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Bringing politics and evidence together: Policy entrepreneurship and the
conception of the At Home/Chez Soi Housing First Initiative for addressing
homelessness and mental illness in Canada
Eric Macnaughtona,*, Geoffrey Nelsonb, Paula Goeringc
aMental Health Commission of Canada, Adler School of Psychology (Vancouver), Canada
bWilfrid Laurier University, Canada
cCentre for Addiction & Mental Health, University of Toronto, Canada
a r t i c l e i n f o
Available online 1 February 2013
Evidence-based policy making
Determinants of health
Multiple streams theory
a b s t r a c t
An interesting question concerns how large-scale (mental) health services policy initiatives come into
being, and the role of evidence within the decision-making process behind their origins. This paper il-
lustrates the process by which motivation to address homelessness, in the context of the upcoming 2010
Vancouver Olympics, was leveraged into a pan-Canadian project including sites in Vancouver, Winnipeg,
Toronto, Montreal and Moncton, New Brunswick. The aim of the initiative was to implement and
evaluate an intervention, Housing First, to provide housing and support to previously homeless people
with mental illness. This qualitative case study was conducted between December 2009 and December
2010, employing grounded theory, and drawing on archival documents and interviews with 19 key in-
formants involved in the conception of the project. Overall, the findings affirm that policy-making does
not follow a rational, linear process of knowledge translation/exchange (KTE) and implementation,
whereby evidence-based “products” are brought forward to address objectively determined needs and
then “placed into decision-making events” (Lomas, 2007, p. 130). Instead, evidence-based policy making
should be understood within the much more complex context of “policy entrepreneurship” (Kingdon,
2003; Mintrom & Norman, 2009) which entails taking advantage of windows of opportunity, and
helping to bring together the “streams” of problems, politics, and policy ideas (Kingdon, 2003).
? 2013 Elsevier Ltd. All rights reserved.
The At Home/Chez Soi project is the largest mental health ser-
vices trial ever mounted in Canada. Funded by Health Canada and
carried out by the Mental Health Commission of Canada (MHCC),
the project uses a randomized controlled trial (RCT) design, fol-
lowing more than 2200 previously homeless people with mental
illness in five cities for two years to examine outcomes (Goering
et al., 2011). The focus of the current paper is on a qualitative
study of the process of the conception of the At Home/Chez Soi,
which the project team believed would provide useful lessons for
other jurisdictions regarding the diffusion of innovative ideas for
addressing complex health and social problems, like mental illness
As the research proceeded, it became evident that moving the
ideas behind this initiative into policy entailed effectively
positioning the outlines of a potential solution within a complex
political climate, a process that can be understood as “policy
entrepreneurship” (Kingdon, 2003; Mintrom & Norman, 2009),
which brings the three “streams” of “politics”, “problems” and
“policies” together. Given the current focus on “evidence-based”
policy making, and growing attention to the complex intersections
between evidence and the political and social aspects of decision-
making and “agenda setting” (Battams & Baum, 2010; Fischer,
2003; Kingdon, 2003; Russell, Greenhalgh, Byrne, & McDonnell,
2008; Tiernan & Burke, 2002), this investigation thus offered
a valuable chance to broaden understandings on innovative policy-
making in the mental health field. Finally, the present research,
with its qualitative, case-study approach, also offers a chance to
build our understanding of what is increasingly recognized as the
“complex, dynamic, and social” nature of evidence-based policy-
making approaches, such as knowledge exchange (Ward, Smith,
House, & Hamer, 2012).
The focus of the paper is on the political phase of the At Home/
Chez Soi initiatives’ conception; hence, the perspective taken looks
outwardfromKingdon’s “political stream” towards the “policy” and
* Corresponding author. 5475 Sophia St., Vancouver, BC V5W 2W2, Canada.
Tel.: þ1 604 6873996.
E-mail address: email@example.com (E. Macnaughton).
Contents lists available at SciVerse ScienceDirect
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Social Science & Medicine 82 (2013) 100e107
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“problem” spheres, and focuses on how policy entrepreneurship
helped link these spheres during this initial phase and resulted in
the initiatives’ funding. This paper is abstracted from a larger study
(Macnaughton, Nelson, Piat, Eckerle Curwood, & Egalité, 2010) that
also looks more closely at how the initiatives’ policy specifics were
adapted in response to local communities’ perspectives on the
problem. Factors related to cross-site implementation of the ini-
tiative (e.g., the coherence of the policy idea) or the longer-term
sustainability of this (still in progress) demonstration project, will
thus not be closely examined in this paper.
