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When analyzing public policies, it is important to consider that if a complex problem reaches the political agenda, negotiations between different coalitions and actors are possible, enriching policies through consensus or stopping them when there is high-level dissent.
Intersectoral health promotion initiatives in Chile to address obesity and non-communicable diseases (NCDs) are long-standing, but also have undergone a high degree of changes in their design, implementation, and financing, in line with political differences and intervention models.
The “Vida Chile Councils” and the “National Health Promotion Plan”1 in 1998, were followed by the “Global Strategy Against Obesity, EGO-Chile” in 20062 (Figure 1) and then the “Choose Healthy Living System” (“Sistema Elige Vivir Sano”) that was approved by Law 20,670 in 20133.
Figure 1 Historical perspectives of health promotion policies in Chile. NCDs: Non-Communicable Diseases WHO: World Health Organization; PASAF: Programa de Alimentación Saludable y Actividad Física; AUGE: Acceso Universal con Garantías en Salud; EGO: Estrategia Global contra la Obesidad.
The National Health Promotion Plan (1998) and Vida Chile Councils implemented during Ricardo Lagos’ government (centre-left coalition), aspired to address obesity and NCDs through a set of promotion actions and intersectoral coordination of public and private institutions, led by the Ministry of Health. Under this initiative, regional and community councils were created to carry out different activities financed from the central level1. These councils functioned until 2005, but the National, Regional and Communal Promotion Plans are still in force today, despite government and political changes1,4.
In 2004, member countries of the World Health Organization (WHO) signed an agreement of a global strategy related to healthy eating and physical activity, alarmed by the high mortality attributable to NCDs5,6. In this context, the government of Michelle Bachelet (centre-left coalition) launched a new intersectoral strategy in 2006, the Global Strategy Against Obesity2. Under the wings of a structural strategy, the design of a legislative bill on food warning labeling and advertising restrictions began in 20087. This strategy also included a multidisciplinary diet and physical activity program for overweight and obese people in Primary Health Care8 and a set of actions in schools like healthy food kiosks, active recreation, extracurricular physical activities4,9,10. This program disappeared in the following government (centre-right coalition), but the aforementioned bill on food labeling and advertising continued to advance7.
Until then no clear results had been achieved in sedentary lifestyle, poor diets, obesity and NCD prevalence11,12.
In 2010, Sebastián Piñera assumes the Presidency with a drastic change of the political coalition. After 20 years of the centre-left coalition, a center-right coalition reaches the executive power. This change explains the launch of a new strategy, the “Choose Healthy Living System” dependent directly of the First Lady Cecilia Morel, which entails a wide presence in the media. This System is inspired by “Let's Move” program previously launched by Michelle Obama in the US, and represents a view of individual responsibility (choice) of lifesytles. This program was characterized by a public-private partnership that organized various events and developed a set of messages to promote health. The concept of choosing has not been exempt of criticism from the opposition coalition and various social and academic actors, who defend WHO model of Social Determinants of Health (SDoH) that proposes structural policies for changing lifestyles13. “Choose Healthy Living System” was transformed into Law 20,670 in 2013, that creates the depending of the Ministry of Social Development as an intersectoral policy3.
The aim of this article is to analyze the “Choose Healthy Living System” under Sabatier's Advocacy Coalition Framework (ACF), addressing its discussion on the political agenda and its implementation in subsequent government coalitions.
Methods
Framework Definition
The theoretical framework that seems most appropriate to analyze the “Choose Healthy Living System” would be that of ACF, proposed by Sabatier. This framework defines that in order to understand the process that leads to public policy change, the following premises must be fulfilled14:
Understanding the process of policy change and policy-learning requires the perspective of at least a decade.
It should focus on a policy subsystem, that is, on the interaction between actors from different institutions interested in a policy area.
Public policy can be conceptualized in a similar way as belief systems, that is, the sets of values and priorities and the causal assumptions of each coalition are intended to be embodied in public policy.
System and subsystem components
The components of ACF are summarized in Figure 2, adapting it to the case in study. These include relatively stable system parameters that generally do not lead to policy change: 1) the basic attributes of the problem; 2) the basic distribution of natural resources; 3) cultural values and social structure, and 4) basic constitutional structure14.
