Healthy Public Policy

AB. Inambao
 Healthy Public Policy
• Major influence of health status are outside the
immediate control of individual.

• Health Promotion has emphasised the

environmental determinants of health rather than
individual behaviour and this has seen healthy
public policy to be essential in creating supportive
environments for people to lead healthy lives
(WHO, 1988)

• Hence HPP was the major focus of the 2nd global

conference on health promotion
 Healthy Public Policy
• What can be policy
– Label for a field of activity
– Statement of aspiration/purpose
– Specific proposals
– (Government) decisions
– Formal authorisation
– Programme
– Outputs
– Outcomes
– Theory or model
– process
 Key elements of policy
• Authority –Official endorsement

• Expertise –Applied to problem area and

identifying what should be done about it

• Order –decisions are not arbitrary but

consistent and structured

• * Implication-policy is concerned with

action, but it can equally involve inaction-
deciding not what to do
 What is Healthy Public Policy
• There is a clear distinction btn ‘Public
health policy’, which focuses narrowly on
health care and frequently, illness
management, and healthy public policy,
which is much broader

• HPP is concerned with the role of

government and the public sector in
creating conditions that create health
 Healthy Public Policy
• Public Policy has been defined as the “guide to
government action-sets the range of possibilities
for choices made by public and private
organisations, commercial and voluntary
enterprises, and individuals. In virtually every
facet of living, the creation and use of goods,
services, information and environments are
affected by government policies-fiscal, regulatory,
service provision, research and education, and
procedural” (Milio, 1988)
 Healthy Public Policy
• Healthy Public Policy aim at making
“government activity across the board
contribute as much as possible to health
development, while recognising the trade
offs that are inevitable and necessary part of
the policy process” (Draper,1988)
• HPP therefore should be;
– Ecological in perspective
– Multi-sectoral in scope
– Collaborative in strategy
 Healthy Public Policy
• Characteristics of healthy public policy
(Draper, 1988)
– Commitment to social equity
– Recognition of the important influence of
economic, social and physical environment of
health
– Facilitation of public participation
– Cooperation between health and sectors of
society
Illustrate with Sen’s work
 Devt and health
• Questions
– How does health relates to devt?
– Is health the major objective of development?
– How important is health among the development objectives?
– Is health best promoted through the general process of
economic growth, which involves the a rising real
national income per capital, or is the advancement of
health as goal to be separated out from the process of
economic growth?
– Do all things go together in the process of development
or are there choices to made on the priorities to be
chosen?
 Devt and health
Two contrasts
• Contrast no. 1- there are high growth economies
and had great success in raising the length and
quality of life (such as South Korea) and there are
those with no much success (such as Brazil)
• Contrast no. 2 – Between different economies with
high achievements in life expectancy and quality
of life but some have high success in economic
growth while others are not
 Devt and Health
• The contrasts is explained by two concepts
– Growth mediated health

– Support led health

 Devt and Health
• Growth mediated
– “Works through fast economic growth and its
success depends on the growth process being
widely based and economically broad, and also
on the utilisation of the enhanced economic
prosperity to expand the relevant social
services, including health care, educations and
social security”

– Sen, 1999
 Devt and Health
• For example, Anand and Ravallion have
found that life expectancy have a significant
correlation with GNP per capital.
• However, this relationship works through
the impact of on
– The incomes of the poor
– Public expenditure on health care
 Devt and health
• Actually, poverty and public expenditure
are explanatory variables on their own such
there is little effect of including GNP in the
analysis

• If anything the relationship between GNP

per capital and life expectancy vanish all
together
 Devt and Health
• “ It is important to emphasise that the
finding does not show that life expectancy
is not enhanced by the growth of GNP per
capita, but does indicate that the connection
tend to work through the public expenditure
on health care, and the success of poverty
removal”
 Devt and health
• Support led
– Does not operate through fast economic growth but
works through a program of skillful social support of
health care, education and other relevant social
arrangements

– For example, China, Costa Rica, Sri Lanka or the

Indian state of Kerala have had rapid reduction in
mortality rates and enhancement of living conditions,
without much economic growth
 Devt and health
• Support led
– Therefore, the support led process does not wait
for dramatic increases in per capita income, and
it works through priority being given to
providing social services (particularly health
care and basic education) to reduce mortality
and enhance the quality of life
 Devt and health
Conclusion
• How does health relate with development?
1) Enhancement of health is a constitutive part
of devt. Good health is also an integral part of
devt
2) Given other things, good health and economic
prosperity tend to support each
 Devt and Health
Conclusion
• 3) ‘other things’ are not given, and the enhancement of good
health can be health by a variety of actions including public
policies

