Lecture 6 - Power and the Policy Process

Question 1

What are the 3 notions of power?

Answer 1

1. Power to (ability to achieve an outcome)
2. Power over (asymmetrical relation between two or more actors or group of actors)
3. Power with (power from links or consensus with others)

Question 2

What are Foucalts 2 key concepts of power?

Answer 2

1. Repressive power
2. Constitutive power

Question 3

How are repressive and constitutive power interlinked?

Answer 3

These two forms of power are not entirely separate.

Repressive power often relies on a certain kind of knowledge and understanding produced by constitutive power. For example, laws are not just arbitrary restrictions, but often reflect and reinforce existing social norms.

Conversely, constitutive power can be used to reinforce and legitimize repressive power. For example, educational systems might teach students to accept certain laws and regulations as natural and necessary.

Question 4

What is repressive power?

Answer 4

A force that restricts, prohibits or punishes those who exhibit a certain behaviour or action

e.g. laws, regulations, censorship, incarceration

Question 5

What is constitutive power?

Answer 5

A force that shapes what we beleive to be normal or acceptable

e.g. social norms, educative practices, language

Question 6

What are Stephen Luke’s 3 dimensions of power?

Answer 6

1. First dimension: focuses on decision-making, looks at results of when there is disagreement, some win while others lose, power is understood in terms of its effects
2. Second dimension: focuses on what issues are left off of the agenda (non-decision making), who sets the agenda?
3. Third dimension: how we think, what ideas and values are behind our actions, why are some things political issues to begin with? Construction of discourse and language

Question 7

What are some examples of the second dimension of power?

Answer 7

Structural power: entrenched expectations or norms

Legislative power: when can an issue be raised?

Institutional arrangements: what decision-making bodies exist? For which decisions?

Allocation of authority: who can make decisions?

Question 8

Using the case study of high drug prices in the US, explain how Stephen Luke’s 3 dimensions of power can help us understand why drug prices continue to be so high.

Answer 8

First Dimension: Decisions
* Lack of government regulation: the US has weaker government oversight of drug prices in comparison to other developed countries. This allows pharmaceutical companies to set their prices. In addition, pharmaceutical companies negotiate directly with pharmacy benefit managers to determine insurance rebates, but these deals are confidential.
* Patent laws: strong patent laws give pharmaceutical companies exclusive rights to produce new drugs, creating a monopoly, allowing them to charge higher prices.
* There is some Medicare negotiation for certain high-cost drugs in certain situations.

Second Dimension: Non-decisions
* Lobbying power of pharmaceutical companies: pharmaceutical companies spend vast amounts of money lobbying Congress and regulatory agencies to influence drug pricing policies and weaken efforts of price control
* Limited public discourse: policymakers may not prioritise addressing high drug prices due to powerful lobbying interests and weak pressure from the public
* Government is not involved in setting drug prices

Third Dimension: Shaping preferences
* Medicalisation of everyday life: The pharmaceutical industry heavily influences public perception of health, promoting pharmaceuticals as the solution to people’s problems. This can increase demand regardless of cost
* Direct-to-consumer advertising: the US is one of 2 countries in the world that allows for direct-to-consumer advertising of pharmaceuticals (New Zealand is the other). This creates the perception that certain medications are necessary for good health so patients need these medications.
* Individualism and responsibility: The dominant ideology in the US emphasises individual responsibility for health, leading people to blame themselves if they cannot afford medications.

Analysis/Takeaways
Helps us to understand why high drug prices persist in the US. Findings can inform strategies to combat the power which maintains these high prices.
* Pharmaceutical companies wield significant overt power through lobbying, ability to set drug prices, and patent laws.
* The second dimension of power is exercised by limiting public discourse on drug pricing and the strong lobbying power of pharmaceutical companies.
* Power in the third dimension is exercised as the pharmaceutical industry shapes public perceptions of health and illness, fostering a culture that accepts high drug prices and blames patients for not being able to afford drug prices.