Figure 2 Advocacy coalition framework adapted to the “Choose Healthy Living System” (Law 20,670). Adaptaded de Sabatier (1988)14. NCDs: Non-Communicable Diseases. Coalition A, “Coalition for Change” (prior “Alianza por Chile” and subsequently “Chile Vamos”, moderate right wing) includes the following political parties: Unión Democrática Independiente (UDI), Renovación Nacional (RN), movimiento “Chile Primero”, movimiento “Norte Grande” y movimiento “humanista cristiano”. Coalition B,” New Majority” (prior “Concertación”, moderate left wing) includes the following political parties: Partido Demócrata Cristiano (DC), Partido Socialista de Chile (PS), Partido por la Democracia (PPD), Partido Radical Socialdemócrata (PRSD), Partido Comunista de Chile (PC), Partido Izquierda Ciudadana de Chile (IC) and Movimiento Amplio Social (MAS).
The most important components are those that are dynamic and external to the system, since their unstable nature have a greater influence in generating changes in public policies. Among them, we find changes in socioeconomic and technological conditions (an economic crisis, digital development), a change in the ruling coalition, and finally, policy decisions and their impact on other subsystems. Later revisions have added new components as a path for major policy changes: 1) internal shocks of the subsytem, which redistribute power to the minority coalition beliefs; 2) negotiated agreement: in which a major policy change occurs after decades of debate without the occurrence of external or internal events; and 3) opportunity structures to mediate how stable parameters of the system affect coalition behavior15. It is important to consider that the policy subsystems are partially autonomous and that they depend on the policies of other subsystems.
Policy subsystem and coalitions perspectives
The definition of ACF proposed by Sabatier is an alternative to the model of institutional actors, which have the authority to make policy changes, but do not allow us to understand the role of actors involved in policy learning. A subsystem is defined as a set of actors, active and latent, involved with a policy problem. An advocacy coalition includes non-institutional actors and individuals such as researchers, academics and leaders of different interest groups who are involved with the problem and who share a set of beliefs. An institutional model does not allow us to understand the changes in position within the same institution, nor does it allow us to consider the influence of specific individuals who move between one organization and another. Sabatier also proposes considering a group of actors called “policy brokers” defined as those who are interested in achieving consensus, maintaining a low level of political conflict and who defend a comprehensive model to solve the problem, considering individual and structural aspects14.
Results
Figure 1 summarizes the health promotion policies enacted before and after the “Choose Healthy Living System”. Figure 2 shows the components of the ACF applied in the analysis. Since 1990 there has been a stable democratic institutionality governed by the same political coalition until 2010. Within the values and social structure, a free economic system stands out in a successful democratic transition to date, stable natural resources, a small state with a subsidiary system, basic constitutional norms with a reform to the constitution carried out in the year 2005. From the dynamic factors proposed by Sabatier14,15, the change in the governing coalition was a key factor in the case of study. All the actors involved in the problem of obesity and NCDs belong to the health promotion policy subsystem, among the main ones: research centers, scientific and academic societies, health professionals, executive power (Ministry of Health and others), legislative power, politicians, primary care centers, the media, civil society, small producers and traders, the food industry, large supermarkets, and the marketing industry.
Table 1 summarizes for the case of Chile, the actors, transversal beliefs, beliefs related to politics and beliefs of secondary aspects of each coalition. One coalition includes center-right politicians (coalition A), the food industry and economic elites, who defend individual freedom and has as its main belief that lifestyles depend on individual choices. For this coalition the solution for obesity and NCDs requires educational campaigns and the generation of awareness in the population to achieve changes in diet and physical activity, as the “Choose Healthy Living System” did between 2010 and 2013. The other coalition (coalition B: center-left) strongly believes in the role of the state, and finds the causal root of obesity and NCDs in social injustice and inequities in availability and access to a healthy life. This coalition, closely linked to the WHO SDoH Commission13,16 privileges structural transformations that address urban environment, socioeconomic and educational level, working conditions and food environments, to modify the lifestyles of the population, considering that the context determine the behaviour17,18.
