Title: Lessons Learned from Putting the Public in Public Health Policy Making at a US Federal Agency
1Lessons 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
2Why 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
3Background 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
4Background 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
5Workshop 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!
6Working 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.
7The 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
8Quote 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!
102x10 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.
112x10 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.
122x10 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
13Model 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
14Projects 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
15Projects 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
16Pending 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?
17Results from Citizen Meetings
- 1000 Participants in 12 Meetings
- Go Easy 23
- Moderate 52
- Full Throttle 25
18Stakeholder Meeting (N30)
- Go Easy 3
-
- Moderate 40
- Full Throttle 57
19Conclusions
- 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 -
20Conclusions
- Stakeholders from 8 key sectors (advocacy,
minority, professional, federal agencies, local,
state, military and manufacturing) prefer a
full-throttle approach.
21Conclusions
- For the public and the stakeholders, the most
important values are protecting the most people
against H1N1 and preventing the most
hospitalizations and deaths.
22Outcomes
- 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
24Accomplishments 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
25Accomplishments 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
26Accomplishments 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
27Lessons 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
28Lessons 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
29Lessons 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
30Lessons 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
31Lessons 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
32Lessons 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
33Lessons 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
34Possible Results From and Responses To a Public
Consultation
35Summary 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
36Summary 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
37For 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.
38For the Future
- We need to move from the leader as the hero, to
the leader as the host. - -Margaret Wheatley
39Favorite 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