronto to accept women as medical students in the late 19th century. The college provided an opportunity for women to study and practise medicine. The hospital retained the word College in its name as a reminder of this history. In 1960, Women’s College Hospital sought affi liation with the University of Toronto and became a teaching hospital. Starting in the late 1980s, Ontario governments grew increasingly concerned about controlling hospital expenditures. One of several hospitals running a defi cit during this period, Women’s College Hospital received one-time-only bridge grants of $2 million for the 1988/89 and 1989/90 fi scal years on the condition that it eliminate its defi cit (Lownsbrough, 1990). In October 1989, the hospital board voted in favour of pursuing a merger with the larger Toronto Hospital, which had already merged with its western division, Toronto Western Hospital. Women’s College Hospital’s medical staff association and other staff opposed the proposed merger. Friends of Women’s College Hospital was formed to oppose the merger and worked with the medical staff association on this aim. By reframing the issue as a stakeholder debate, these combined forces defeated the merger at a public meeting, where 648 of 700 hospital shareholders voted against the merger. In November 1995, the newly elected provincial Conservative government introduced legislation—Bill 26, the Savings and Restructuring Act (also referred to as the Omnibus Bill)—that created the Health Services Restructuring Commission (HSRC) (The Caledon Institute, 2001). The bill empowered the commission to close and merge hospitals across Ontario in order to eliminate $1.3 billion from the hospital budget within two years. In Analysis involved identification of key ideas associated with the use of knowledge in political advocacy and policy change. Inductive analysis was used to analyze notes taken during the document review. Comments from the interviews were used to devise additional categories to accurately reflect emerging themes and patterns in the data. This approach allowed for consideration of alternative explanations and understandings. Participants identified a range of issues on knowledge and its uses in political advocacy. The focus was on issues relating to the types of knowledge brought to bear on the hospital restructuring process by Women’s College Hospital. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

114 Health Policy in Canada Metropolitan Toronto, the goal was to close 12 of 44 hospitals. The commission recommended closing Women’s College Hospital and merging its in-patient services with Sunnybrook Health Sciences Centre. In the end, Women’s College Hospital applied suffi cient pressure to force the HSRC to reverse its decision to close the hospital. Specifically, it threatened to sue the commission, which helped to secure the outcome the hospital sought. Not only did the hospital avert closure, it legally secured its existence in legislation—a first in any jurisdiction—and was reconfigured as an ambulatory care centre for women’s health programs. It has since reclaimed its independent status, as the Ontario Liberal government severed the merger in 2006. Th rough document review and interviews with key strategists for the hospital and policy analysts, among others, the case study considered how the board of Women’s College Hospital infl uenced the health policy change outcome (Bryant, 2001, 2003). Of key interest was whether knowledge presented by Women’s College Hospital was the decisive factor in the fi nal decision of the commission. Box 4.7: Case of Women’s College Hospital during the Hospital Restructuring Process in Ontario, 1995 “Without the word being used, it was defined as woman-driven and woman-centred and woman-positive at its founding … in direct response to discrimination from the University of Toronto … you wouldn’t necessarily use the term ‘feminist’ … if you look at what was said and you look at the values and whatever the defining term was, it was about equal opportunity.” —Participant Interview Source: Bryant, T. (2003). A critical examination of the hospital restructuring process in Ontario, Canada. Health Policy , 64 , 193–205. Among the fi ndings was that Women’s College Hospital advocates used various forms of evidence to avert closure in its dealings with the HSRC. By doing so, it mobilized women across the province to help fi ght the closure. Yet, while there was careful selection and deployment of various forms of knowledge in its submissions to the commission and in informing its supporters, it was the combination of political skills and access to the government that may have clinched the outcome for the hospital. Th e Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 115 hospital’s strategists arranged meetings with Cabinet ministers in the Ontario government through contacts of board members. Some of the themes that emerged from this analysis have direct implications for understanding the policy change process. FINDINGS FROM THE WOMEN’S COLLEGE HOSPITAL STUDY The detailed findings from this case study are available (Bryant, 2003). Generally, it was found that advocates for Women’s College Hospital used various forms of evidence to avert closure in their dealings with the Health Services Restructuring Commission. By doing so, they mobilized women across the province to help fight the closure. HSRC’s Emphasis on Quantitative Evidence The commission