Table 1 Actors and beliefs of each advocacy coalition identified in “Choose Healthy Living System” (Law 20,670)
| Coalition A: pro “Healthy Living” | Coalition B: pro “Social Determinants of Health” | |
|---|---|---|
| Deep core beliefs (normative) | Economic and individual freedom | Social justice and equity |
| Near core beliefs (policy) | Health and lifestyle depend on individual choices Approach to social determinants deviates from the focus of health The role of the State is to carry out education and health promotion Public-private partnerships |
Health and lifestyles depend on the social determinants of health Reducing economic inequality is key to achieving health and behavioral change The role of the state is to guarantee conditions so that individuals can have healthy lifestyles Private economic actors must be regulated and not participate in public policy |
| Beliefs related to secondary aspects | Health promotion media campaigns. Sporting events with private financing. Health education and health promotion is a priority. Healthy schools and workplaces. |
Health promotion is insufficient. Regulation of the food industry. Taxes on unhealthy foods. Marketing regulation (food, tobacco, alcohol) Improving food and community environments. Participatory social and community programs. |
| Actors | “Chile Vamos” politicians (moderate right wing) Food industry First Lady 2010-2014 (Cecilia Morel) Chile Foundation Health Ministry 2010-2014 (Jaime Manalich) Social Development Ministry 2012-2014 (Joaquin Lavin) |
“Nueva Mayoría” politicians (moderate left wing) Academics and researchers related to social determinants of health. Ministry of health 2014-2018 Ministry of Social Developmnt 2014-2018 |
Adapted from Sabatier (1988)14.
As can be seen in Table 2, the hypotheses proposed by Sabatier are fulfilled for advocacy coalitions and policy learning during the creation and evolution of the “Choose Healthy Living System” (2011-2021). Table 3 describes in detail changes in each one of the government coalitions in relation to the creation and evolution of the “Choose to Live Healthy System” and policy brokers identified in the process.
Table 2 Hypotheses proposed in the conceptual framework of cause coalitions proposed by Sabatier and compliance with “Choose Healthy Living System” (Law 20,670)
| Advocacy Coalition Framework Hypothesis | Application in Law 20,670 (“Choose Healthy Living System”) | |
|---|---|---|
| Advocacy coalitions | On major controversies within a policy (i.e. when core beliefs are in dispute), the lineup of allies and opponents will tend to be rather stable over periods of a decade or so | Actors who criticized the “Choose Healthy Living System ” program (2011-2013) support Law 20,606 (Nutritional Labeling) and the reformulations with subsequent governments and viceversa |
| Actors within the same coalition will have substantial consensus on the core beliefs of the policies, but less on secondary aspects | Some actors in favor of health promotion and education see as a fundamental secondary aspect the incorporation of food policies within the Ministry of Education (an instrument that is not transversal within the coalition) | |
| An actor or coalition will give up secondary aspects of his belief system before aknowledging weakness in the policy core | Creation of the law “Choose Healthy Living System” has an intersectoral vision coordinated by the Ministry of Social Development (core aspect: individual choice and interventions, secondary aspect: intersectoral approach) | |
| The core (attributes) of a government program are unlikely to be significantly revised while the coalition which institute the program remains in power | Law 20,670 is not revised until the governing coalition changes, which is a disruption of an external component to the subsystem (Second Government of Michelle Bachelet). This government had a lower priority for health promotion financing, but is later relaunched when the governing coalition changes again (Second Government of Sebastián Piñera) | |
| The core attributes of a government program are unlikely to be changed until there is significant disruption to components external to the subsystem | ||
| Policy learning between coalitions | Learning from politics between belief systems is likely to occur if there is an intermediate level of reported conflict between the two. This requires: 1) both coalitions have the technical resources to carry out a debate and 2) the conflicts are between core attributes of the politics of one coalition and secondary aspects of another or between secondary aspects of both belief systems | Law 20,670 arises from policy learning incorporating secondary aspects of the opposition coalition. This would be that its intersectoral coordination is in charge of the Ministry of Social Development, maintaining the central axis and priorities of the “ Choose Healthy Living System “ Program. There is a degree of conflict between core or transversal beliefs, which slows down the learning process |
| Policy learning between belief systems of both coalitions is more likely to occur if a forum exists that is: 1) prestigious enough to force professionals from both coalitions to participate, and 2) dominated by professional norms | Scientific societies’ meetings allow discussing the approach to obesity and non-communicable diseases from different perspectives evaluated through scientific research (biomedical, prevention and health promotion, social determinants, food and community environments) | |
| Problems for which there are quantitative performance indicators are more conducive to policy learning than those with subjective indicators | Although there are increasing quantitative indicators of obesity, there are no successful policies worldwide to date. Furthermore, diet has a significant measurement error and is interrelated with culture and society. Behavior is a complex area to address, a transdisciplinary perspective is required. Therefore, learning is more difficult | |
| Problems involving natural systems are more conducive to public policy learning than purely social ones because controlled experimentation is more feasible and the critical variables are not active by themselves | The problem of obesity and its determinants addresses social, cultural, economic, and biological aspects. Therefore, policy learning is more complex and requires a transdisciplinary perspective |
Hypotheses cited and adapted from Sabatier (1988)1.
