Kingdon’s Three Stream Policy Window Model
World is changing fast with the growing developments in the technological, social and cultural contexts, so the success of organizations depend upon their movement parallel to these developments. However to keep this movement in the right track there is need of policies and procedures but these also seek modifications or change, time to time as per demands. Further for navigating the policy making process or change in policies, the change theories act as roadmaps.
In this blog I am going to focus on John Kingdon’s three stream policy window model, and how it relates to policy for coverage of heart failure under cardiac rehabilitation program. Kingdon’s policy window model of agenda setting tries to clarify why some issues are considered in the policy process and some are not. He identified three streams such as problem, policy and political, which must be coupled to make a policy change. Problem stream is a condition considered as a problem, policy stream is related to the alternatives that can be implemented and political stream is willingness and ability of politicians to make a policy change. This model seems to fit well with the issue of coverage of heart failure under cardiac rehabilitation program of Medicare.
Problem Stream
The increased attention to an issue or some major events can release the problem stream. The identification of an issue or problem is the first step in the Kingdon’s model. The main problem on which the policy related to coverage of heart failure under cardiac rehabilitation is based, is the disproportionate increase in the incidence of heart failure and tremendous growth in the aging population, because majority of them are suffering with heart failure. It is evident in the literature that heart failure is chronic progressive and costly syndrome, responsible for higher rates of morbidity and mortality, readmissions and hospitalizations and cost of care.
The other factor which made this problem more prominent is the maximum spending and poorer health outcomes by United States as compared to other (OECD) countries. How to reduce the costs and maximize the benefits among patients with heart failure gave birth to the problem stream in the cardiac rehabilitation policy. However cardiac rehabilitation policy was already in place and required modification related to coverage, but main challenge was to generate adequate evidence because in the past heart failure was not included under the coverage due to inadequate evidence. The fundamental drivers in this policy were the interest groups who generated the adequate evidence.
Political stream
The other stream which starts flowing alongside problem stream is the political stream. In this stream the problem is shared among policy communities that are composed of specialists in the area such as cardiovascular health in case of cardiac rehabilitation policy as well as different committee members in the congress, media and public. Further this community of specialists generates proposals, redrafts and debates them. The proposals are selected and considered seriously. The ideas from these experts flow like molecules and collide and ideas which are more powerful are carried forward in the movement by preparing an agenda. But during this movement the collaboration among participants is of paramount importance to reach the aimed target. However agenda related to coverage of heart failure under cardiac rehabilitation program has already crossed this stream.
Policy stream
Policy stream produces short list of proposals but this is not consensus rather it is agreement that certain proposals are prominent. The major driving forces here are the interest groups who are committed to a particular policy change. In coverage of heart failure the main committed groups are American Heart Association, American College of Cardiology, and American Association of Cardiovascular and Pulmonary rehabilitation. The movement of policy stream continues by making variety of suggestions publicly and privately to resolve the problem. In cardiac rehabilitation the research has been conducted by focusing on different aspects such as infrastructure, process of carrying out the cardiac rehabilitation and technology requirements, to generate evidence and to reach the agreement.
Windows
Convergence of problem, politics and policy stream results in public policy. These convergences according to Kingdon are called windows. There are driving forces like national mood, organizational interests, election repercussion, and orientation of elected politicians which open the window and lead to restructuring of the decision agenda but it requires joining of all three streams. So cardiac rehabilitation policy, according to Kingdon model has passed through the window after the convergence of problem, political and policy streams. As this policy is moving toward its approval so after that many formal and informal mechanisms and regulations are going to play a role in the implementation process. The impact of this policy change can be measured by using outcome based measures. Outcome driven mapping such as cataloguing desired outcomes, identifying potential policy and research paths, quantitative analysis of data and case studies can help diverse stakeholders in decision making and evaluating the effect of policy.
According to Fieldlng and Briss (2008) accelerating the integration of scientific discoveries into routine public health practice and policy deserves priority attention and in the policy related to coverage of heart failure under cardiac rehabilitation program the evidence has been given prior attention. The policy makers have addressed the burden of disease, program and policy options, the distribution of benefits among the affected, situation specific solutions, political and technical feasibility and cost and cost effectiveness. The road map approach includes the input from both experts and public about what is health and which societal level outcomes are desired that can shape the healthcare system. In addition to this contextual awareness among the policy makers and stakeholder is crucial for the decision making (Garfinkel, Sarewitz, & Porter, 2006).
References
Kritsonis, A. (2005). Comparison of change theories. International journal of management, Business and Administration, 8(1),
Garfinkel, M. S., Sarewitz, D., & Porter, A. L., (2006). A societal outcomes map for health research and policy. American Journal of Public Health, 96(3), 441-446.
Liebman, J B. (2013). Building on recent advances in evidence-based policy making. A paper jointly released by results for America and the Hamilton Project. Retrieved from http://www.brookings.edu/research/papers/2013/04/17-liebman-evidence-based-policy
Kingdon, J. W. (2010). Agendas, alternatives and public policies, updated Edition (2nd ed.). London: Longman Publishing Group.
Fielding, J. E. & Briss, P. A. (2008). Promoting evidence-based public health policy: can we have better evidence and more action? Health Affairs, 25(4), 969-978. Doi: 10. 1377/hlthaff.25.4.969.
Heart failure coverage under Medicare 
Hi Ramesh, The Kingdon’s Three Stream Policy Window Model is very interesting to focus on three perspectives: current problems, pilitical issues, and relative policies. I agree that helath policy should be established after considering the the three top parts in order to make more effective and comprehensive policy.
Thank you Mihyun for finding the post interesting. As we know the models and theories help to make the complex issues simple and easily understandable and Kingdon’s model is remarkable in that way.
Ramesh –
Here is another interesting point of view. Currently in the political health innovation arena, Flanagan, Uyarra, Laranja (2011) claim that policy makers who consider themselves evidence based advocates are changing the way actors go through Kingdon’s (2010) three streams: problem, politics and policy window model. The authors define these moderating influences upon Kingdon’s (2010) three streams as having a ‘policy mix’, meaning that policy change agents are collaborating across the government levels coordinating. Policy change agents use a theory based approach to work though the tensions while sorting out policy rationales, policy goals and implementation. As the window approaches a number of goals are horizontally presented through a mutual adaptation between the multiple policy change agents. Kingdom (2010) defines this movement as a convergence of streams through the window a conglomeration of fragmented processes, but Flanagan et al. (2011) claim this is rather the moderating effect of entrepreneurial coordination between policy change makers and thier diverse goals.
Zaha
Flanagan, Uyarra, Laranja (2011). Reconceptualising the ‘policy mix’ for innovation. Research Policy. 40 702-713
Thank you Zaha for bringing in the innovative perspective of Flanagan, Uyarra and Laranja (2011) that is focused on the interactions and inter-dependencies between policies and how they affect the outcomes. They have very rightly said that scholarly theories are never adapted as a whole in the policy making process but elements of interest are selected by the policy makers according to their interest and influenced by their values, beliefs and pressure. So there is interaction between two bodies of knowledge, theories developed by scholars and rationales pertaining to values and beliefs, held by policy makers. However Kingdon’s model also support collaboration among multiple actors for selecting the prominent idea for final agenda and influence of policy makers on the agenda especially when window opens or opportunity comes. But I agree, in an era of innovations, policy making process can not escape from its influence.Thanks for the great comment.