was identified as being focused on objective, quantitative indicators such as the condition of the physical plant of a hospital, the number of patients receiving care, and the number of procedures carried out at a given hospital, rather than information about the experiences that women had when they were patients at the hospital. This focus led to the exclusion of quality of care issues and the neglect of women’s health issues. Feminist Issues and Feminist Policy Analysis The strategists used gender and gender issues to market the hospital. They viewed the hospital as committed to feminist principles, a pioneer in women’s health research, and as having a history of providing quality health services to women. The uniqueness of the hospital was also expressed in terms of its organization of power and its collaborative approach to care. Use of Legal Arguments and Analysis Legal arguments and analysis were applied in both the 1989 and 1995 anti- merger campaigns. During the 1989 campaign, the issue was defined as a Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

116 Health Policy in Canada shareholder fight. Advocates sought legal advice on litigation options, although litigation was not pursued. Participants perceived legal arguments and analysis as strengthening the case of the hospital in the restructuring process. Knowledge Is Political It was concluded that knowledge and its use were profoundly political in this case. Both the government and the advocates saw each piece of information provided through the lens of political ideology. When considering the hospital’s outcome, some advocates considered the hospital unsuccessful, since it lost its independence, while others saw it as being successful, since it secured its existence in legislation. As one interview participant argued, it may have been not lack of knowledge but lack of power that determined the outcome in the restructuring process. In summary, the use of various forms of knowledge was consistent with the conceptual framework presented. The findings add to an understanding of how different forms of knowledge can influence the health policy development process. Particularly important was not only the gender and abilities of the hospital strategists, but also their close association with the governing Conservative Party at Queen’s Park. Many were lawyers and highly skilled, and therefore knew how to strategize to meet their political objectives. In other words, specific interests drove the process. The elite did not achieve the outcome it sought, which was retaining the independence of Women’s College Hospital. Thus, in the end, the outcome can be attributed not so much to knowledge and its uses during the restructuring process, but rather to the dominance of specific interests and structures that ensured particular policy outcomes. Women represented an important constituency that the Ontario Conservative government did not wish to offend. Women’s College Hospital represented the health interests of predominantly white, middle- class, professional women. There was little concern with the health issues of marginalized women, such as women of colour, women who are homeless, and other communities of women who may use the health care system, but lack a political voice to assert their interests in the political arena. Different Ways of Knowing about a Social Issue Different ways of knowing were used to influence policy change in this case. The approach of Women’s College Hospital to the selection of knowledge and Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 117 evidence was affected by the priorities of the Health Services Restructuring Commission and the commitments of the hospital’s board. Since the commission emphasized instrumental knowledge in its use of objective indicators, such as volume of care issues, program levels, clinical activity, and the state of the physical plants of hospitals, the strategists provided these kinds of information, as well as interactive and critical information. This evidence and other information were developed through legal cases. Legal arguments are made using verifiable evidence and judicial rulings. Rulings arising from legal cases are considered authoritative and demand discipline in the construction of cases. Th e diff erences in approaches to knowledge used by the commission and Women’s College Hospital can be understood as a clash of world views. The hospital emphasized quality of care and women’s perspectives on health care issues, while the commission emphasized objective indicators such as the number of procedures carried out at a hospital to justify hospital closures. Th e impact of this framing was to limit debate and depoliticize the process, and potentially silence opposition to the restructuring process and how it was carried out. The case of Women’s College Hospital demonstrates the use of instru- mental, interactive, and critical ways of knowing in political advocacy. While knowledge was important and helped to establish the credibility of the hospi- tal, it did not emerge as the decisive factor in the case. Political considerations were more important in shaping the outcome. Th e relative success of the hospital can be attributed to a number of factors. Among these is its use of gender, its status as an institution, its capacity to initiate legal action to force a policy change to achieve its objectives, and the political connections of some board members to the Ontario Conservative government. Some board members were card-holding members of the Ontario Conservative Party. Th e hospital and women represented constituencies that the government did not wish to off end and identifi ed as important to its future electoral success. THE CASE OF THE TENANT PROTECTION ACT The second case provides an example of analysis of a health-related public policy change. The case study on housing policy change focused on the Tenant Protection Act (Government of Ontario, 1997). This study systematically examined the context within which the new provincial regime changed rental Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

