Public policies as process of practical action: the case of Belgian mental health reforms

This paper analyses the process of preparing and devising the policy programme of Reform 107, i.e. the ongoing reform of Belgian mental healthcare delivery. Based on empirical data collected through documentary analyses, semi-structured interviews with policy-makers and civil servants, and direct observations of meetings and conferences, it analyses the processes of preparing and devising Reform 107. The analysis of the 15-year process during which Reform 107 had been prepared evidences that policy-makers came to know about the Reform’s scope and objectives as they went through local, national and international events and meetings, which relate more or less directly to the issue of mental health care delivery. The Reform’s scope and objectives thus varied during 15 years following, among other, international conferences held by the World Health Organisation ; advisory notes produced by Belgian interest groups ; special requests expressed by service users’ groups ; policy makers’ visits to local mental healthcare services in Belgium and other European countries. Then, the analysis focuses on the three-month process following the policy decision to start Reform 107. During that short period, two special committees, the think tank and the task force, had translated the Reform’s objectives into a policy guide presenting the reform’s implementation plan. The analysis of the task Force and think tank’s meetings helps to highlight three types of policy learning -learning by assembling, learning by meeting and learning through strategic thinking, which are associated to three kinds of policy decisions defined as ambiguous, innovative and contested. The inscription of such ambiguous, innovative and contested decisions into the policy guide caused many disagreements and misunderstandings between policy-makers and local actors involved in the reform’s implementation. Those disagreements caused, in turn, changes in the reform’s objectives, scope and implementation. By drawing on those results, we argue that Belgian mental health policies change as they are done. Consequently, those policies exist only as a process made of practical actions and social interactions leading to more or less significant variations in one or more aspects of policy programmes. Concrete implications for researches on public policy making and implementation are finally drew from our research’s results.