Some may argue whether demonstration projects could be
considered “policy”, given questions about continuation of funding;
this risk, however, was weighed carefully against the tremendous
opportunity to create a long-term policy legacy. At the time of
writing, there has been formal commitment to continue funding
the Housing First model at all sites beyond the end of the dem-
onstration period, either indefinitely or for a transitional period,
while the possible options for permanent funding are negotiated. In
the event that plans are not fully realized in a local site, the project
will transition those participants to other housing and support
services. There are also many examples of the ways in which the
project has already achieved shifts in program and system policy,
both nationally (Goering & Tsemberis, inpress), and internationally,
including the launching of similar demonstration initiatives in
France (Goering et al., 2012), Australia, and Portugal.
Community mental health and homelessness
Despite the reforms of the community mental health move-
ment, there is a general consensus that a large “quality chasm”
exists between what the research suggests people with serious
mental illness should receive and the proportion of individuals
actually receiving those services (Lehman, 2010). The inadequacies
of mental health services are reflected by the over-representation
of people with mental illness among the justice system and
among the ranks of the impoverished and homeless (Rochefort,
1997). Indeed, a study of two North American cities showed that
people with serious mental illness accounted for approximately
50% of total bed days within homeless shelters, which have become
a de facto parallel system of care for homeless people with mental
illness (Culhane & Metraux, 2008).
As Battams and Baum (2010) described, inadequate housing for
people with mental illness has been compounded by issues such as
affordability, loss of housing stock, divided accountability, and lack
of a “common view” about solutions that could facilitate action
across the various policy and service delivery partners involved in
housing people with mental illness. Moreover, in Canada specifi-
cally, as in other Western nations, a political climate of neo-
liberalism has contributed to the withdrawal of government from
the social housing sphere, both in terms of funding and policy
attention (Gaetz, 2010); the result is that what were previously
federal and provincial responsibilities for social housing have now
been increasingly placed on municipal governments, which lack
funding to fill the policy void (Carroll & Jones, 2000).
In regards to homelessness and mental illness, there has been
slow progress in implementing appropriate interventions, which
the Nelson, Aubry, and Lafrance (2007) review shows, should
combine Assertive Community Treatment (ACT) or Intensive Case
Management (ICM), with supported housing, as does the Pathways/
Housing First approach. Unlike traditional purpose-built mental
health housing, the Pathways approach provides the individual
with independent housing, and provides support on a mobile basis
(Tsemberis, Gulcur, & Nakae, 2004).
Mental health policy responses
In response to the policy failure of community mental health in
North America, and due to the growing public concern that
accompanied it, Canada and the United States have recently un-
dergone large-scale federal policy review processes. In the United
States, a major consultation known as the President’s New Freedom
Commission was conducted. In Canada, a cross-country Senate
report Out of the Shadows (Kirby & Keon, 2006). In both cases, these
reviews resulted in a series of recommendations oriented towards
developing evidence-based, recovery-oriented supports for people
with serious mental illness. In Canada, supported housing was
a central plank of the overall recommendations, and the report lead
to the formation of the MHCC, funded for 10 years to spearhead
and committee structure that includes people with mental illness,
family members, and mental health professionals. Through its
committee structure the MHCC is also closely linked to an informal
Steve Lurie, is well connected to an Ontario policy network that has
The rationalist, evidence-based approach to mental health policy-
In both countries, mental health policy reform coincided with
efforts within the health services and policy fields to develop sys-
works into concrete policies and practices, a process often referred
to in Canada as “knowledge exchange”, “knowledge translation” or
knowledge translation and exchange (KTE). For instance, the
“Knowledge to Action” model, which has been adopted by the Ca-
for developing, synthesizing, tailoring and applying knowledge to
The CIHR model in fact does encompass non-linear events such as
interaction and mutual learning between researchers and policy-
makers, and evidence is acknowledged to encompass experience
and expertise. However, the emphasis of the model is arguably on
policy and practice to address evidence/practice gaps.
In the United States, Damschroder et al. (2009) review a number
“implementation science.” Internationally, a number of authors
have contributed to a special issue of Health Research Policy and
Systems on “evidence-informed policy-making”, which describes
systematic procedures for using evidence during three stages e
problem clarification, options formulation, implementation plan-
ning e of the policy-making process (Oxman, Lavis, Lewin, &
Underlying all of these approaches is the apparently reasonable
assumption that effective policy reform hinges on the ability to
develop and apply systematic techniques e or “technicist” ap-
proaches (Ward et al., 2012) e for addressing these evidence/
practice gaps. Another underlying assumption here is that objective
solutions exist to clearly manifested problems that potential
knowledge users (e.g., policy-makers or clinicians) can be per-
suaded and helped to implement.
Critique of the rationalist, evidence-based approach
In an alternative constructionist view, such problems are by
nature not objectively apparent, but are usually multi-faceted in
E. Macnaughton et al. / Social Science & Medicine 82 (2013) 100e107
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nature and thus amenable to being conceptualized in different
ways (Fischer, 2003; Kingdon, 2003). Given this complexity and
ambiguity, difficult social problems (e.g., homelessness and mental
illness) are subject to contestation, negotiation and “claims mak-
ing” (Humphreys & Rappaport, 1993; Kingdon, 2003), and thus are
part of a process that is intrinsically social and political in nature.
