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Lessons Learned from Putting the Public in Public Health Policy Making at a US Federal Agency

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Title: Lessons Learned from Putting the Public in Public Health Policy Making at a US Federal Agency


1
Lessons Learned from Putting the Public in Public
Health Policy Making at a US Federal Agency
  • Roger Bernier, PhD, MPH
  • Presented at the Democracy and ParticipationThre
    e Days in Montaione First Edition, Conference
  • Montaione, Italy
  • Nov 12-14, 2009

2
Why Latest Enhanced Version of Public
Engagement Was Started?
  • Citizen comment at a congressional public hearing
    in 2001
  • Your CDC research is dead on arrival
  • Working together on policy decision was chosen as
    a trust-building approach
  • Goal was to build more trust over the long term
    between government and citizens

3
Background on Public Engagement At CDC
  • 1. Citizens have legal rights to access
    information and to participate in a limited way
    in advisory committee meetings, though
  • 2. Agency not regulatory, and has not legal
    requirement for public participation
  • 3. Agency has a long history of working with
    non-government partners to implement programs,
    but not to make policy

4
Background on Public Engagement At CDC
  • 4. 2005-2006 Public deliberation pilot projects
    on pandemic influenza --- proof of principle
    that the public can reach a productive outcome on
    an important CDC policy question.
  • 5. CDC has had a strategic imperative to be
    customer centric
  • 6. Workshop on Public Deliberation in 2007
  • 24 previous projects involving some form of
    public participation

5
Workshop ConclusionCommon Ground at CDC
  • We share a conviction that creating a genuine
    sense of ownership in public health endeavors
    among persons affected by or interested in the
    outcomes of our work is an effective but
    under-utilized approach for improving and
    achieving our objectives.
  • In short, we believe participation works!

6
Working Definition of Public Engagement In This
Framework
  • The practice by which the agency very actively
    involves members of the public-at-large and
    representatives of stakeholder organizations in
    group dialogue and deliberation sessions to
    better inform a pending policy decision.

7
The Rationales for Public Engagement
  • Main Product
  • Better decisionsmore correct, feasible, and with
    greater integrity
  • Byproducts
  • Greater sense of ownership and possible support
    for decisions made
  • Greater development of individual capacities and
    sense of self-efficacy and well-being
  • Greater social capitalmore connections between
    people, enhanced trust

8
Quote from Michael MarmotThe Lancet, Sept 2007
  • At the heart of the concern with social
    determinants of health, and health inequity, is
    concern for people without the freedom to lead
    flourishing livesPeople need the basic material
    requisites for a decent life, they need to have
    control over their lives, and they need political
    voice and participation in decision making
    processes.

9
  • Democracy is good for y(our) health!

10
2x10 Principles of Consequential Public Engagement
  • 1. Both the desire for advice the decision on
    the table are real.
  • 2. Both adequate time to deliberate clarity of
    purpose are provided.
  • 3. Both knowledge of facts attachment to values
    underlie the choices to be made.

11
2x10 Principles of Consequential Public Engagement
  • 4. Both active agency staff sufficient
    resources are committed to the process.
  • 5. Both impartial citizens-at-large partisan
    stakeholders participate.
  • 6. Both a critical mass diverse group of
    persons participate.

12
2x10 Principles of Consequential Public Engagement
  • 7. Both unbiased information neutral
    facilitation are provided.
  • 8. Both genuine dialogue thoughtful
    deliberation occur.
  • 9. Best option is chosen and agreed-upon
  • 10. Publics advice receives serious
    consideration participants obtain candid
    feedback about the decision

13
Model of a Consequential Public Engagement Table
(CPET)
  • 4 geographic areas represented
  • 100 citizens representative of the population by
    age, race, and sex in each area (N400)
  • Day long dialogue and deliberation events
  • Stakeholder representatives from key sectors
    affected (N30-40)
  • Two day long meetings for stakeholders before and
    after the citizens meetings

14
Projects To Date 2005-09
  • 1. Vaccine priorities I for pandemic flu--2005
  • 2. Community control measures for pandemic
    flu--2006
  • 3. CDC goals selection--2006
  • 4. Vaccine priorities II--2008
  • 5. Identification of at risk populations for
    pandemic influenza---2008

15
Projects to Date 2005-09
  • 6. Six State Demonstration Projects on Pandemic
    Influenza Policy, 2008-09
  • 7. Priorities for the National Vaccine Plan, 2009
  • 8. Criteria and Priorities for the CDC Vaccine
    Safety Research Agenda, 2009
  • 9. Target Level of Preparedness for the H1N1 Mass
    Vaccination Program, 2009
  • 10. Components of a National Vaccine Safety
    System, 2009-10

16
Pending Decision for the H1N1 Project
  • Should the US take a full-throttle or a
    go-easy approach to vaccination against novel
    H1N1 or an approach somewhere in between?
  • In other words, what should be the target level
    of preparedness? Should we get ready to achieve a
    low, moderate, or high level of vaccination
    coverage?

