Leading the Health System through Policy Development

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Leading the Health System through Policy
Development

• New Roles for Public Health

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The Ten Essential Public Health Services

• Monitor health status
• Diagnose and investigate health problems
• Inform and educate
• Mobilize communities to address health problems
• Develop policies and plans

• Enforce laws and regulations
• Link people to needed health services
• Assure a competent health services workforce
• Evaluate health services
• Conduct research for new innovations

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Essential Services A Different View
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Inform, Educate, and Empower People About Health
Issues

• Initiatives using health education and
  communication sciences to
• Build knowledge and shape attitudes
• Inform decision-making choice
• Develop skills and behaviors for healthy living
• Health education and health promotion
  partnerships within the community to support
  healthy living
• Media advocacy and social marketing

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Mobilize Community Partnerships to Identify and
Solve Health Problems

• Constituency development and identification of
  system partners and stakeholders
• Coalition development
• Formal and informal partnerships to promote
  health improvement

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Develop Policies and Plans That Support
Individual and Community Health Efforts

• Policy development to protect health and guide
  public health practice
• Community and state planning
• Alignment of resources to assure successful
  planning

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Health Issues Have Moved to the Forefront of
Public Attention

• Unrelenting health care cost pressures
• Large gaps in health care quality safety
• Persistent disparities in health outcomes
• Rapidly growing obesity epidemic related
  chronic diseases
• Newly emerging infectious diseases
• Concerns about public health infrastructure
  preparedness for emerging threats

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Creating a Unique Window of Opportunity for
Policy Change

• Educating informing elected officials
• Mobilizing health professionals
• Engaging businesses/employers
• Building coalitions with community organizations
• Empowering consumers to take action

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Death Rates 1860 1970
Tuberculosis Whooping Cough Measles
Deaths per 100,000
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Focusing on disease prevention has led to major
achievements
Actual and Expected Death Rates for Coronary
Heart Disease, 19501998
700
Rate if trend continued
600
500
Peak Rate
400
Age-adjusted Death Rate per 100,000 Population
300
200
Actual Rate
100
50
1950
1960
1970
1980
1990
1995
1955
1965
1975
1985
Year
Marks JS. The burden of chronic disease and the
future of public health. CDC Information Sharing
Meeting. Atlanta, GA National Center for Chronic
Disease Prevention and Health Promotion 2003.
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But the pictures look different when we examine
summary measures of health (or affliction)
14 increase
Source Centers for Disease Control and
Prevention. Health-related quality of life
prevalence data. National Center for Chronic
Disease Prevention and Health Promotion, 2003.
Accessed March 21 at lthttp//apps.nccd.cdc.gov/HRQ
OL/gt.
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Leading Causes of Death, 1990
Developed Nations
Developing Nations

• Heart disease
• Cerebrovascular disease
• Cancer lung, trachea
• Lower respiratory infections
• Chronic Obstructive Pulmonary Disease
• Cancer colon, rectum
• Cancer stomach
• Traffic accidents
• Self-inflicted injuries
• Diabetes

• Lower respiratory infections
• Heart disease
• Cerebrovascular disease
• Diarrheal diseases
• Perinatal conditions
• Tuberculosis
• Chronic Obstructive Pulmonary Disease
• Measles
• Malaria
• Traffic accidents

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Some important drivers of population health
Changes in the environment
Disparities in health status and access to care
Infectious disease threats Including MAN-MADE
ONES!!
Globalization
A social and political environment that
prioritizes health
Advances in biotechnology and information
technology
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Political Theory 101
Potential Solutions
Perceived Problems
Political Dynamics
Window of Opportunity
Policy Change
Kingdon J.W. Agendas, Alternatives, and Public
Policies (1984, 2003)
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Our Challenge as Public Health Leaders

• Lead policy change while the window remains open
• Identify promising policy solutions
• Engage stakeholders across the health system
• Promote evidence-based policy development

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The Health System

• The full complement of individuals and
  institutions whose actions influence the publics
  health

-Institute of Medicine
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Health System Dynamics that Influencethe
Publics Health
Demand for response
Demand for response
Demand for response
Public Health
Medical Care
Other Sectors
Source Adapted from Bobby Milstein, CDC
Syndemics Prevention Network
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Spectrum of Action within the Health System
Policy Development
Time Horizon
SHORTmonths-years
LONGdecades-centuries
INTERMEDIATEyears-decades
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Decision-making the Interface of Policy
Leadership

• Decisions that determine the current and future
  structure and operation of the health system and
  its impact on the publics health
• Decision-makers government, health
  professionals, employers, industry, consumers ?
  communities

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Examples of Traditional Public Health Policies

• Seat belt laws
• Indoor air regulations
• Helmet laws
• Immunization requirements
• Product labeling
• Others..

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What Policies and Policy-makers are Relevant to
Public Health?