Unlike the traditional mental health services research fields,
which tend to be dominated by psychology and psychiatry, disci-
plines such as sociology, political science and policy studies have
been turning away from rationalist approaches to understanding
policy decision-making over the past few decades. For instance, an
influential paper within sociology (Hilgartner & Bosk, 1988) has
pointed out how regardless of any evidence attesting to their
importance, social problems must nevertheless compete with each
other for attention within policy-making “arenas”. Hilgartner and
Bosk further note the key role oftenplayed by “policy operatives” in
this struggle to move a particular issue forward (i.e., individuals
who understand how to position issues within policy arenas).
Similarly, Kingdon (2003) talks about the role of “policy entre-
preneurs” in helping policy problems and solutions survive the
competition with other pressing issues, and grab the attention of
decision-makers. Policy entrepreneurship is essentially about the
skill of certain individuals and the capacity of small groups of in-
dividuals to take advantage of unique windows of opportunity and
to frame a solution in terms that catalyse a convergence of the
“streams” of “problems, politics, and policy ideas”. As Kingdon ar-
gues, in order for a policy idea to go forward, a social issue must be
defined as a “political problem”. Then, a solution must be advanced
that facilitates a convergence of various interested stakeholders,
both internal and external to government, into a cohesive “policy
coalition” in support of the particular idea (Sabatier, 1988). As
Kingdon argues, and as Mintrom and Norman (2009) later elabo-
rate, the role of the policy entrepreneur is often crucial in taking
advantage of emerging opportunities and putting forward ideas
that facilitate consensus and collective action towards a solution.
The study employed key informant interviews and qualitative
analysis using constructivist grounded theory (Charmaz, 2006) to
address the research question, which was: what is the process by
which the broad outlines of the At Home/Chez initiative came into
Constructivist grounded theory consists of three stages: initial
coding, focused coding and theoretical coding. The use of dis-
ciplinary theory is considered appropriate during the theoretical
coding stage, providing the theory is not a predetermined lens, and
“earns its way into the analysis” (cf. Charmaz, 2006). Between
December 2008, and April of 2009, the researchers interviewed 19
individuals at various locations in this Pan-Canadian study who
were involved in the inception of the project, and who were known
by At Home/Chez Soi project leaders as being intimately familiar
with the various aspects of the projects’ origin from different per-
spectives. These informants included decision-makers familiar
with the federal political context (n ¼ 4), informants who were
familiar with the evolving policy formation process at the federal
level (n ¼ 5), and informants who were more familiar with how the
politics and policy-making played out at each of the sites (n ¼ 10).
Participants were contacted initially, usually by email, and then
interviewed in person (n ¼ 10), or over the phone (n ¼ 9), by one of
four researchers, who obtained their informed consent for the
study. Interviews were recorded and transcribed verbatim. Ethics
approval was obtained through Wilfrid Laurier University, includ-
ing approval to use identifying quotes for those respondents who
gave consent to be named.
Consistent with grounded theory, the interview guide was not
guided by any specific theoretical framework. Instead informants
were asked to “tell the story of how the At Home/Chez Soi project
came into being”. They were then probed on issues such as timing,
key players, how funding was assured, how the policy and research
aspects of the project were conceptualized, as well as facilitating
and hindering factors in the initial conceptualization phase.
A potential limitation of key informant interviews was the
possibility that interviewees, often senior policy-makers, would
withhold sensitive information. In order to facilitate more open
dialogue, two senior researchers conducted in-person interviews
determined to be of a more sensitive political nature. Also, for
purposes of triangulation of data sources, and to understand more
fully the political context surrounding decision-making, the re-
searchers also examined a number of relevant documents. These
included media and policy documents related to the period
immediately before the idea for what became the At Home/Chez
Soi project arose in the political sphere (i.e., between April, 2007
and January, 2008), and project planning documents (e.g., a funding
agreement, Project Precis) developed between January and
A team approach to coding was adopted, in which two re-
searchers read and initially coded transcripts, then subsequently
met and achieved consensus on major codes, which were then
reviewed by three other project team members. The coding was
completed by hand (rather than by computer program). Re-
searchers employed member-checking with key informants (i.e.,
returning the data, the chronology and analysis to them to ensure
its trustworthiness). This resulted in some new data and helped
optimize the credibility of the findings. Overall, key informants
concurred with the factual account and with the thematic analysis.
It should be noted that Michael Kirby, who emerged as a key actor
in the study, was also a key informant. His account, and the sub-
sequent thematic analysis that featured his involvement, was cor-
roborated through the member-checking process. Comments
emphasizing his role must be taken in context of the chronology
created by the document analysis, particularly the Vancouver back
story, which happened prior to the project.