Table 3 Change of governing coalitions in the period 2010-2021: creation and evolution of the “Choose Healthy Living System” (Law 20,670)
Discusion
According to the information reviewed, the “Choose Healthy Living System” suits the Sabatier's advocacy coalitions framework. We observed how a coalition that defends individual freedom and establishes a program based on its beliefs, then incorporates aspects of the opposite coalition (intersectoral and social policy) but also allows the institutionalization of the policy by a Law3. It is important to highlight that the lack of permanent financing has generated interruptions and slows down the policy learning process in a policy that must be continuous to achieve results.
In the beginning, the “Choose to Live Healthy Program” was successful regarding the communication field and the development of massive sporting events, allowing it to establish as a permanent state policy that is sustainable over time and that incorporate social aspects. However, policy results are not measurable in the short term. They require continuity, commitment from civil society and various actors, support from the media, and transgenerational structural and sociocultural changes to have impact, as demonstrated by the North Karelia Project19–21. Although no results have been observed in obesity, sedentary lifestyle decreased from 88.7% in 2010 to 86.7% in 2017, which was significant in the group of young adults (30-49 years: from 92.5% to 86.2%)17. Although these results are still insufficient, they could have long-term implications for obesity and NCDs.
The “Choose Healthy Living System” has recently completed 10 years as a public policy, which is roughly the minimum time to evaluate a policy under the Sabatier framework14,22. During this time, it is possible to observe how initial learning occurs to achieve a consensus and implement a state policy with subsequent changes and execution assumed by each ruling coalition. These differences are evident not only in political management, but also in the discourse of the actors of each coalition with some level of conflict between deep core beliefs, which slows down the policy learning process. One coalition criticizes the vision of individual choice, questioning whether there is absolute freedom to choose in an unequal environment. “Why treat the population and then return it to the living conditions that make it sick?”16. On the other side, criticism of the SDoH vision is based on the fact that addressing health issues outside the health spectrum can result in a lack of prioritization because “When everything is important, nothing is important”23. However, many of the actors involved in the political subsystem do not belong to any of these coalitions and contribute according to healthy interests and abilities.
An essential aspect of the “Choose Healthy Living System” is that it did not consider a significant increase in fiscal spending. It only considered financing to create the Executive Secretary in the first year and coordinate existing programs from other Ministries. Therefore, it was processed quickly in Congress and approved unanimously since it did not generate an economic conflict affecting interest groups. However, not considering permanent financing is a weakness that leaves this policy susceptible to the freezing of resources in the case of “external events” and thus affects its continuity and sustainability in the long term. This fact has been the historical problem of policies in the field of health promotion. Some deputies requested to incorporate more funding to include regional teams that would adapt and coordinate the policy in the local context, but it was rejected. Since this System is only a coordinating entity dependent on the Ministry of Social Development, it does not have sufficient power over the other Ministries, which are its real executing arms, thus allowing the modification of environments that promote a healthier lifestyle in the population. When it was in the hands of the First Lady's cabinet, it had greater power.
Obesity and unhealthy lifestyles do not generate clear discontent in society, since various treatments have prevented cardiovascular mortality, so they are not seen as urgent problems to solve. According to Bradshaw, we can define this problem as a normative need raised by health professionals, academics and authorities rather than a need expressed by those affected24. Therefore, obesity and NCDs prevention within the agenda do not give political benefit as they are not considered a priority by the population, which prioritizes curative medical care. In addition, they involve social aspects, which slows down the policy learning between coalitions, according to the ACF.
It is important to note that according to Sabatier's framework there can be more than 2 coalitions of cause within a policy subsystem. Within those related to health promotion, new coalitions related to different visions of the problem could emerge, for example, the “Body Positive” movement and “Fat Feminism”. Within this movement, the use of body size or body mass index or an “obese body” as an indicator of health is criticized, alleging the existence of “fatphobia” and discrimination. This type of movement does not yet have a significant political force to affect the subsystem. Still, if it does, it could influence how to approach the problem25.
In conclusion, “Choose Healthy Living System” falls within the ACF as the key components were identified through the policy change and learning process. However, learning was slowed down because the problem involves conflicts between deep beliefs of both coalitions, wich affects the continuity of the policy.