118 Health Policy in Canada housing policy from 1995 to 1998. It focused on how tenant advocates in Toronto, the largest urban centre in Ontario, attempted to influence the policy change process. A particular focus was how oral presentations that challenged the provisions of the legislation were constructed through the selection of specific forms of knowledge and evidence. These oral briefs were means by which tenant advocates constructed their arguments and selected evidence, and the epistemological commitments within these briefs shaped how decisions were made in their attempts to influence the government. A number of other activities occurred at this time: media campaigns, speeches, material distribution by advocates, and Opposition party activities. The use of briefs provided a selected sample of information-rich exemplars of the processes used to influence government policy by civil society actors. Canadian provincial governments have constitutional responsibility for providing social housing and rent control. Most provide some form of housing subsidy, but fi scal conservatism in recent years has reduced these subsidies. In Ontario from the 1970s until 1995, successive provincial governments were committed to rent regulation to protect an aff ordable rental housing stock in the private rental housing market, and to increase the number of social housing units. In 1975, the Conservative government introduced rent-control legislation as an anti-inflation strategy. In 1995, the Conservative Party won a majority government on a Common Sense Revolution platform (Progressive Conservative Party of Ontario, 1995). This platform reversed many long-held commitments to social housing and rent control. For example, it emphasized cutting taxes and increasing effi ciencies to reduce the provincial deficit. The document proposed shelter allowances for low-income populations, but did not identify the government’s intention to eliminate rent control. Th e 1996 Tenant Protection Act replaced all existing legislation related to rental housing and introduced vacancy decontrol to remove rent control one unit at a time (Government of Ontario, 1997). Vacancy decontrol allows landlords to increase rent without restriction when a tenant vacates a rental unit. Th e tenant is protected from large rent increases provided she or he does not move. The act also amended the Ontario Human Rights Code to allow landlords to use income criteria to screen potential tenants. This amendment sharply reduced the access of low-income groups to housing. In addition, the government imposed a moratorium on social housing construction, ending the prospect of 18,000 planned social housing units. Shortly after its election, the government also reduced social assistance by 22 percent. These changes had severe implications for low-income populations who were dependent on these programs for shelter and income. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 119 FINDINGS FROM THE CASE OF THE TENANT PROTECTION ACT Detailed findings from this case are available (Bryant, 2004b). The findings were very similar to those of the Women’s College Hospital case study. The advocates were all professional policy analysts, yet described a participatory process in which they drew upon their professional work as lawyers and community workers. They emphasized the use of a variety of forms of knowledge. Some collected primary data through systematic research processes consistent with positivist assumptions about knowledge and evidence. They also provided evidence that considered the lived experiences of low-income tenants and provided a critical analysis of how the proposed legislation would affect an especially vulnerable group of people. Uses of Evidence Empirical evidence applied in the briefs was grounded in the lived experience of tenants. Advocates emphasized the need for empirical data to support their claims and to persuade politicians and the public of the validity of their positions. Advocates also used legal analysis and arguments that contained elements of instrumental, interactive, and critical ways of knowing. Getting on the Public Record Participants did not believe that their presentations would change the legislation to address their issues. Participating in the public hearings, however, provided a means to mobilize tenants and plan for future changes in government to elect offi cials who would be more likely to address the concerns of low-income tenants. Different Ways of Using Knowledge about a Social Issue Participants used various strategies, including legal knowledge and interpretation of the provisions of the act. They also used personal stories drawn from their professional and clients’ experiences with landlord and tenant issues, and political-strategic approaches to navigate the political system by meeting with senior civil servants in the Ministry of Housing to influence the government. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