Member-checking using outside informants minimized the
possibility of interpretive bias of researchers who were part of the
At Home/Chez Soi project, and thus part of the political and policy
streams themselves that they were studying, though it should be
emphasized that none of the authors has an ongoing working
relationship with Mr. Kirby. Emergent themes identified were those
that had repeatedly been coded by the research team tothe point of
theoretical saturation. In order to optimize the trustworthiness of
the findings, and to ensure that the theoretical coding framework
had appropriately “earned its way” into the analysis, the re-
searchers delayed doing an extensive literature review until later in
the analysis. Interview data and the document analysis was also
used to reconstruct a chronology of the At Home/Chez Soi project,
and of the context leading up to the initial decision to consider
a homelessness initiative in one of the key sites.
The story of the conception of the At Home/Chez Soi project
The At Home/Chez Soi project has its roots in the MHCC.
Beginning in 2003, Senator Michael Kirbychaired a SenateStanding
Committee on Social Affairs, Science and Technology. After holding
more than 50 meetings and hearing separately from more than 300
people from across Canada, the committee produced a report
(Kirby & Keon, 2006) that recommended the creation of the MHCC.
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In March 2007, Prime Minister Harper and Minister of Health Tony
Clement asked Senator Kirby to chair the Commission.
In January, 2008, Mr. Kirby received a telephone call from a se-
nior member of the Canadian government, who asked for his
assistance in formulating a project for homeless people with
mental illness in Vancouver. Said Kirby of this call: “I knew they
weren’t messing around” and that “there was money around
because it was year-end.” Over the next several weeks, Mr. Kirby
interacted with representatives of the federal government, as well
as certain members of the mental health community, to con-
ceptualize the broad strokes of an initiative, which at this point was
conceived as entailing both research and service.
Without divulging the funding source, Mr. Kirby enlisted the
help of Mr. Steve Lurie, Executive Director of the Canadian Mental
Health Association/Toronto branch and head of a key MHCC com-
mittee, who brought in Dr. Paula Goering, a researcher with the
Centre for Addiction and Mental Health in Toronto, to help for-
mulate the project, which grew quickly from one to five cities. Once
the sites were proposed, Mr. Kirby spoke with government repre-
sentatives from the provinces in which the five cities were located
to get their “buy-in” to the project. With the exception of Québec,
politicians from the other provinces that would host a project site
gave their endorsement.
Kirby then appointed Dr. Jayne Barker, the Commission’s Di-
rector of Policy and Research, to lead the initiative, who, together
with MHCC Chief Operating Officer (COO), Dr. John Service, nego-
tiated with Health Canada the broad parameters of a funding
agreement that specified the guiding principles of a project that
would be announced in the federal budget in March, 2008.
Vancouver: the back story
Vancouver’s Downtown Eastside, known as Canada’s “poorest
postal code”, represented the countries’ most visible, concentrated
manifestation of homelessness. Speaking to an audience convened
at Vancouver’s Board of Trade in May 2007, Phillip Mangano (the
U.S. “Housing Czar”) referred to this situation as “one of the worst”
examples of homelessness he had witnessed. Echoing local senti-
ments, he expressed hope that the (then) upcoming Winter
Olympics would provide a catalyst for addressing the issue. Unlike
Atlanta’s 1996 Summer Games, where homeless people had been
criminalized or offered one-way bus tickets out of town (Burbank,
Andranovich, & Heying, 2001), Vancouver’s Organizing Committee
had ambitiously proclaimed their Games would be the world’s first
“socially sustainable” Olympics, which would create an “affordable
housing legacy” (Author, 2002).
Armed with this “Olympic promise”, local housing advocates
pressed for sustained attention to this issue. Around the time of
Mangano’s visit, a local “Olympic watchdog” coalition gave the
Organizing Committee a grade of D- on its social sustainability
agenda in a widely covered media event. The concerns of other
advocates about Olympic-related gentrification of Single Room
Occupancy (SRO) hotels in the cities’ Downtown Eastside also
received considerable media exposure. These events in turn led to
national media attention, particularly around the Vancouver
Mayor’s statement later in May 2007 that the province should deal
with the housing problem by reopening closed portions of the
province’s main psychiatric institution and use these for “semi-
independent living”. The Mayor also reminded the federal gov-
ernment, then in a minority parliament position, that the “world
would be arriving at our doorsteps” for the Olympics in 2010, and
suggested that “they had a problem”.
In early June of 2007, the attention on homelessness and the
Downtown Eastside of Vancouver was compounded by the release
of a United Nations affiliate organization’s report on the impact of
Olympics and other mega-events on housing displacement, which
expressed concern about Vancouver’s situation. Soon after the
release of this international report, following a human rights
complaint supported by the Olympic watchdog group, a UN “spe-
cial rapporteur” was sent to Canada in the fall of 2007 (Delisle,
2010). Based on the findings of the visit, on November 1, 2007,
the UN released a set of recommendations addressing housing and
homelessness in Canada, which paid particular attention to Van-
couver’s situation (Kothari, 2007). Finally, on January 23, 2008, the
Federation of Canadian Municipalities (a national council of “big
city” Mayors, at the time co-chaired by Vancouver’s Mayor)
released a report calling for a “national plan to end homelessness
and deliver affordable housing” (Author, 2008). As noted, it was in
January 2008 that Mr. Kirby received his phone call.