• 4) Even when an economy is poor, major health

improvements can be achieved through using available
resources in a socially productive way

• 5) The issue of social allocation of economic resources

cannot be separated from the role of participatory politics
and the reach of public informed discussions
 Devt and health

• “The public has to see itself not merely as

patient s, but also as an agent of change.
The penalty of inaction and apathy can be
illness and death”
 Infrastructure for devt of HPP
• Infrastructures are a basic condition for
development of HPP;
“refers to institutions, organisations and
associations; the human resources, and
competences associated with them; and the
finances needed to develop and support
them” (Moodie et al; 2000)
 Infrastructure for HPP
• It is important therefore to audit the
infrastructure that will facilitate the building
of HPP
• This can include
– Assessing the infrastructures at national and
sub-national levels
– Focus on potential for improvements
– Cooperation with key stakeholder such as
WHO experts, International development
agencies and national leaders
 Advocacy for healthy public
policies
• HPP requires effective advocacy from
health professional, stakeholders and policy
makers
• Advocacy was identified as a key strategy
by Ottawa charter
• Advocacy has been traditionally used to
describe activity on behalf of those in less
powerful position
 Advocacy for healthy public
policies
• The IUHPE identified 3 areas in which
advocates can operate
– Influencing government to develop healthy
policies and legislation
– Influencing commercial and other organisations
to consider the health impact of their activities
– Influencing individuals and groups to make
healthy choices and support initiatives to
promote health
The advocacy institute (2002): Nine key
questions for advocacy

• What do we want? (GOALS)

• Who can give it to us? (AUDIENCES; KEY

PLAYERS; or POWER-HOLDERS)

• What do they need to hear? (MESSAGES)

• Who do they need to hear it from?

(MESSENGERS)
 Nine key questions for advocacy
• How can we get them to hear it? (DELIVERY)

• What do we have? (RESOURCES)

• What do we need to develop? (GAPS)

• How do we begin? (FIRST STEPS)

• How do we tell if it’s working? (EVALUATION)

 The Advocacy Institute (1992)
• Possible advocacy efforts;
– Coalition and alliance building
– Media advocacy
– Using symbols ( e.g. red ribbon)
– Lobbying
– Information dissemination and communications
– Grass roots organisation
– Strategies for countering opposition
 Advocacy for healthy public
policies
• Baum suggest that successful advocacy
should

– Set an agenda
– Frame the issue for public consumption
– Advocate specific solutions
 Advocacy for health public
policies
• The John Hopkins Centre for
communication programs identified six
stages in the advocacy process
– Analysis of the problem, the need for policy
change, stakeholders (supporters, opponents,
decision makers, vote swingers, policy- making
structures and processes and means of
influencing decision makers
– Strategy based on clear objectives suited to the
context
 Stages of advocacy process
cont’d
– Mobilisation of potential partners and coalition
building to maximise resources and power
– Action –Achieving maximum visibility for the cause
using credible messages and appropriate channels,
including the media
– Evaluation to identify what has been achieved and what
still needs to be done.
– Continuity planning for the longer term, keeping
coalitions together, keeping arguments fresh and
adapting them to current circumstances
Policy making

AB Inambao
Problem centred policy analysis
Policy
Performance
Evaluation Forecasting
Problem
structuring

Policy Problem
Problem
Policy structuring problems
structuring Policy
Outcomes futures
Problem
structuring

Recommendation
Monitoring Policy
actions
The supremacy of the problem in
policy analysis
 Understanding the problem
“Successful problem solving requires finding
the right solution to the right problem. We
fail more often because we solve the wrong
problem than because we get a wrong
solution to the right problem”