120 Health Policy in Canada Finally, they met with Opposition parties to help them develop amendments to the proposed legislation. While the knowledge and evidence they presented did not influence the government, it helped Opposition parties in developing their positions. In the end, participants described the government as interested only in evidence that reinforced its ideological commitments. The Role of Political Ideology Participants identified how government ideology was a barrier to their effectiveness in the policy change process. Political ideology drove the legislation and therefore hampered their ability to protect the interests of their constituencies. Advocates considered the current regime in Ontario to be unreceptive to perspectives that did not agree with its own, and motivated solely by ideological considerations. CONCLUSIONS FROM BOTH CASE STUDIES Political ideology and influence play a particular role in both health care and health-related public policy change. The political ideology of the state shapes perspectives on health care and health-related issues and determines, in large part, the policy responses developed to address these issues. Political influence shapes government receptivity to information. Although knowledge came to the government from diverse sources inside and outside government, political influence and ideology emerged in the housing case study as one of the most important dynamics influencing housing policy change during the Harris Conservative regime in Ontario under Premier Mike Harris. The case studies identified the complex of actors who can work to influence policy. They exemplified the existence and application of various forms of knowledge in the policy change process identified in the knowledge paradigms policy change framework. They also allow for specifying the kinds of change that eventually occur. In both case studies, political and economic structures and interests shaped the outcomes. CONCLUSIONS This chapter examined two approaches to understanding and explaining the policy change process. Hall’s policy paradigms is primarily a rational model Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 121 concerned with the role of ideas in shaping public policy change outcomes. Policy paradigms refer to the system of ideas in which policy-makers work. They determine the policy instruments and goals of policy, and define the issues that will be recognized as public issues requiring government action. Policy paradigms focus on the role of social learning, whereby policy-makers make decisions based on experience with previous public policies and new information on a given issue in a policy fi eld. As such, the policy paradigms model is concerned with the role of experts such as social scientists in the public policy process. Hall applied the model to understand the ascendance of neoliberalism led by Margaret Th atcher in the United Kingdom in the late 1970s. Th e model builds on the insights of historical institutionalism, which emphasizes how institutions structure politics and thereby infl uence political outcomes. Above all, it demonstrates how institutions can obstruct policy change. The model considers a limited range of participants in the public policy process and seems to consider the close association between experts and policy- makers as unproblematic. The model does not seem to recognize inequality in access to the political system and in the distribution of political power as being important factors shaping the policy change process. The knowledge paradigms policy change framework builds on Hall’s insights into knowledge, but considers a broader range of knowledge and approaches to influencing the public policy process. The framework is also concerned with the role of political and economic structures such as political ideology, inequality, political power, and the privileging of information and groups in the political process. Applied to the cases of Women’s College Hospital during the hospital restructuring process and changes to the Tenant Protection Act in Ontario, the framework highlights the influence of political issues upon knowledge development, state receptivity, and its eventual application. Policy change, especially in health care and health-related public policy, can be politically charged. Many areas of health policy are contentious. Dominant health interests attempt to hide behind a veil of objectivity and intellectual detachment from issues. The aura of scientific inquiry can sometimes draw attention away from the highly conflictual nature of the health policy field. In the next chapter, the various actors who attempt to influence health policy are examined. CRITICAL THINKING QUESTIONS 1. What do you think are critical determinants of recent health policy changes? Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