Question 9

Over the past 40 years public policies have become more neoliberal. What does this mean for health systems?

Answer 9

Neoliberalism: market-oriented reform policies such as “eliminating price controls, deregulating capital markets, lowering trade barriers” and reducing state influence in the economy.

• Reduced public responsibility for health
• Increase choice and market
• Move towards insurance-based health care
• Privitisation of medical care
• Individuals are responsible for health improvements

Question 10

What did Rogers et al (2018) say about the reason for the obesity epidemic?

Answer 10

• Matt Hancock, UK health secretary from 2018, framed obesity as personal responsibility
• Rogers et al (2018) showed that all ages, both male and female, had a spike in obesity after the 1970 regulatory changes which allowed for more sugar to be included in food and sugar becoming cheaper
• Therefore it is implausible that each age, sex, and ethnic group had a simultaneous decline in willpower related to healthy nutrition or exercise

Question 11

What is are 4 Typology of Capitals as per Pierre Bourdieu?

Answer 11

Capitals are assets you can draw upon to generate power

Economic: wealth, material resources
Cultural: knowledge, skills, education
Social: networks, relationships
Symbolic: legitimate right to hold power

(ECSS)

Question 12

What are the 2 theories to describe where power comes from?

Answer 12

Typology of Capitals (Bourdieu)

Source of Authory (Weber)

Question 13

What are the 3 Sources of Authority as per Max Weber?

Answer 13

Legal-rational: based on formal rules
Charismatic: traits of an individual
Traditional: long-standing customs and social arrangements

Question 14

Do resources always lead to influence?

Answer 14

No - the translation of resource into influence is dependent on the policy context

Question 15

What is epistemic power vs normative power?

Answer 15

Epistemic power - derived from expertise e.g. the Lancet is the leading global health agenda setter

Normative power - claims of moral or ethical legitimacy e.g. WHO Framework on Tobacco control (stopping smoking in population is ethically right)

Question 16

Explain the power cube proposed by Gaventa, 2006.

Answer 16

Approach to conceptualising power in different social and political contexts. Used to analyse strategies for change and how they impact power relations.

Involves spaces, place and power

Spaces
- Closed spaces: where decision-making is exclusive and controlled by a few individuals or groups. Power is concetrated, there is limited access for others to participate.
- Invited spaces: More includive decision-making process. Power is more distributed. There is an effort to include diverse voices and perspectives.
- Claimed spaces: Spaces where marginalised or excluded groups attempt to challenge and claim more influence. Sites of resistance and mobilisation.

Levels
- Local level: Power relations and decision-making at community level
- National level: Power relations and decision-making at the national level
- Global level: Power relations and decision-making at the global level

Power
- Visible: Most explicit/observable form of power (e.g. political authority, legal structures, economic control)
- Hidden: More subtle, ability to shape agendas, control information, or influence perceptions
- Invisible: Power to shape beliefs, values and norms so certain issues or perspectives are accepted and difficult to challenge

Question 17

Explain how Gaventa’s power cube can be used to analyse the case study of water flouronation in the US?

Answer 17

Fluoridation of public water supplies to prevent tooth decay

o Local level (invited and claimed spaces): Local city councils or water boards might hold public hearings (invited space) to discuss fluoridation. However, anti-fluoridation groups may hold rallies or organize protests (claimed space) to voice their concerns and pressure decision-makers.
o National level (closed and invited spaces): The US Centers for Disease Control and Prevention (CDC) strongly recommends fluoridation (second dimension). However, some national debates on fluoridation safety might occur in scientific conferences or media outlets (invited space), potentially limiting broader public participation.
o Global level (invited spaces): International recommendations on water quality by the World Health Organization (WHO) might endorse fluoridation (second dimension). However, the influence of anti-fluoridation movements in other countries (invisible power) could be a factor in shaping public opinion in the US.