what drives/motivates providers. In a nutshell, these authors assert that any healthcare system built on market principles is doomed to eventual crisis as payers (meaning patients by and large, whether directly or through government taxation) attempt to receive adequate care while reducing the flow of dollars to providers while providers attempt to increase the flow of dollars for the same or lower levels of care (Harrington & Estes, 2008). Issues of personal and medical ethics aside, it must be acknowledged that in any other market setting this would perfectly describe behavior, and though this view is commonly bandied about in public discussion and political rhetoric it is not a frequent feature of empirical research. Though this might be due to the causal assertion this perspective makes it could potentially point to the capitalist bias that exist in healthcare policy examination in the United States, and is worthy of further consideration.
Equally infrequent, though due to a lack of evidence rather than a potential theoretical bias, are discussions of real public involvement in governmental decision-making when it comes to healthcare policy (Mitton et al., 2009). A review of this issue was forced to rely on parallel research in non-healthcare settings in addition to the scant information available regarding public input into healthcare policy in order to make up for the many gaps identified in understanding how the public influences healthcare policy and what the risks and benefits of this influence are (Mitton et al., 2009). This study concluded that most governments have an attitude of responsibility towards engaging various public groups in policy-making decisions and that generally health attitudes regarding the diversity of the public and their opinions exist in the developed world and lead to more effective policy making, yet in issues of healthcare policy the public's role is still grossly underutilized and to a large extent is still not understood because of this lack of use (Mitton et al., 2009).
As the above-cited research shows, the filed of healthcare policy analysis is in a great deal of flux with no truly clear trends emerging in the literature. There are a variety of specific perspectives and subject areas vying for attention, but the field as a whole is stuck in a mode of attempting to define itself and the frameworks that will help to move it forward. A combination of abstract values and practical realities must of course be brought be bear on matters of healthcare policy, yet an effective means for achieving this combination has yet to be produced. Current research appears to be working on all of the attendant ideas but will little agreement in terms of coming together to form this much needed combination.
Theoretical Underpinnings of Healthcare Policy Analysis
While the research community is still attempting to develop a sense of cohesion and simple agreement on definitions when it comes to direct empirical examinations of healthcare policy, this research itself is also in need of greater theoretical grounding. Gilson & Raphaely (2008) found that in low- and middle-income countries especially, healthcare policy analysis studies generally fail because they are not supported by extensive enough healthcare systems and are generally unable to produce reliable data. The notion that policy change can be affected by research also appears to be missing from many of the studies conducted in regards to such countries, the authors contend, and the descriptive nature of most studies does not provide room for the analysis and comparison needed to bring research to a practical and implementable level (Gilson & Raphaely, 2008). Analytical rigor and a perspective of practicality are strongly called for in this research (Gilson & Raphaely, 2008).
In the developed world, including the United States, rural areas continue to provide a confounding set of data both for healthcare practice and for healthcare policy analysis (Edelman & Menz, 2008). Healthcare needs assessments by rural populations, healthcare acceptance, and payment features and values all vary considerably from rural to non-rural healthcare systems, and the current theoretical frameworks and large-scale policy guidelines in place do not adequately account for these differences or allow for such significant departures from expected norms (Edelman & Menz, 2008). Rural residents in the United States also benefit disproportionately from a variety of public health services, which has financial and ethical implications that further complicate this issue and that rarely receive direct attention in policy research despite invocations in policy debates (Edleman & Menz, 2008). Establishing a framework that differentiates needs and values while encouraging a cohesive system will undoubtedly be difficult but is necessary to increase the efficacy of current research efforts (Edleman & Menz, 2008).
Another call for more focused and better-defined research comes from Lomas and Brown (2009), who found in their review of policy models and practice evidence that evidence-based practice by medical practitioners was often conflated with evidence-informed policy analyses and formation. While the two are related, there is a need to understand policy as distinct from practice even in empirical research that explores the relationship between the two, else there is the risk of relying on site- and scenario-specific information in broader policy decisions and a conflation of research methods (Lomas & Brown, 2009). Developing a more concrete functional framework for evidence-based policy investigations is believed to be the most effective route towards this desired end and a more consistent and accurate approach to healthcare policy analysis (Lomas & Brown, 2009).
Differences in the developing and developed worlds and between rural and urban communities represent some of the practical issues not yet adequately addressed by current theoretical approaches to healthcare policy analysis, and Helderman et al. (2012) would add the increase in government regulation of healthcare systems to that list. While different governments and societies support different levels of healthcare regulation and drastically different healthcare policies, a worldwide trend towards increasing regulation of healthcare systems can be observed in the data and yet remains under-reported and most significantly under-utilized in the development of healthcare policy analysis theories (Helderman et al., 2012). Again, the research has been able to identify real and concrete trends in healthcare policy development that require full understanding if they are to be appropriately used in the furtherance of healthcare policy research and recommendations, and yet there is not even a proper theoretical foundation available to explain and extrapolate from the significant increases in regulation that this particular research asserts to exist (Helderman et al., 2012).
The issues of positionality and perspective identified in the introduction were also to be found fundamentally lacking areas of theoretical acknowledgment by Walt et al. (2008). Though there is a great deal of understanding given to the importance of conducting healthcare policy research and analysis, these authors found very little attention being paid to how that analysis was being conducted or from what perspective questions were asked and findings delivered (Walt et al., 2008). The authors recommend more specific and well-defined theories along with stricter control of methodology and an awareness of researcher reflexivity as a means of addressing current shortcomings in theory and research (Walt et al., 2008).
Researchers in healthcare policy areas are not only working with incomplete and inadequate theories, according to Lavis et al. (2005), but are also working with an incomplete set of facts due to their general lack of inclusion of healthcare managers and certain other identified parties in their research efforts. Much like the lack of appropriate public input has been identified as a practical gap in healthcare policy development, the lack of relevant input by a variety of healthcare workers and support organizations is demonstrative of a theoretical gap that needs addressing, according to this research (Lavis et al., 2005). Broader perspectives will yield more practically and academically relevant information and the development of more comprehensive and predictive frameworks (Lavis et al., 2005).
Even the very language and discourse methodologies employed in healthcare policy discussions and analysis has come under criticism as inadequate to support effective growth in these areas (Russell et al., 2008). Russell et al. (2008) assert that rhetoric is inescapable in policy discussions, and that rather than striving to distance research from rhetoric the rhetorical terms and devices must be closely examined and defined so that frameworks and their inherent rhetorical discussions can be properly understood. At its most fundamental level, this theoretical analysis is calling fro a better understanding of the science of policy analysis as a science, with defined terms and mechanisms rather than opposing ideologies and inferences that often end up working at cross purposes (Russell et al., 2008).
Healthcare policy analysis theory appears to be in much the same shape as healthcare policy analysis as a practical proposition. There are many ideas but there is little consensus, and while many gapes in theoretical foundations have been identified very few effective and comprehensive solutions have been offered. Ongoing research should contend with the most commonly identified gaps and the proffered solutions as a means of developing a more concrete and consistent theoretical framework that includes…