122 Health Policy in Canada 2. Which of the two policy change models presented in this chapter explain recent health policy changes that have occurred in Canada or elsewhere? 3. How can we understand the role of institutions, gender, or social class in health policy change outcomes? 4. How does political ideology influence public policy change? 5. How can civil society actors have greater influence on the health policy change process? FURTHER READINGS Bennett, C., & Howlett, M. (1992). The lessons of learning: Reconciling theories of policy learning and policy change. Policy Sciences , 25 (3), 275–294. The authors provide an excellent assessment of the learning models of policy change and compare conflict-based theories with new institutionalist approaches. In particular, they highlight some of the limitations of these approaches to understanding policy change. Bryant, T. (2003). A critical examination of the hospital restructuring process in Ontario, Canada. Health Policy , 64 , 193–205. Building on some of the insights of Hall’s policy paradigms, Bryant presents the knowledge paradigms policy change framework to examine the case of Women’s College Hospital during the hospital restructuring process in Ontario in 1996. One of the key findings was that although knowledge was important, political considerations were more decisive in the final outcome for the hospital. Fischer, F. (2003). Reframing public policy: Discursive politics and deliberative practices . New York: Oxford University Press. Frank Fischer appraises Hall’s policy paradigms model. While he extols Hall’s efforts to demonstrate the influence of institutions on the public policy change process, he provides a post-positivist alternative that focuses on policy discourse and argumentation. Hall, P.A. (2013). Brother, can you paradigm? Governance , 26 (2), 189–192. Hall re-examines paradigm shifts. He considers the potential for a paradigm shift from neoliberalism to a policy paradigm that promotes major shifts in economic and social policy. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 123 Hawkesworth, M.E. (1988). Theoretical issues in policy analysis . Albany: State University of New York. This book provides an excellent discussion about gender in public policy analysis. Hawkesworth articulates a convincing case for feminist policy analysis and its key elements. RELEVANT WEBSITES Canadian Research Institute for the Advancement of Women (CRIAW) www.criaw-icref.ca/en CRIAW is the only women’s organization in Canada focused exclusively on nurturing feminist research and making it accessible for public advocacy and education. All CRIAW activities flow from an overarching goal to provide tools to help organizations taking action to advance social justice and equality for all women. It carries out research on a wide range of public policy areas, including health. Center for Health Policy www.brookings.edu/about/centers/health This website provides tools for policy change, as well as definitions of policy and how communities can engage to change health policies. Although based in the United States, the site focuses on civil society as a key actor in the health policy change process. The Change Foundation www.changefoundation.ca Th e Change Foundation was founded and endowed by the Ontario Hospital Association. It is a health policy think tank that focuses on research and information on health care policy issues to promote health care policy change. The Health Communications Unit https://www.publichealthontario.ca/en/ServicesAndTools/HealthPromo tionServices/Pages/default.aspx The Health Communications Unit is part of the Health Promotion Capacity Building Team of Public Health Ontario. Its mandate was recently expanded to include health policy change. The site provides tools and workshops to help communities and public health authorities work for health policy change. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

124 Health Policy in Canada The Policy Project www.policyproject.com The Policy Project is based in the United States and provides another approach to health policy. Its focus is on helping governments and civil society organizations in developing countries to advance policies on family planning and HIV/AIDS, and promote human rights and gender equality through multisectoral activity. REFERENCES Albaek, E. (1995). Between knowledge and power: Utilization of social science in public policymaking. Policy Sciences , 28 (1), 79–100. Anderson, C. (1978). The logic of public problems: Evaluation in comparative policy research. In D. Ashford (Ed.), Comparing public policies (pp. 19–41). Beverly Hills, CA: Sage. Bennett, C., & Howlett, M. (1992). The lessons of learning: Reconciling theories of policy learning and policy change. Policy Sciences , 25 (3), 275–294. Blitzer, W. (2005, September 11). Aftermath of Hurricane Katrina: New Orleans mayor pleads for help; Race and class affecting the crisis? CNN.com . Retrieved from http:// transcripts.cnn.com/TRANSCRIPT/05/09/01/sitroom.02.html. Bryant, T. (2001). The social welfare policy change process: Civil society actors and the role of knowledge (Unpublished PhD thesis). University of Toronto. Bryant, T. (2002a). The role of knowledge in progressive social policy development and implementation. Canadian Review of Social Policy , 49 (50), 5–24. Bryant, T. (2002b). Role of knowledge in public health and health promotion policy change. Health Promotion International , 17 (1), 89–98. Bryant, T. (2003). A critical examination of the hospital restructuring process in Ontario, Canada. Health Policy , 64 , 193–205. Bryant, T. (2004a). Housing and health. