From Mid-Level Policy Analysis to Macro-Level Political Economy Comment on “Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia” Ronald Labonté * Abstract This latest contribution by the evaluation research team at Flinders University/Southgate Institute on their multi- year study of South Australia’s Health in All Policies (HiAP) initiative is simultaneously frustrating, exemplary, and partial. It is frustrating because it does not yet reveal the extent to which the initiative achieved its stated outcomes; that awaits further papers. It is exemplary in describing an evaluation research design in which the research team has excelled over the years, and in adding to it an element of theory testing and re-testing. It is partial, in that the political and economic context considered important in examining both process and outcome of the HiAP initiative stops at the Australian state’s borders as if the macro-level national and global political economy (and its power relations) have little or no bearing on the sustainability of the policy learning that the initiative may have engendered. To ask that of an otherwise elegant study design that effectively engages policy actors in its implementation may be demanding too much; but it may now be time that more critical political economy theories join with those that elaborate well the more routine praxis of public policy-making. Keywords: Health in All Policies, Evaluation Research, Program Theory, Political Economy Copyright: © 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Labonté R. From mid-level policy analysis to macro-level political economy: Comment on “Developing a framework for a program theory-based approach to evaluating policy processes and outcomes: Health in All Policies in South Australia.” Int J Health Policy Manag. 2018;x(x):x–x. doi:10.15171/ijhpm.2018.12 *Correspondence to: Ronald Labonté Email: rlabonte@uottawa.ca Article History: Received: 30 December 2017 Accepted: 3 February 2018 ePublished: 7 February 2018 Commentary Canada Research Chair, Globalization and Health Equity, Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada. htp://ijhpm.com Int J Health Policy Manag 2018, x(x), 1–3 doi 10.15171/ijhpm.2018.12 T here are two ways in which one can approach the well- crafted paper by Lawless et al 1 : as a contribution to a deeper understanding of the potential for Health in All Policies (HiAP) to achieve notable health-positive outcomes, or as an approach to policy studies more generally. The two ways are not exclusive, although as a contribution to the literature on HiAP the paper is frustratingly limited, focusing as it does on an evaluation design rather than on outcomes per se. There is only passing reference to a single HiAP example (changes to improve bicycle paths, which the authors acknowledge still awaits findings on the more distal outcomes), with the teasing promise of future results-oriented papers based on interview and survey data and drawing from several detailed case studies. Process evaluations of these HiAP ‘health lens analysis’ [HLA] case studies have already been posted by the South Australian Health Department, 2 including a summary report providing a rationale for their selection 3 ; as well as earlier papers by the authors that argue that the HLA process ‘had a number of positive effects’ 4 (p.i138), and an analysis of enablers or barriers to the HiAP process. 5 These assessments, however, remain descriptive evaluations of process and are not the ‘detailed findings…shaped by the framework’ in the present article 1 (p.10) being promised in subsequent papers. Presumably these papers-in-progress will include analyses of changes in government investments and policies, and offer some assessment of whether South Australia has indeed become ‘a better place to live with increased population health and equity’ (two of the outcomes noted in Figure 1). In terms of whether or not HiAP leads to sustained, health equitable impacts, at least as manifest through the South Australian initiative, thus remains a matter of future anticipation. It is the second reading of the paper, as a reasonably detailed summary of how one might pry open the ‘black box’ of policy processes such as those undertaken in the South Australian HiAP initiative, that the authors make a solid contribution to the public health literature. Adopting what appears to be a constructivist epistemology with its emphasis on the dynamic role of actors in meaning and knowledge construction, 6 the paper begins by acknowledging many of the travails of contemporary policy research: from difficulties in getting access to policy makers, to the contingent dynamics of day- to-day politics (in French, politique means both policy and politics which in English has somehow become bifurcated concepts), to challenges in causal attribution. While acknowledging that the policy world is ‘complex’ (a term invoked seven times in the article), the theory-based approach they outline is surprisingly devoid of reference to complexity theory itself (Table 2). Since the evaluation design described