Public Health from the Middle-Out: A New Analytical Perspective

Obstacles to collaborative public health frameworks such as Health in All Policies continue to emerge. Partnership-based public health programs present opportunities to study how public servants and practitioners address these barriers in real time. To this end, we utilized “Middle-Out,” a socio-technical analytical approach that highlights the importance of Middle Actors-stakeholders positioned between policymakers and grassroots—to policy diffusion, innovation and collaboration in public health. We conducted participatory observation in administrative settings of Israel’s National Program to Promote Active, Healthy Lifestyle, 30 stakeholder interviews and document analysis. We examined two dimensions of impact from the Middle-Out: Directions of Influence—Middle-Up, Middle-Down and Sideways, and Modes of Influence—Enabling, Mediating and Aggregating. Through Middle-Out’s lens, our analysis transcends visible benchmarks such as legislation and macro-level resource-allocation, focusing, instead, on elusive administrative spaces within which Middle Actors shape policies, steer funding and facilitate continuity. Incorporating Middle-Out into public health’s conceptual toolbox, we conclude, can improve understanding of complex public health policy arenas, increase recognition of critical socio-technical changemakers and catalyze more effective design of policy tools and strategies that specifically harness Middle Actors’ strengths and qualities.