• Legislative policy local, state, and federal
  levels
• Regulatory policy government agencies
• Professional policy associations (AMA, APHA,
  NAIC)
• Industry self-regulatory policy (AHA, NCQA,
  PhaRMA)
• Institutional policy individual orgs/coalitions
• Employers - Community organizations
• Insurers - Health departments
• Universities

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What Are Our Policy Instruments?

• Traditional instrument regulatory authority
• Exists for only a very narrow scope of activities
• Must be backed by enforcement costly
  difficult
• Effective only for specific purposes not always
  for changing behavior of individuals/organizations
  
• Carrots vs. sticks
• Restricting choices vs. changing how decisions
  are made

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What Policies and Policy-makers are Relevant to
Public Health?

• Many of the policies affecting the publics
  health lie outside the field of public health
• Education
• Land use
• Economic development
• Agriculture food production
• Competition trade law/regulation
• Labor/human resources

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What Are Our Policy Instruments?

• Non-traditional instruments increasingly
  important
• Financing incentivize performance, reward
  results
• Data/information inform consumers, providers,
  employers, insurers, communities
• Convening power bring together stakeholders for
  voluntary policy change enforced by peer pressure
• Leading by example institutional policy changes
  adopted by public health agencies,replicated by
  others

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Policy Leadership in ArkansasHealthy Arkansas
Initiative

• Launched by Governor Huckabee in May 2004
• Focus on promoting healthy lifestyles
• Reduce tobacco use
• Increase physical activity
• Reduce obesity
• Work across life stages through multiple channels
• Schools
• Workplaces
• Public programs (Medicaid)
• Community aging centers

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Current Approaches in ArkansasHealthy Arkansas
Initiative

• ADH must achieve the following goals by January
  2007
• Increase from 64 percent to 85 percent the
  percentage of juveniles who are active at least
  three times a week for at least 20 minutes.
• Increase from 15 percent to 30 percent the
  percentage of adults who exercise at least three
  times a week for at least 30 minutes.
• Reduce the percentage of obese children from 11
  percent to 5 percent.
• Reduce the percentage of obese adults from 23
  percent to 15 percent.
• Reduce the percentage of adolescents who smoke
  from 36 percent to 16 percent.
• Reduce the percentage of adults who smoke from
  24 percent to 12 percent.

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Policy Instruments in Healthy Arkansas

• Financing create financial incentives in the
  state employee health plan to quit smoking,
  improve BMI
• Information market effective worksite health
  promotion strategies to employers
• Convene leading employers to agree on wellness
  coverage
• Lead by example Adopt worksite wellness at ADH
  and document, disseminate results

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Current Approaches in ArkansasAct 1220 Child
Obesity Initiative

• Passed by the state legislature in 2003
• Annual BMI assessments for all public school
  children (450,000 kids)
• Annual feedback reporting to families, schools,
  and districts
• Changes in school policy to improve nutrition,
  increase physical activity

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Policy Instruments in Act 1220

• Information Customized reports provide feedback
  to families on BMI risks and advice on risk
  reduction
• Convening power bring together schools,
  providers, community organizations to design and
  implement broad-based prevention strategies
• Leading by example Facilitate pilot projects
  that allow schools to test policy changes (e.g.
  vending machines) and disseminate results to
  others

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Current Approaches in ArkansasUAMS Smoke Free
Campus Initiative

• First medical center in AR to go completely smoke
  free, including outdoor areas
• Implemented in July 2004
• Counseling and cessation support for employees,
  students and patients

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Policy Instruments in Smoke Free Campus Initiative

• Financing enhanced coverage for cessation
  counseling and aides
• Leading by Example Promotion of UAMS policies
  designed to encourage other hospitals and work
  sites to follow suit

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Policy Instruments in National Public Health
Infrastructure

• Agency Accreditation linked to incentives
• Agency Accreditation as a condition of
  participation
• Certification of Public Health Officers
• Licensure of Public Health Officials
• Registratoin of public health units

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The Essential Role of Policy Research

• Effective policy development ultimately must be
  based on evidence
• Critical need to expand the evidence base on
  effective public health policy
• Take every opportunity to evaluate new policies
  and measure their impact!!

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The Essential Role of Policy Research

• The Committee had hoped to provide specific
  guidance elaborating on the types and levels of
  workforce, infrastructure, related resources, and
  financial investments necessary to ensure the
  availability of essential public health services
  to all of the nations communities. However, such
  evidence is limited, and there is no agenda or
  support for this type of research, despite the
  critical need for such data to promote and
  protect the nations health.

Institute of Medicine, 2003
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The Future for Public Health Policy Development

• Evidence-based policy decision-making is the
  goal
• Policy innovation and creativity is critical, but
  must be coupled with policy evaluation
• Learn what works where
• Disseminate, replicate, adapt
• Capitalize on the open window for policy
  changewhile it lasts