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To request permissions please use the Feedback form on our webpage. http://researchspace.auckland.ac.nz/feedback General copyright and disclaimer In addition to the above conditions, authors give their consent for the digital copy of their work to be used subject to the conditions specified on the Library Thesis Consent Form and Deposit Licence. Mental Health Policy Transfer and Localisation in Samoa and Tonga: International Organisations, Professionals and Indigenous Cultures Timothy Philip Fadgen A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Political Studies University of Auckland 2013 Abstract This thesis explores the development of mental health systems in the Pacific Island Countries (PICs) of Samoa and Tonga through an examination of several policy transfer events from the colonial to the contemporary. Beginning in the 1990s, mental health became an area of global policy concern as reflected in concerted international organisation and bilateral aid and development agendas, most notably those of the World Bank, World Health Organization, and the Australian Agency for International Development. Tonga and Samoa both reformed their respective mental health systems during these years, after relatively long periods of stagnation. By undertaking a comprehensive investigation of the respective governments’ policy- and law-making processes from 2000-2007, this thesis identifies three distinct levels of policy implicated in mental health system transfer processes from developed to developing nations: (1) colonial authority and influence; (2) decolonisation processes; and (3) the global development agenda surrounding health systems. I use the policy transfer literature to explain these policy outcomes and expand it to include consideration of the historical institutional dimensions evidenced by contemporary mental health systems. These policy levels include (1) formal policy transfers, which tend to be prescriptive, involving professional problem construction and the designation of appropriate state apparatus for curative or custodial care provision; (2) quasi-formal transfers, which tend to be aspirational and involve policy instruments developed through collaborative, participatory processes; and (3) informal transfers that tend to be normative and include practices by professional actors in delivering service merged with traditional cultural beliefs as to disease aetiology as well as reflecting a deep understanding of the cultural context within which the services will be delivered. I conclude that informal policy transfer through information-sharing, training and social networks effectively delivered the values of the respective mental health systems many years prior to formal or quasi-formal transfers. The informal transfers involved medical professional policy entrepreneurs influencing service delivery practices to their respective community-based service visions. These informal transfers were marked by a high degree of hybridisation of international and indigenous mental health best practices. Formal and quasi-formal policy transfers, by contrast, occurred only with the direct intervention of foreign experts. i Dedication I wish to dedicate this thesis to several people, without whom the past several years’ research would not have been possible and this work would never have developed. First and foremost, Meg: for your constant support, patience and love. Last but not least, shortly after embarking on this journey, Edie and Eoin Fadgen joined the family and I wish to thank them for the joy and purpose they provide. Thank you from the bottom of my heart. ii Acknowledgements I wish to recognise the important contribution of my doctoral adviser Dr Jennifer Curtin. Her attention, focus, thought, comments and care have made all the difference in completing this thesis. I wish to acknowledge the very kind assistance of Dr Sailau Suaalii-Sauni of Victoria University and Dr ‘Ema Wolfgramm-Foliaki for their very kind assistance in making introductions to various individuals in Samoa and Tonga, respectively. In addition, the Prime Minister’s Offices of Samoa and Tonga as well the Samoan and Tongan Ministries of Health, Tonga’s Ministry of Education, the National Museum of Samoa Archives, the New Zealand National Archives and especially the Legislative Assembly of Samoa’s Speaker’s Office and Parliamentary Library and Tonga’s Parliamentary Speaker’s Office and Parliamentary Library for their kind assistance in gathering original documents for this research. I wish to acknowledge Melanie Boutin, John Wiinikka, Dana Prescott, Guy Charlton, Sailau Suaalii- Sauni, Tim Tembensel, Maria Rublee, Joe Atkinson and Jon Pierre for reviewing the thesis and ideas at various stages of development and for their helpful feedback. I especially wish to thank my sister, Megan Roman, and Paul Vincent for their meticulous assistance proofreading the manuscript. I would also like to thank Sala Mataele for help with translating Tongan parliamentary debate transcripts. Finally, I wish to acknowledge and express my profound gratitude to the University of Auckland for their generous support of this research over the past several years. iii Table of Contents Abstract ......................................................................................................................... i Dedication ..................................................................................................................... ii Acknowledgements ...................................................................................................... iii Table of Contents ......................................................................................................... iv List of Tables ............................................................................................................... vii List of Common Abbreviations ................................................................................... viii Glossary ....................................................................................................................... ix Chapter 1 ...................................................................................................................... 1 Introduction ................................................................................................................... 1 1.1 Situating the Thesis ........................................................................................................................ 3 1.2 Thesis Outline .................................................................................................................................. 4 1.3 Summary ........................................................................................................................................ 13 PART I: Mental Health Policy Transfer: Background, Theory and Method ................ 15 Chapter 2 .................................................................................................................... 15 Mental Health Policy: Setting the Thesis Context ...................................................... 15 2.1 What is Mental Health? ................................................................................................................ 16 2.2 The Cultural Dimension of Mental Health .................................................................................. 17 2.3 What Makes Up a Mental Health System? ............................................................................... 20 2.4 Can the Mental Health Policy Context Be Understood through Institutionalism? ................ 21 2.5 Mental Health Policy Development at the ‘Policy Core’: North America and Western Europe ...................................................................................................................................................... 27 2.6 The Global Mental Health Context ............................................................................................. 35 2.7 Conclusion ..................................................................................................................................... 38 Chapter 3 .................................................................................................................... 41 Policy Transfer ........................................................................................................... 41 3.1 Explaining Policy Migration: Diffusion, Lesson Drawing, Convergence and Policy Transfer 41 3.2 The Policy Transfer Framework .................................................................................................. 52 3.3 Conclusion ....................................................................................................................................