Thematic analysis of the key informant interviews: factors
contributing to the Initiative’s conception
In this section, we describe themes elucidating why this project
received financial support from the federal government, and illu-
minating how the broad parameters of the initiative were con-
ceptualized. These themes help to explain initiative’s conception,
and will be further elaborated in the Discussion, when we look
them in relation to a specific theoretical framework.
Crystallization of consensus about the need to do something about
description of events depicted in the chronology and indicate the
emergence of a broad-based consensus that was crystallized by the
upcoming Vancouver Olympics:
“I think there was a pivotal time when people recognized that
homelessness was reallyan issue in Canada. ” (federal policy key
Q: “Was this to deflect attention from the Olympics?” A: “Well
partly Olympics, partly, cause the province of B.C. was putting
pressure on them, partly because the local members [of federal
parliament] wanted [action]. You know [.] the Downtown
Eastside is a pretty sore [spot] .” (Michael Kirby)
“[The situationwas discussed politically] . in the context of the
Vancouver 2010 Winter Olympics, which was a very important
factor to acquiring the funding.” (federal policy key informant)
While key informants did not suggest why the Olympics would
be such an important factor in the initiative’s formation, the “back
story” chronology would suggest why. According to the key in-
formants, at this point decision-makers were not clear exactly what
the problem was, or how to proceed, but there was a definite
consensus that something had to be done.
Framing the problem in terms of mental illness
The next theme had to do with the emerging consensus that
successfully addressing homelessness involved recognizing the
links between this issue and mental illness. As the quotations
suggest, the consensus had to do with evidence, perceptions, as
well as political support from the highest level.
“.homelessness and mental illness are linked.it just made
sense.” (federal political key informant)
“The idea started with ‘let’s do something for the homeless on
the downtown east side of Vancouver.’ But because of the Prime
Minister’s interest in dealing with people with mental illness, it
expanded into a project targeted at the homeless mentally ill.”
“.It’s pretty well known that.there’s a huge percentage of
people who arehomeless thathave mentalhealth
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issues.because of the link tothe Commission and the view that
there is a vehicle here, an arm’s length organization from gov-
ernment that was set up . to look at mental health issues. It
was felt that that was more of an appropriate fit [i.e., with the
Commission, rather than with the federal ministry responsible
forhousing, Human Resources & Social Development Canada]..
On that point it’s been. a well known point . that the current
[Conservative] government . philosophically . support(s) .
the engagement of third party organizations.” (federal political
In sum, a convergence of reasons involving research evidence,
public perceptions and political philosophy led the project to be
framed in terms of homelessness and mental illness to be driven by
Key factors influencing the project’s initial framing: trust in
As the next series of comments illustrate, perhaps the most
important characteristic of the vehicle driving the initiative was the
person that led it.
(on Michael Kirby’s qualities): “Obviouslyeveryoneknows . his
political background [as a Liberal politician], but I think Kirby
was able to transcend those political lines, . given that, at the
end of the day, what people really respect are fresh and inno-
vative ideas.. I think that’s what gave him the ability to .
transcend those political lines and to be recognized as an indi-
vidual that can actually get something done.. I think it’s also
.Kirby’s keen sense of how government works that would
allow him to situate his ideas within a machinery that I think we
all kind of recognize can be . cumbersome at times.. But he’s
able to . speak a language that people understand and express
ideas in a way that will resonate with the key decision-makers.”
(federal political key informant)
“I think it depended heavily on Mike Kirby’s relationships . he
was the person that brought this about on the non-
governmental side as far as I can understand it.” (federal polit-
ical key informant)
“Because of Mike Kirby’s previous experience here (in previous
Mental Health Commission consultations) and his relationships,
the idea of the project didn’t seem like some white knight from
the east coming in to save the day.” (site-level policy maker)
As Kirby himself said: “I wasn’t a rabid Liberal. I was known as
a policy guy.”
In sum, the comments suggest that what made Kirby a trusted
driver of the policy-making “vehicle” (the MHCC) was his credi-
bilityas a policy-maker and his ability to express ideas in away that
resonated with decision-makers and transcended political and
Framing a politically reasonable solution
Another aspect of framing the solution had to do with ensuring
the project would be conceptualized so that its external politics
would be seen as “reasonable”, as these quotations from Kirby
“This was meant to be a [research] project from the beginning.
The fedscouldn’t getinto actually providing the services,because
then you’d be in this whole constitutional quagmire. [since
provinces are responsible for (mental) health services delivery]”
“If you’re going to do a demonstrationproject, you’ve got to do it
across the country or you get killed politically. Politically, if
might as well do one in every region of the country.”