-Russell, L. Ackoff, Redesigning the future: A

systems approach to societal problems
(1974)
 Understanding the problem

• “ In the first course in statistics the student learns

that he must constantly balance between making
an error of the first kind (that is, rejecting the null
hypothesis when it is true) and an error of the
second type (that is, accepting [failing to reject]
the null hypothesis when it is false)…
practitioners all too often make errors of third
kind: solving the wrong problem”
Dunn, N.W. (1994) Public policy analysis: An introduction, 2nd ed. New Jersey,
Prentice –Hall, inc.
 Understanding of problem
Characteristics of problems
• Interdependent
– Problem in one area frequently affect problems in other
areas (for example poverty and HIV/AIDS)
– Problems part of the whole systems of problems
– Systems of problems are difficult or impossible to resolve
using Analytical approaches (decomposing problems into
component elements) since problems are rarely defined and
resolved independently.
– Holistic approaches, which view problems as inseparable
and immeasurable are more effective in solving
interdependent problems
 Understanding of problem
Characteristics of problems cont’d
• Subjective
– The external conditions that give rise to a problem
(especially socially related problems like those in
public health) are selectively defined, classified,
explained, and evaluated
 Understanding of problem
Characteristics of problems cont’d
• Artificial
– Problems are socially constructed, maintained and
changed
– Problems have no existence apart from the
individuals and groups who perceive and define
them
– Meaning that there are no ‘natural’ state of society
which in and of themselves constitute problem
 Understanding of problem
Characteristics of problems cont’d
• Dynamic
– There are as many different solutions for a given
problem as there are a definitions of those problems

– “Problems and solution are in constant flux; hence

problems do not stay solved… solutions to problems
become obsolete even if the problem to which they
are addressed do not”

Russell, L. Ackoff, (1974) Redesigning the future: A systems approach to societal

problems (1974)
 Understanding the problem
• Structuring the problem (phases)

Meta problem
Problem Problem
search Definition

Problem
Situation Substantive
problem

Problem
Problem
Sensing
Formal Specification
Problem
 Understanding the problem
Problem Problem
Sensing Situation
Problem
structuring

Problem Problem
Dissolving
No Right Problem
Problem? Un-solving
Yes
Problem
Solving
Problem
Resolving
Solution

Yes No
Solution
Adapted from: Dunn, N.D, (1988) Methods of the second type: coping with wilderness of
Conventional policy analysis,” Policy studies review, 7, no.4, 720-37
Health impact assessment
 Health impact assessment
• As mentioned earlier, HPP also requires an
appraisal of the health impact of all policies

• The purpose of HIA is to improve knowledge

about the potential impact of a policy or
programme, inform decision makers and affected
people, and facilitate adjustment of the proposed
policy in order to mitigate the negative and
maximise the positive effects (Euro Centre for
health Policy, 1999)

• HIA employees both qualitative and quantitative

approaches and multidisciplinary input
 Health impact assessment
• HIA is a “ combination of procedures, methods,
and tools by which policy, program or project
maybe judged as to its potential effects on the
health of a population, including the distribution
of its effects within a population” (Euro centre for
health policy, 1999)

• A more detailed definition- HIA is a

“methodology which enables the identification,
prediction, and evaluation of the likely changes in
health risks, both positive and negative of a
policy, program, plan, or devt action on a defined
population” (Kemm, 2001)
 Health impact assessment
Key questions concerning HIA
• What
– policies will be screened and what are the criteria
for deciding
– impacts will be assessed? will they include
health outcomes, determinants, risks, and equity
• How
– will HIA happen? Will it be integrated or
conducted separately, will it be voluntary or a
legal requirement?
– Can we infer causality between policy and
outcome?
 Key questions concerning HIA
• When
– will HIA be introduced into the policy process
• Who
– does the assessment? will this be the policy
proponent or an external agency?
– Pays
• Where
– at international?
– national?
– local?
 Health impact assessment
• Generally, HIA should be done early to
inform the decision-making process
especially in cases where remedial action is
to be taken
• While, HIA is prospective (predicts the
effects of policy before it is implemented),
it can also be;
– Retrospective –identifying the consequences of
a policy already implemented
– Concurrent –identifies consequences as it is
being implemented especially when negative
impacts are anticipated or not clear
 Stages of HIA
• Screening –establish whether a particular policy is
relevant to health

• Scoping – Identify the relevant health issues and

public concerns that need to be addressed during
appraisal

• Appraisal- identify and if possible quantify the

potential impacts on health and well being – can
be rapid or detailed appraisal. Seek for knowledge,
experiences and opinions of key stakeholders
 Stages of HIA
• Reporting – communicate with
stakeholders about the expected impacts on
health and about how policy, programme,
or any other development can be modified
to minimise negative and maximise positive
impacts
• Monitoring – compliance with
recommendations and of expected health
impacts following implementation policy or
programme.