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Ken Macdonald October 3, 2007
Centre for Health Services and Policy Research Queen’s University
1. CLASS OBJECTIVES • to acquire an initial understanding of the policy process • to learn the basic elements of policy analysis
•To establish frameworks for doing assignments
2. OUTLINE a.Review: “Health policy” and “epidemiology” b.What is policy and how is it made? c.Techniques for doing policy analysis d.Class Exercise: working through an example e.Suggestions for doing assignments
Palfrey C. Key Concepts in Health Care Policy and Planning (London: Macmillan, 2000), Chapters 1 to 3. Supplementary:
Les Pal, Public Policy Analysis (Toronto: Nelson, 1992) CV Patton & DS Sawicki, Basic Methods of Policy Analysis and Planning Englewood Cliff: Prentice Hall, 1993) DL Weimer & AR Vining, Policy Analysis Concepts and Practice (Englewoods Cliffs: Prentice Hall, 1992)
J. Green & N. Thorogood, Analysing Health Policy: A Sociological Approach ( London and New York: Longmans,1998) B. Abel-Smith, An Introduction to Health Policy, Planning and Financing (London and New York: Longmans, 1994) Canadian Institute for Health Information – 2004 “Bridging the Communication Gap Between Researchers and Policy Makers”
4. RELATIONSHIP TO PREVIOUS CLASSES Session #1 discussed some basic definitions: “Health Policy”, “Epidemiology”, “Health Services Research” Session #2 discussed the generic features desirable in any health system & how to evaluate their presence. Session #3 focused on Health Economics Analysis as a policy tool The focus of this session is on making and 6 analyzing policy to construct a health system.
“The study of the distribution and determinants of health-related states or events in specified populations and the application of this study to control health problems.” In this context “control” means “ to promote, protect, and restore health.” (Last, 1995)
“ ...authoritative decisions made within government that are intended to direct or influence the actions, behaviors, or decisions of others pertaining to health and its determinants. These decisions can take the form of laws, rules and operational decisions...Policies can be allocative or regulatory in nature.” (Longest, 1998)
1. An authoritative statement of intent adopted by governments on behalf of the public with the aim of improving the health and welfare of the population, that is, a centrally determined basis for action -”Public Health Policy” 3. What health agencies actually do rather than what governments would like them to do. Health policy can only be determined by the observation of the outcomes of decision-making 9 “Health Care Policy” Palfrey
Basic sciences Clinical medicine biostatistics
Epidemiology< >Health Services Research< >Health Policy
• How does epidemiology inform policy? • Debate between “pure academics” and those researchers who wish to inform/influence policy
Epidemiology and Policy: A Debate
“...the job of the scientist should be to formulate and evaluate scientific hypotheses, rather than to muster support for or marshal evidence against specific policies...The conduct of science should be guided by the pursuit of explanations for natural phenomena, not the attainment of political or social objectives.” (Rothman and Poole, AJPH, 1985)
On the other side:
• “Policy makers are forced to make decisions based on their own experience and those of qualified experts. When epidemiologists avoid helping policy makers formulate public health policy, others less qualified must do so in their stead.” • (Foxman, J Clin Epid, 1989)
How Often to Epidemiologists Make Policy Recommendations?
Jackson, Lee & Samet (AJPH, 1999) reviewed a random sample of articles published in 3 major epidemiology journals from 1991-95. They concluded: the “majority of research articles either contained no policy recommendations or included weak statements.”
• • 24% of papers had a “policy pronouncement” 55% concerned public health practices and 28% clinical practice 30% of papers by authors from government or public health had policy statements, 20% from universities papers dealing with children and African populations had policy statements in 80% of papers; studies re. adults 26%
papers on injury and infectious diseases most frequently included policy recommendations
Information Sources Used by Ontario Decision Makers
Source Colleagues Info. Gathered internally Local experts Scholarly journals Consumers Existing leg./guidelines Usefulness Rank 1 2 3 4 5 6 Acceptability (%) 84 82 78 61 62 71
Feldman et al. Annals of the Royal College of Physicians & Surgeons of Canada c.1999
Sources of Knowledge
Decision-Makers Documents produced with my own organization Management of staff of my organization Internet Searches Documents produced by other government agencies, RHAs, or healthcare facilities Evaluation reports for a project that you were personally involved with Databases (e.g. CIHI, cancer registries, Child Health Survey) Front-line staff of my organization Bulletins and newsletters Clinical practice guidelines Presentations and seminars Physicians Original studies published in scientific journals Information from specialists Computerized literature search (e.g., MEDLINE) Information from colleagues Publications that focus on evidence-based medicine Presentations and seminars Clinical guidelines Systematic reviews (including meta-analysis) Clinical practice guidelines Conference Proceedings
Birdsell et al. The Utilization of Health Research Results17 in Alberta c.2005
A Good News Story
Manitoba Centre for Health Policy study (2000) of seasonal patterns of use at Winnipeg's 7 acute-care hospitals over the past 11 years. Found almost every winter a period of 1 to 3 weeks during which the number of patients arriving at the hospital jumps 10% beyond normal. Pneumonia, influenza and other respiratory conditions are the main reasons for the increase; three-quarters of patients 65 or older. Recommended as a "pre-emptive first step, a comprehensive campaign of flu vaccination." …government did exactly that and other provinces followed in the next few years.