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives (pp. 217–232). Toronto: Canadian Scholars’ Press. Bryant, T. (2004b). The role of political ideology in rental housing policy in Ontario. Housing Studies , 19 , 635–651. Bryant, T. (2009). Housing and health: More than bricks and mortar. In D. Raphael (Ed.), Social determinants of health : Canadian perspectives (2nd ed.) (pp. 235–249). Toronto: Canadian Scholars’ Press. The Caledon Institute. (2001). The Harris record. In R. Cohen (Ed.), Alien invasion: Ontario politics and government 1995–2003 . Toronto: Insomniac Press. Coleman, W.D., Skogstad, G.D., & Atkinson, M.M. (1997). Paradigm shifts and policy networks: Cumulative change in agriculture. Journal of Public Policy , 16 (3), 273–301. Dunleavy, M. (1981). The politics of mass housing in Britain, 1945–75 . Oxford: Clarendon Press. Fischer, F. (2003). Reframing public policy: Discursive politics and deliberative practices . New York: Oxford University Press. Government of Ontario. (1997). Tenant Protection Act (Bill 96) . Toronto: Queen’s Printer. Grabb, E. (2007). Theories of social inequality (5th ed.). Toronto: Harcourt Canada. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

Understanding Policy Change 125 Habermas, J. (1968). Knowledge and human interests (J.J. Shapiro, Trans.). Boston: Beacon Press. Hall, P.A. (1993). Policy paradigms, social learning, and the state: The case of economic policy making in Britain. Comparative Politics , 25 (3), 275–296. Hall, P.A. (2013). Brother, can you paradigm? Governance , 26 (2), 189–192. Ham, C., & Hill, M. (1984). The policy process in the modern capitalist state . Brighton: Wheatsheaf Books. Hawkesworth, M.E. (1988). Theoretical issues in policy analysis . Albany: SUNY Press. Hawkesworth, M.E. (1994). Policy studies within a feminist frame. Policy Sciences , 27 , 97–118. Heclo, H. (1974). Social policy in Britain and Sweden . New Haven, CT: Yale University Press. Heclo, H. (1978). Issue networks and the executive establishment. In A. King (Ed.), The new American political system (pp. 270–303). Washington: American Enterprise Institute. Kendrick, M., & Slade, K. (1993). Spirit of life: The story of Women’s College Hospital . Toronto: Women’s College Hospital. Krieger, J. (1987). Social policy in the age of Reagan and Thatcher. Socialist Register , 23 , 177–198. Kuhn, T.S. (1970). The structure of scientific revolutions . Chicago: University of Chicago Press. Lexchin, J. (2006). Pharmaceutical policy: The dance between industry, government, and the medical profession. In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying alive: Critical perspectives on health, illness, and health care (pp. 325–345). Toronto: Canadian Scholars’ Press. Lexchin, J. (2013). Health Canada and the pharmaceutical industry: A preliminary analysis of the historical relationship. Healthcare , 9 (2), 22–29. Lownsbrough, J. (1990). The insurrection: How the anti-merger troops seized control of Women’s College Hospital. A blow-by-blow account. Toronto Life , 24 (10), 43–93. Milward, H.B., & Wamsley, G. (1984). Policy subsystems, networks, and the tools of public management. In R. Eyestone (Ed.), Public policy formation and implementation (pp. 105–130). New York: JAI Press. Mintrom, M., & Vergari, S. (1996). Advocacy coalitions, policy entrepreneurs, and policy change. Policy Studies Journal , 24 (3), 420–434. National Advisory Committee on SARS and Public Health. (2003). Learning from SARS: Renewal of public health in Canada; A report of the National Advisory Committee on SARS and Public Health . Ottawa: Health Canada. Park, P. (1993). What is participatory research? A theoretical and methodological perspective. In P. Park, M. Brydon-Miller, B. Hall, & T. Jackson (Eds.), Voices of change: Participatory research in the United States and Canada (pp. 1–19). Toronto: Ontario Institute for Studies in Education Press. Progressive Conservative Party of Ontario. (1995). The Common Sense Revolution . Toronto: Progressive Conservative Party of Ontario. Raphael, D. (2014). Beyond policy analysis: The raw politics behind opposition to healthy public policy. Health Promotion International , 30 (2), 380–396. Romanow, R.J. (2002). Building on values: The future of health care in Canada . Saskatoon: Commission on the Future of Health Care in Canada. Sabatier, P.A. (1993). Policy change over a decade or more. In P.A. Sabatier & H.C. Jenkins- Smith (Eds.), Policy change and learning: An advocacy coalition approach (pp. 13–40). Boulder, CO: Westview Press. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.

126 Health Policy in Canada Shapcott, M. (2004). Housing. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives (pp. 201–215). Toronto: Canadian Scholars’ Press. Teeple, G. (2000). Globalization and the decline of social reform: Into the twenty-first century . Aurora, ON: Garamond Press. Towers, B. (1989). Running the gauntlet: British trade unions under Thatcher, 1979–1988. Industrial and Labour Relations Review , 42 (2), 163–188. Tuohy, C.J. (1999). Accidental logics: The dynamics of change in the health care arena in the United States, Britain, and Canada . New York: Oxford University Press. Weir, M., & Skocpol, T. (1985). State structures and the possibilities for Keynesian responses to the Great Depression in Sweden, Britain and the United States. In P. Evans, D. Rueschemeyer, & T. Skocpol (Eds.), Bringing the state back in (pp. 107– 168). Cambridge: Cambridge University Press. Bryant, T. (2020). Health policy in canada, second edition : Everything matters. Canadian Scholars. Created from utoronto on 2023-09-14 14:36:15. Copyright © 2020. Canadian Scholars. All rights reserved.