17
Results from Citizen Meetings
  • 1000 Participants in 12 Meetings
  • Go Easy 23
  • Moderate 52
  • Full Throttle 25

18
Stakeholder Meeting (N30)
  • Go Easy 3
  • Moderate 40
  • Full Throttle 57

19
Conclusions
  • There appears to be strong consistency in the
    judgments of citizens across ten geographic areas
    of the US and in web engagement that a moderate
    intensity mass vaccination program against H1N1
    influenza virus is the preferred approach

20
Conclusions
  • Stakeholders from 8 key sectors (advocacy,
    minority, professional, federal agencies, local,
    state, military and manufacturing) prefer a
    full-throttle approach.

21
Conclusions
  • For the public and the stakeholders, the most
    important values are protecting the most people
    against H1N1 and preventing the most
    hospitalizations and deaths.

22
Outcomes
  • No change adopted in the unofficial full
    throttle approach
  • Currently, vaccine supplies have been more
    limited than projected.
  • Public demand exceeds supply in many areas

23
  • Overview of the public engagement experience
    between 2001-2009

24
Accomplishments to Date
  • Never doubt that a small group of thoughtful,
    committed citizens can change the world. Indeed,
    it is the only thing that ever has.
  • Margaret Mead

25
Accomplishments to Date
  • We have raised awareness of public engagement and
    increased expectations for both citizens and some
    government professionals that the public can and
    should be involved in some decisions.
  • We have obtained additional evidence (proof of
    principle) that public engagement can be done
    productively and can provide useful advice
    adopted by policy makers

26
Accomplishments to Date
  • We have articulated a set of sound principles for
    guiding agency work in this area.
  • We have developed a feasible model for engaging
    productively with citizens
  • We have increased the capacity of agency
    representatives to conduct public engagement

27
Lessons Learned to Date
  • There is nothing more difficult to carry out,
    nor more doubtful of success, nor more dangerous
    to handle, than to initiate a new order of
    things.
  • Niccolo Machiavelli

28
Lessons Learned to Date
  • It is difficult to identify and get support for
    public engagement projectsthe culture has not
    changed significantly.
  • The benefits of engaging with citizens are not
    appreciated or valued
  • There are many examples of bad public
    consultations
  • No CDC structure created yet to conduct public
    engagement

29
Lessons Learned to Date
  • Even when supported, the nature and purpose of
    public engagement is poorly understood---there is
    no common agreement about what public engagement
    is.
  • Degrees of involvement are not differentiated
  • Seen more as persuasion than consultation and
    deliberation

30
Lessons Learned to Date
  • Obtaining clarity about the decision to be made
    and the purpose of the project are the most
    difficult tasks
  • These most difficult tasks are also the most
    critical to the success
  • It is as if we needed a process before the real
    process to get the kind of clarity needed for
    success
  • Too much preparation is not feasible

31
Lessons Learned to Date
  • Public engagement is not rocket science! Its
    more difficult than rocket science!
  • Citizen interest is low
  • Getting representative participants for open
    meetings can be difficult
  • Getting unbiased information and truly neutral
    facilitation is challenging
  • Genuine dialogue and deliberation is difficult in
    a limited time frame
  • Assuring the use of the information always a
    challenge
  • Getting real feedback is impractical and rare

32
Lessons Learned to Date
  • It is difficult to isolate and measure the
    contribution of the publics advice in the larger
    stream of all inputs that are used in the final
    decision making.
  • Multiple parties contribute to decision making
  • There can be a long delay between the
    consultation and the final decision

33
Lessons Learned to Date
  • Honest, accurate evaluation is a difficult.
  • People do not want to say that talking with
    citizens is not a worthwhile thing to do in a
    democracy
  • The perception is that there are many intangible
    benefits to engaging the public

34
Possible Results From and Responses To a Public
Consultation
35
Summary of the Evidence
  • When done well, public participation improves
    the quality and legitimacy of a decision and
    builds the capacity of all involved to engage in
    the policy process
  • US National Research Council, 2008

36
Summary of the Evidence
  • Public participation should be fully
    incorporated into environmental assessment and
    decision-making processes, and it should be
    recognized by government agencies and other
    organizers of the processes as a requisite of
    effective action, not merely a formal procedural
    requirement.
  • US National Research Council, 2008

37
For the Future
  • We need to try more letting-go in a new
    letting-go world
  • Adapted from remarks by Walker Smith at the
    CDC/NCHM conference this month.

38
For the Future
  • We need to move from the leader as the hero, to
    the leader as the host.
  • -Margaret Wheatley

39
Favorite Quote
  • When big things are at stake, the danger of
    error is great. Therefore, many should discuss
    and clarify the matter together so the correct
    way may be found.
  • Shotoku Taishi, first Buddhist emperor, 604 AD
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