As these comments suggest, in order for the project to be polit-
ically reasonable, it had to be conceptualized as a research demon-
Feeding the beast: using inside knowledge to mobilize political
The comments of one key informant from the federal political
sphere suggested that the process of policy-making could be con-
sidered as “feeding the beast”. That is, while it involves numerous
players, and the processing of much policy information, as the
following comments by Kirby illustrate, it ultimately came down to
a fast, closed process involving a relatively small group of insiders,
where Mr. Kirby played a pivotal role.
“So [after I had the initial phone call] I said ‘who do I know who
could possibly know anything about this project?’ so I phoned
(name of individual), and I talked to (name of individual) and I say
‘does it make any sense that we would look at this crowd and so
on.’ And he says ‘absolutely’. And I said ‘do we know anybody
that could work with you [over the weekend] to give me the
rough outline of, a research project’. So I talked and he said the
person you’ve got to talk to is (name of individual) .so this is
where the subterfuge came in. Because of the secrecy sur-
rounding the budgeting process I told them we’ve got a large
.then the question [from senior government representatives]
was ‘howdo we know that the provinces aren’t going to get mad
and start accusing us of meddling in their [jurisdiction] right?’
.I said ‘. why don’t you just phone them and ask them?’ It
seemed pretty simple to me. Okay. Got a call back later that day
and said ‘we discussed that, we think you may actually have
faster from people than going the bureaucratic route . So after
talking with [B.C. Premier] Gordon Campbell [and later with
other political leaders], I phone them back and I say ‘done’ .
In sum, the comments suggest howMichael Kirby usedhis skills,
resources and access as an insider e both within the mental heath
movement as he drew on his contacts within the mental health
arena, and within government itself e to quickly ascertain the
feasibility of the project and then to build broad-based support
amongst the key decision-makers whose “buy-in” was necessary
for establishing the project as a national initiative.
Framing the project in broad brush strokes
As the next series of comments from a variety of informants
indicate, while the project was conceptualized as a national “whole
of society”, or multi-sectoral, demonstration project addressing
homelessness and mental illness, other than specifying some key
guiding principles, the funding agreement contained few specifics.
“. no one level of government could actually do something that
would help address that issue. So here in government we say
.you .need a whole of societyapproach. .we all need to be in
this together to actually affect change.” (federal political key
“The funding agreement specifies a set of outcomes. But they
didn’t say ‘is it going to be a randomized controlled trial? Is it
going to be done nationally or done in the individual site?’ They
didn’t shape it in that way at all.” (federal policy key informant)
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“It was so wide open at that point, I mean when you have .
essentially a white board up there and you have a number, 110
million, five cities, the cities are specified, nothing else. [Earlier,
at a meeting that took place after the funding agreement had
been finalized] the talk was about whether the intervention
would somehow be Housing First because that was the most
evidence-based housing intervention . but that there would be
a need to make sure that it worked for the Canadian context and
to expand it a bit.” (federal-level policy key informant)
Research evidence was involved at this point, when Kirby
obtained advice about feasibility from a key researcher in his net-
work. However, this large initiative was initially funded without
a specific policy proposal, and without any detailed consideration
of the evidence behind any specific intervention, a consideration of
which came after the initial funding agreement was signed. Below,
we consider a specific theoretical framework that can help explain
the limited role of research evidence in the initiative’s inception, as
well as provide insight into the other themes that were identified.
As will be discussed below, what the case study illustrates is
how a person (Michael Kirby) who has all the attributes of a policy
entrepreneur found himself in a unique position of influence
because of a convergence of events. A man who came to public
prominence as the person most responsible for negotiating the
Canadian Constitution on behalf of the late Liberal Prime Minister
Pierre Trudeau, Kirby later worked as pollster and as one of the
country’s most influential political strategists (Wikipedia, accessed
February, 2011) before his appointment to the Senate, and then as
the founding Chair of the MHCC by Conservative Prime Minister
Stephen Harper (Author, 2007).
Undoubtedly, the unique position of influence Kirby found
himself in was created by the surrounding context, i.e., the con-
vergence of what Kingdon (2003) would call the political and
problem streams. In particular this involved the emergence of
homelessness as an area of public and political concern in advance
of the 2010 Olympics, sustained media attention, and interest by
a conservative government in carrying out an initiative that framed
homelessness in terms of mental illness, and thus did not conflict
with their worldview. At the same time, the broad outline of a so-
lution that emerged in the policy stream clearly went beyond the
agency of single actors, given its conceptualization as a “whole of
society” approach, requiring the involvement of many sectors in
order to address the complexity of the issue.
