8256609 Health Policy Analysis Example[1]

Health Policy Analysis

Ken Macdonald October 3, 2007

Centre for Health Services and Policy Research Queen’s University

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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

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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 3

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) 4

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” 5

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.

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 9 “Health Care Policy” Palfrey

Health Sciences: Basic sciences Clinical medicine biostatistics

Epidemiology< >Health Services Research< >Health Policy

Social policy

Public Policy 10

EPIDEMIOLOGY • How does epidemiology inform policy? • Debate between “pure academics” and those researchers who wish to inform/influence policy

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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)

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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) 13

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.” 14

Key findings: •

24% of papers had a “policy pronouncement”

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55% concerned public health practices and 28% clinical practice

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30% of papers by authors from government or public health had policy statements, 20% from universities

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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

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71

Feldman et al. Annals of the Royal College of Physicians & Surgeons of Canada c.1999 16

Sources of Knowledge Decision-Makers

Physicians

Documents produced with my own organization

Original studies published in scientific journals

Management of staff of my organization

Information from specialists

Internet Searches

Computerized literature search (e.g., MEDLINE)

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

Information from colleagues

Evaluation reports for a project that you were personally involved with

Publications that focus on evidence-based medicine

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

Presentations and seminars

Front-line staff of my organization

Clinical guidelines

Bulletins and newsletters

Systematic reviews (including meta-analysis)

Clinical practice guidelines

Clinical practice guidelines

Presentations and seminars

Conference Proceedings

Birdsell et al. The Utilization of Health Research Results17in 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. 18

Affinities and Barriers 1. Affinities population level focus for both policy and epidemiology 

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policy is concerned with the operation of the health system; epidemiology provides health services researchers with techniques to measure and evaluate systems

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2. Barriers 

advocacy vs evidence-based conclusions



generalizability



timelines



dissemination and uptake of findings

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

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

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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? • Elected representatives • Courts • Civil servants • Interest groups • Public

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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 24

Schematic of the Policy Process

INPUTS

WITHINPUTS

OUTPUTS

OUTCOMES

Imperatives Constraints Uncertainties Pressure

Political Administrative

Policy Levers for implementation

Results

Based on David Easton, A Framework for Political Analysis (1965) 25

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.

Ministry

Other Mins

Mgmt. Board

Leg. Counsel

Branch

Other Brs

Policy & Priorities

Legislat.

Cabinet

Committe

LAW

Legislat

Agencies

Public

IMPLEMENT

Analyst

Legal

Branch

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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.” 29

The Core Of Policy Analysis Goal

Objectives

Evaluation Criteria

Options

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A Basic Framework for Policy Analysis [“GOCO”] Goal

Objectives

Criteria

Option #1

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

assessment of how well each option achieves each criteria

Option #2

Option #3

b. c. #2

a. b. c.

#3

a. b. c. 31

CONSTRUCTING A POLICY ANALYSIS Goals Objectives Evaluation Criteria 32

GOAL to 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 34 [CIHI 2006]

Criteria for Each Objective GOAL to enhance the health of homeless persons through the provision of optimal primary care

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

enhancing the population orientation of primary health care providing comprehensive whole person care

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

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

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

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Writing a policy paper

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Doing Policy Analysis (*Policy Paper forma 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] 38

Policy Debates 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