Affinities and Barriers
population level focus for both policy and epidemiology
policy is concerned with the operation of the health system; epidemiology provides health services researchers with techniques to measure and evaluate systems
advocacy vs evidence-based conclusions generalizability timelines dissemination and uptake of findings
Optional Readings: a. theoretical
R.A.Spassoff, Epidemiologic Methods for Health Policy, (New York & Oxford: Oxford University Press, 1999)
J.A.Muir Gray, Evidence-based Healthcare, How to Make Health Policy and Management Decisions, (Edinburgh, London, New York: Churchill Livingstone, 1997)
“...a course of action or inaction chosen by public authorities to address a given problem or interrelated set of problems.” ( Pal, 1992)
Who Makes Policy?
• Elected representatives • Courts • Civil servants • Interest groups • Public
Policy Recommendations Nine desirable qualities
• • • Timing – window of opportunity Evidence-based Acceptable Ideology/Congruence with Government Core Values • Practical, Concrete, Prescriptive • Political Credit • Affordable • Time to Payoff/Results • Acceptable to Key Stakeholders/Public • Credibility of the Recommender Owen Adams-CMA
Schematic of the Policy Process
Imperatives Constraints Uncertainties Pressure
Policy Levers for implementation
Based on David Easton, A Framework for Political Analysis (1965)
• • • • • •
inertia delegation moral suasion economic: spending, taxation rule making: regulation, law public enterprise
Developed by the Institute on Governance- Reprinted in: “Bridging
the Communication Gap Between Researchers and Policy Makers”
Canadian Institute for Health Information - 2004
THE POLICY PROCESS
Other Mins Other Brs Legal
Mgmt. Board Policy & Priorities Cabinet
Leg. Counsel Legislat. Committe
Policy Analysis: Definitions
Pal (1992) “ the disciplined application of intellect to public problems ” Weimer & Vining (1992) “ client-oriented advice relevant to public decisions and informed by social values ” Patton & Sawicki (1993) “ a process that usually begins with problem definition rather than the broader inventory phase of the planning process. It also yields alternatives, but the final document is likely to be a memorandum, issue paper, or draft legislation. It has a specific client and a single point of view, a shorter time horizon, and an openly political approach. The final product of such a process is called policy analysis.”
The Core Of Policy Analysis
Goal Objectives Evaluation Criteria Options
A Basic Framework for Policy Analysis [“GOCO”]
statement of a general principle or broad intent, e.g., improve the health of Canadians
#1 concrete targets which together will achieve the broader goal
a. standards to judge attainment of objective, plus data and sources b. c.
assessment of how well each option achieves each criteria
a. b. c.
a. b. c. 31
CONSTRUCTING A POLICY ANALYSIS Goals Objectives Evaluation Criteria
GOAL to enhance the health of homeless persons through the provision of optimal primary care
Objectives 3. assuring access to primary health care through a regular primary health care provider 4. enhancing the population orientation of primary health care 5. providing comprehensive whole person care 6. enhancing an integrated approach to 24/7 access 7. strengthening the quality of primary health care 8. building patient-centered care 9. promoting continuity through integration and co-ordination 34 [CIHI 2006]
Criteria for Each Objective
GOAL to enhance the health of homeless persons through the provision of optimal primary care OBJECTIVES assuring access to primary health care through a regular primary health care provider enhancing the population orientation of primary health care providing comprehensive whole person care EVALUATION CRITERIA 1. entitlement documents not required for care or for ancillary services 2. service available at venues likely to suit homeless persons 1. collaboration with public health authorities on harm reduction strategies 1. multidisciplinary team care 2. established referral routes for specialty services 3. social work assistance available for benefit entitlement, housing 1. service available at times likely to suit homeless persons 2. evidence of reduced emergency room use 1. special expertise in areas germane to the clinical conditions of homeless persons, e.g. substance abuse, sexually transmitted diseases. 1. user involvement in service planning and operation 1. appropriate access to electronic medical records by multiple providers
enhancing an integrated approach to 24/7 access
strengthening the quality of primary health care
building patientcentered care promoting continuity through integration and co-ordination
Writing a policy paper
Doing Policy Analysis (*Policy Paper forma
Issue introduction Background Key issues Stakeholders Constraints Goal Objectives Evaluation Criteria Options Risks Recommendations Implementation
Advice to the Minister
Issue: 1 -2 lines Background: 5 to 10 key points Options: 2 or 3, with weighted pros/cons for each Recommended Ministerial Action: e.g. Option # x Next Steps: e.g. press conference, legislative
amendment, regulation change
Contact person: name, title, branch [2 pages maximum, use headings & bullet points, no references]
1. Issue Description - 4 minutes 2. Policy Goal and Objectives - 2 minutes 3. Evaluation Criteria - 5 minutes 4. Options - 5 minutes 5. Recommendation - 4 minutes – per speaker
6. **Facilitated Discussion ** - 5 mins. 7. Coordinator’ Summary – 5 mins.
Note: #1 - #4: to be presented jointly #5: clearly articulated defense of different options by each team member 39 #6: presenters responsible for directing class discussion
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