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Health Policy Analysis

Centre for Health Services and Policy ResearchQueen’s University

Ken MacdonaldOctober 3, 2007

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1. CLASS OBJECTIVES

• to acquire an initial understanding of the policy process

• to learn the basic elements ofpolicy analysis

•To establish frameworks for doing assignments

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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

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3. READING

Palfrey C. Key Concepts in Health Care Policy and Planning (London: Macmillan, 2000), Chapters 1 to 3.

Supplementary:

a. General

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)

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b. Health

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”

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4. RELATIONSHIP TO PREVIOUS CLASSES

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

Session #1 discussed some basic definitions: “Health Policy”, “Epidemiology”, “Health Services Research”

The focus of this session is on making and analyzing policy to construct a health system.

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Epidemiology

“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)

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Health Policy

“ ...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)

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Health Policy

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

“Health Care Policy”Palfrey

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Epidemiology< >Health Services Research< >Health Policy

Health Sciences:Basic sciences

Clinical medicinebiostatistics

Social policy

Public Policy

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EPIDEMIOLOGY

• How does epidemiology inform policy?

• Debate between “pure academics” and those researchers who wish to inform/influence policy

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“...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)

Epidemiology and Policy: A Debate

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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)

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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.”

How Often to Epidemiologists Make Policy Recommendations?

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Key findings:

• 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

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Information Sources Used by Ontario Decision Makers

Source Usefulness Rank Acceptability (%)

Colleagues 1 84

Info. Gathered internally 2 82

Local experts 3 78

Scholarly journals 4 61

Consumers 5 62

Existing leg./guidelines 6 71

Feldman et al. Annals of the Royal College of Physicians & Surgeons of Canada c.1999

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Sources of Knowledge

Presentations and seminars

Clinical practice guidelines

Bulletins and newsletters

Front-line staff of my organization

Databases (e.g. CIHI, cancer registries, Child Health Survey)

Evaluation reports for a project that you were personally involved with

Documents produced by other government agencies, RHAs, or healthcare facilities

Internet Searches

Management of staff of my organization

Documents produced with my own organization

Decision-Makers

Conference Proceedings

Clinical practice guidelines

Systematic reviews (including meta-analysis)

Clinical guidelines

Presentations and seminars

Publications that focus on evidence-based medicine

Information from colleagues

Computerized literature search (e.g., MEDLINE)

Information from specialists

Original studies published in scientific journals

Physicians

Birdsell et al. The Utilization of Health Research Results in Alberta c.2005

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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.

A Good News Story

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1. Affinities

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

Affinities and Barriers

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2. Barriers

advocacy vs evidence-based conclusions

generalizability

timelines

dissemination and uptake of findings

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b. applied

J.A.Muir Gray, Evidence-based Healthcare, How to Make Health Policy and Management Decisions, (Edinburgh, London, New York: Churchill Livingstone, 1997)

Optional Readings:

a. theoretical

R.A.Spassoff, Epidemiologic Methods for Health Policy,(New York & Oxford: Oxford University Press, 1999)

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Policy

“...a course of action or inaction chosen by public authorities to address a given problem or interrelated set of problems.”( Pal, 1992)

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Who Makes Policy?

• Public

• Interest groups

• Civil servants

• Courts

• Elected representatives

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Policy RecommendationsNine 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

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ImperativesConstraints

UncertaintiesPressure

PoliticalAdministrative

PolicyLevers for

implementationResults

INPUTS WITHINPUTS OUTPUTS OUTCOMES

Schematic of the Policy Process

Based on David Easton, A Framework for Political Analysis (1965)

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Policy Levers

• inertia • delegation• moral suasion

• economic: spending, taxation

• rule making: regulation, law• public enterprise

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Developed by the Institute on Governance- Reprinted in: “Bridging the Communication Gap Between Researchers and Policy Makers” Canadian Institute for Health Information - 2004

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THE POLICY PROCESS

Gov’t.

Agencies

Public

Branch

Ministry

Analyst

OtherBrs

Legal

OtherMins

Mgmt.Board

Policy &Priorities

Cabinet Committe

Legislat.

Leg.Counsel

Branch LegislatIMPLEMENT LAW

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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.”

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The Core Of Policy Analysis

Goal Objectives Evaluation Criteria Options

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statement of a general principle or broad intent, e.g., improve the health of Canadians

Goal

assessment of how well each option achieves each criteria

Option #1 Option #2 Option #3

c.

b.

a.

c.

b.

a.

c.

b.

a. standards to judge attainment of objective, plus data and sources

Criteria

#3

#2

#1 concrete targets which together will achieve the broader goal

Objectives

A Basic Framework for Policy Analysis [“GOCO”]

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CONSTRUCTING A POLICY

ANALYSIS

Goals

Objectives

Evaluation Criteria

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GOALto enhance the health of homeless persons through the provision of optimal primary care

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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 [CIHI 2006]

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Criteria for Each Objective

GOAL OBJECTIVES EVALUATION

CRITERIA

assuring access to primary health care through a regular primary health care provider

1. entitlement documents not required for care or for ancillary services 2. service available at venues likely to suit homeless persons

enhancing the population orientation of primary health care

1. collaboration with public health authorities on harm reduction strategies

providing comprehensive whole person care

1. multidisciplinary team care 2. established referral routes for specialty services 3. social work assistance available for benefit entitlement, housing

enhancing an integrated approach to 24/7 access

1. service available at times likely to suit homeless persons 2. evidence of reduced emergency room use

strengthening the quality of primary health care

1. special expertise in areas germane to the clinical conditions of homeless persons, e.g. substance abuse, sexually transmitted diseases.

building patient-centered care

1. user involvement in service planning and operation

to enhance the health of homeless persons through the provision of optimal primary care

promoting continuity through integration and co-ordination

1. appropriate access to electronic medical records by multiple providers

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Writing a policy paper

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Doing Policy Analysis (*Policy Paper format )

Issue introduction

Background

Key issues

Stakeholders

Constraints

Goal

Objectives

Evaluation Criteria

Options

Risks

Recommendations

Implementation

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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]

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Policy Debates1. 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

Note: #1 - #4: to be presented jointly#5: clearly articulated defense of different options by each team member#6: presenters responsible for directing class discussion

6. **Facilitated Discussion ** - 5 mins.

7. Coordinator’ Summary – 5 mins.