Chapters 3-9 trace, in roughly chronological form, the development of health policy in Britain, the US, the Netherlands and Canada from the mid-twentieth century to the present. In each case we observe a pattern of policy cycling in “normal” times between episodes in which the scale of change is sharply increased, the pace of change is rapidly accelerated, or both. Although the focus is one the episodic bursts of change, the periods of cycling are also traced in some detail.

The bursts of change are not fully explained by the opening of “windows of opportunity,” which provide a necessary but not a sufficient condition. Windows of opportunity occur when a set of political leaders judges that it has the institutional and electoral resources necessary to form a winning coalition and also perceives a partisan imperative to act. In each of the cases presented, these conditions pertained.

Even then, however, would-be policy reformers must decide upon the scale and pace of change to pursue. For each case I describe the formation of strategic judgments about scale and pace, and then show how the chosen strategy unfolded throughout the process of enacting the reforms. The early implementation period is also discussed.

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