While the alignment of these contextual factors in these three
streams (problem, politics, and policy) was consistent with what
multiple streams theory (Kingdon, 2003) would suggest was
necessary for some change to happen, our data nonetheless affirms
that personal agency or leadership played a crucial role in making
that change substantive. Because of the importance of Mr. Kirby’s
role in the conception of the At Home/Chez Soi initiative, our ana-
lytical framework, rather than employing the general framework of
multiple streams theory, instead foregrounds the concept of policy
entrepreneurship. As noted, the concept was originally formulated
by Kingdon (2003) as part of multiple streams theory, which sug-
gested that policy entrepreneurs can actively foster convergence
between the streams of problems, politics and policy ideas.
More recently, policy entrepreneurship has been explicated as
a broader concept by Mintrom and Norman (2009), composed of
four elements: social acuity, problem definition, working in teams,
and leading byexample. Below, we discuss the relevance of these to
the present situation.
Social acuity is the ability to intuit opportunities that present
themselves, which in this casewas an opportunity tomovethe “Out
of the Shadows” Report housing agenda forward. Kirby makes
comments that reflect that acuity (e.g., that when the government
called “I knew they weren’t messing around”). Moreover, it was by
being embedded and having credibility within policy networks
(part of Kingdon’s “policy stream”), that he was in position to
become aware of potential opportunities from the inside, and then
be able to draw on his external policy network within the MHCC, so
that he could judge whether the opportunity was feasible.
Astute problem definition, or “framing” (Benford & Snow, 2000)
was perhaps the most salient attribute of the initial phases of the At
Home/Chez Soi initiative. By publicly framing the problems of
Vancouver’s Downtown Eastside in terms of failed mental health
policy, Vancouver’s Mayor helped frame homelessness in terms of
mental illness. By asking a trusted political insider with a non-
partisan reputation and by placing responsibility in the hands of
the non-governmental MHCC, the government then framed the
problem in terms that were congruent with, or at least not anti-
thetical to, its own “small c” conservative political philosophy.
Finally, in order to go forward as a substantive, rather than sym-
bolic, policy initiative “pandering to the Olympics”, Kirby framed
the At Home/Chez Soi project as a pan-Canadian initiative that
respected provincial jurisdiction, “position(ing)” his ideas within
the political machinery in a way that “transcended boundaries”,
both partisan and jurisdictional. Despite Kirby’s pivotal role, it
should be noted that problem definition involved the decisions of
a series of individuals.
Working in teams
The essential attribute of “working in teams” is that a policy
entrepreneur does not single-handedly advance a solution onto the
policy agenda. Because he or she is embedded and trusted within
multiple networks within the policy stream (Kingdon, 2003) and
sees those networks as “repositories” of skills and information, the
policy entrepreneur is inclined and able to draw upon those re-
sources to move a solution forward (Mintrom & Norman, 2009). In
the current case, Kirby was able to draw upon the resources of his
MHCC network to ascertain whether the project was feasible and
worthwhile, and later he was able to recruit key individuals who
could articulate a more coherent approach for moving forward. By
framing the potential project in terms of sensitive federalism (i.e.,
as a federally initiated research project respecting provincial
jurisdiction for health care delivery), he was also able to mobilize
a coalition of high-level political supporters within each of the
provinces where the project would be located.
Leading by example
The policy entrepreneurship process entails proceeding in the
face of risk. In this context, it is the policy entrepreneur’s social
capital, developed by demonstrating past commitment and success
(e.g., with the “Out of the Shadows” Report) that gives senior
decision-makers the confidence to go forward. As one key
informant noted, “it was Kirby and his relationships” that enabled
the project to move ahead. As Kirby himself noted, the MHCC was
E. Macnaughton et al. / Social Science & Medicine 82 (2013) 100e107
Author's personal copy
offered the chance to lead the project because of the trust that
senior decision-makers, including the Prime Minister himself, had
in his abilities as someone who was about “ideas” and “getting
Consideration of other relevant cases
A consideration of other relevant cases, both negative and
positive, also suggests the crucial role of policy entrepreneurship.
As noted, Battams and Baum (2010) demonstrated how housing
policy development for people with mental illness in South Aus-
tralia was hindered by lack of a “common view” within the mental
health community and a fragmented policy network and stream.
