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Problems of Policy Implementation

Equality, Equity and Policy: Problems of Policy Implementation

Theoretical framework

Implementation is the process of turning policy into practice. However, it is common to observe a ‘gap’ between what was planned and what actually occurred as a result of a policy. There are three major theoretical models of
policy implementation (Buse et al, 2005).

Top-down approach: This approach sees policy formation and policy execution as distinct activities. Policies are set at higher levels in a political process and are then communicated to subordinate levels which are then charged with the technical, managerial, and administrative tasks of putting policy into practice.  Political scientists have theorized that the top-down approach requires that certain conditions be in place for policy implementation to be effective including:

  • Clear and logically consistent objectives
  • Adequate causal theory (to how particular actions would lead to desired outcomes) See section: Epidemiology: Association & Causation
  • An implementation process structured to enhance compliance by implementers  (incentives and sanctions)
  • Committed, skilful implementing officials
  • Support from interest groups and legislature
  • No changes in socio-economic conditions that undermine political support or the causal theory underlying the policy
  • Adequate time and sufficient resources available
  • Good coordination and communication

Problems associated with the top down approach:

  • It is very unlikely that all pre-conditions would be present at the same time
  • Only adopts perspective of those in higher levels of government and neglects the role of other actors
  • And therefore, it risks over-estimating the impact of government action (neglects other factors)
  • Difficult to apply where no single, dominant policy or agency is involved
  • Policies change as they are being implemented

Bottom-up approach: This approach recognizes that individuals at subordinate levels are likely to play an active part in implementation and may have some discretion to reshape objectives of the policy and change the way it
is implemented.  The bottom-up approach sees policy implementation is an interactive process involving policy makers, implementers from various levels of government, and other actors. Policy may change during implementation.

Problems of the bottom-up approach:

  • Evaluating the effects of a policy becomes difficult
  • Difficult to separate the influence of individuals and different levels of government on policy decisions and consequences. (Important for bureaucratic accountability)

Principal-agent theory:  In each situation there will be a relationship between principals (those who define policy) and agents (those who implement policy), which may include contracts or agreements that enable the
principal to specify what is provided and check that this has been accomplished. The amount of discretion given to the agents and the complexity of the principal-agent relationship are affected by:

  • The nature of the policy problem- including scale of change required, size of affected group, simple vs. complex intervention, ill-defined vs. clear policy, many cause vs. single cause, degree of political sensitivity, length of time before changes become apparent.
  • The context or circumstances surrounding the problem- political and economic climate, technological change
  • The organization of the machinery required to implement the policy- number of formal and informal agencies, amount of skills and resources required

In practice

Whether policies are implemented from the top-down, bottom-up or according to the principal agent theory, policy implementation involves 3 activities (Anderson and Sotir Hussey, 2006):

Interpretation: translation of the policy into administrative directives

Organization: establishment of administrative units and methods necessary to put a programme into effect

Application: routine administering of the service

Interpretation of policy directives requires the translation of knowledge on interventions into the particular local context. Factors to take into account when interpreting health policy include (Jenkin et al 2006):

  • Local resources, including human resources and infrastructure
  • Specific characteristics of the population
  • Baseline incidence of the health problem
  • The latency period  before an effect of the intervention will be observed
  • A balance between achieving targets that reflect process change and those that reflect risk factor change
  • Local variations in the likely effectiveness of particular interventions

Gunn (1978 in Hunter 2003) has identified ten common barriers to effective health policy implementation:

  1. The circumstances external to the implementing agency impose crippling constraints
  2. Lack of adequate time and sufficient resources (See Box 1)
  3. The required combination of resources is not available
  4. The policy to be implemented is not based on a valid theory of cause and effect
  5. The relationship between cause and effect is indirect and there are multiple intervening links
  6. Dependency relationships are multiple
  7. There is a poor understanding of, and disagreement on, objectives (See Box 1)
  8. Tasks are not fully specified in correct sequence
  9. There is imperfect communication and coordination (See Box 1)
  10. Those in authority are unable to demand or obtain perfect compliance

Box 1: Problems of policy implementation in acute care services in the UK

Powell and colleagues (2009) have investigated problems of policy implementation in acute pain services in the UK.

In 1990, the Royal College of Surgeons’ report Pain after Surgery recommended the introduction of an acute pain service to all major surgical hospitals in the UK in order to tackle the long-documented problem of poorly treated postoperative pain. The report was followed by a number of government documents which endorsed and developed the recommendations. By 2002 the majority of hospitals did have an acute pain service in some form, but many services were struggling to embed the necessary improvements in postoperative pain management in routine practice across their hospitals, leading to continuing deficits in basic care.

Through qualitative case study interviews with health professionals and managers working in and around acute pain services in three hospitals, Powell and colleagues identified multiple factors undermining service change around postoperative pain management which they divided into three linked categories.

Issues around the content of the change: what is an acute pain service and why have one here?

  • Lack of agreement that improvement was necessary
  • Lack of clarity about the nature of the change and how the proposed new services fitted with existing and related services

Issues around the context of the change: the idiosyncrasies of the local environment

  • Poor fit with local organizational priorities
  • Poor fit with local organizational structures (e.g. directorates)
  • Adverse effects of local organizational histories (e.g. service reorganizations, mergers)
  • Lack of direct and indirect resources to support the change

Issues around the process of the change: service change challenges professional roles and identities

  • Divergent views among health professionals about responsibility for this aspect of patient care
  • Conflict with longstanding professional boundaries and norms

These factors did not just impact as single factors, but also worked in combination and impacted on each other in complex ways. The authors conclude that national policy recommendations about changes in patient care are useful but not enough. Practitioners must also use the growing body of knowledge on health service change to select and tailor appropriate strategies at each organizational level, recognizing that the combination of factors that enable development and adoption of new working practices in one setting may not apply in exactly that form elsewhere.

Source: Powell et al 2009



  • Anderson G, Sotir Hussey P (2006). Influencing government policy. In: Pencheon D, Guest C, Melzer D, Muir Gray JA (eds) Oxford Handbook of Public Health. Oxford University Press.
  • Buse K, Mays N, Walt G (2005). Making Health Policy. Understanding Public Health Series Open University Press.
  • Gunn LA (1978). “Why is implantation so difficult?” Management Services in Government, 33: 169-76.
  • Hunter DJ (2003). Public Health Policy. Cambridge: Polity Press.
  • Jenkin RA, Frommer MS, Rubin GL (2006) Translating indicators and targets into public health action. In: Pencheon D, Guest C, Melzer D, Muir Gray JA (eds) Oxford Handbook of Public Health. Oxford University Press.
  • Powell AE, Davies HTO, Bannister J, Macrea WA (2009) “Understanding the challenges of service change – learning from acute pain services in the UK.” Journal of the Royal Society of Medicine, 102(2): 62-8.

© Rebecca Steinbach 2009