This study also served to identify aspects of the political stream,
especially neo-liberalism, which influenced which general housing
policy ideas could go forward in Australia. The current case could
arguably be seen as influenced by this neo-liberal climate, given
that the Olympics has been seen as an exercise in image creation or
“place-branding” that host cities engage in to be seen as world
economic centres (Burbank et al., 2001); and given the fact that the
initiative was initially catalysed by image concerns in relation to
homelessness on Vancouver’s Downtown Eastside. However, the
events of the current case show that policy entrepreneurship,
taking advantage of this opening in the political stream created by
the Olympics, was what moved the project beyond symbolic poli-
tics andinto a major national initiativewith significant implications
Similarly, a consideration of the policy-making process sur-
rounding the more widespread implementation of Housing First in
the United States also suggests the importance of policy entre-
preneurship (albeit in a different form) in translating the home-
lessness issue into a politically viable policy solution, which was
skillfully navigated through an environment of neo-liberalism to
advance progressive ideas. In explanation of the progress of this
wider Housing First movement, Stanhope and Dunn (2011) have
pointed to the leadership of Bush-era Housing Czar Philip Man-
gano, and suggested how the nuanced presentation of his policy
strategy created a broad coalition of support, using a strategy that
bridged interests of the right (e.g., “accountability”, “quality of
life”, i.e., in cleaned up Central Business Districts frequented by
tourists) with those of the centre and left (i.e., providing supported
housing and income support, housing as a “right”), while focussing
on a group of people, largely those with mental illness and ad-
dictions, whose welfare has become more of a concern for society
Commenting on Housing First, Culhane and Metraux (2008) also
discuss not only the evidence in its favour, but its ability to meet the
interests of a range of stakeholders within different “policy co-
alitions” (Sabatier, 1988), in this case from the left and right of the
political spectrum. Our earlier analysis suggests that Mangano
possesses the attributes of a policy entrepreneur who, in bringing
forward an evidence-based solution framed in terms acceptable to
diverse stakeholders, facilitated the convergence of the streams of
problems, politics, and policies.
Policy entrepreneurship: implications for knowledge exchange,
evidence-based policy-making and for researchers
Instead of seeing themselves as part of a linear process, the re-
sults of the current study instead lend support to Greenhalgh and
Russell’s (2005) notion that proponents of knowledge translation/
exchange and evidence-based policy-making see themselves as
embroiled in a “rhetorical drama”, which the policy entrepreneur-
ship process represents. While our case study foregrounded the
activities of a political person, it also suggests certain implications
for researchers and others seeking to help advance ideas into pol-
icy. In our example, for one member of the research team, it was
a matter of being present in the network of the principle actor and
being willing to first provide advice in a quick and efficient manner
and later bring a more systematic appraisal of evidence-based
practice into the project design. Ongoing relationships between
researchers and those in government and politics that they hope to
influence are seen by both sides as an important factor facilitating
the use of research (Mitton, Adair, McKenzie, Patton, & Perry, 2007;
Waddell et al., 2005). In order to form and maintain such re-
lationships, researchers have to be willing to assume multiple roles
that often take them out of the academic realm and into the fray of
committee work, consultation, and other activities not always
appropriately valued by universities (Goering & Wasylenki, 2003;
Jacobson, Butterill, & Goering, 2004).
Thus, if researchers want to advance solutions, they must do
more than develop techniques for advancing solutions forward to
address evidence/policy gaps. They must also be prepared to un-
derstand and enter the policy and political streams, work collec-
tivelywith strategic allies withinthem. Operatingeffectively within
those streams then entails looking for windows of opportunity, and
framing solutions in ways that resonate with external stakeholders
and internal decision-makers.
Summary & conclusion
Our analysis has shown how a trusted insider was able to help
advance an idea forward for funding in the political arena, even
though only the “broad strokes” of a policy solution were present.
An unansweredquestion which
(Macnaughton et al., 2010) concerns how the idea behind the At
Home/Chez Soi was formulated more specifically in the policy
arena to facilitate its adoption at the site level. The question of how
Housing First catalyses reform more broadly in the mental health
and housing policy arenas is also an important concern that needs
to be examined.
Despite some unanswered questions, our study supports the
notion that the evidence-based policy reform process is not simply
a “technical exercise that places [knowledge] products into
[decision-making] events” in a linear fashion (Lomas, 2007, p.130).
Instead, the process involves taking advantage of windows of op-
portunity within the complex policy-making world. As our case and
others show, when these open, and when arising problems con-
verge with events in the political sphere, it is policy entrepre-
neurship that helps unify the often fragmented worlds of mental
health and housing-related policy-making, and helps all parties
move forward with cohesive, coherent action. The events sur-
rounding the initial conception of the At Home/Chez Soi initiative
should remind us of the power of a small group of committed
people, connected with their larger networks, to change the policy-
we address elsewhere
The national At Home/Chez Soi project team: Jayne Barker, PhD
(2008e11) and Cameron Keller, MHCC National Project Leads;
Catharine Hume, M.Sc., National Program Director and approx-
imately 40 investigators from across Canada and the US. In addition
there are 5 site coordinators and numerous service and housing
providers as well as persons with lived experience. We thank the
members of the At Home/Chez Soi National Qualitative Research
Team, Myra Piat, Nathalie Egalité, Lauren Polvere, Greg Townley,
and Susan Eckerle Curwood for their contributions to this research.
The authors also wish to thank the anonymous reviewers for their
helpful comments and feedback.
E. Macnaughton et al. / Social Science & Medicine 82 (2013) 100e107
Author's personal copy Download full-text
This research has been made possible through a financial con-
tribution from Health Canada to the Mental Health Commission of
Canada. The first author was supported through a fellowship from
the Canadian Health Services Research Foundation.
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