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 6.

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

Essential Services: A Different View

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

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

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

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

…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

Death Rates 1860 – 1970

3500 3000 2500 2000 1500 Tuberculosis Whooping Cough Measles 1000 500 0 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970

Focusing on disease prevention has led to major achievements

Actual and Expected Death Rates for Coronary Heart Disease, 1950 –1998

700

Rate if trend continued

600 500

Peak Rate

400 300 200 100 50 1950 1955 1960 1965 1970 1975 Year 1980 1985 1990 1995

Actual Rate 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.

But the pictures look different when we examine summary measures of health (or affliction)

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 .

Leading Causes of Death, 1990

Developed Nations Developing Nations

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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 1.

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

Some important “drivers” of population health Changes in the environment Infectious disease threats Including MAN MADE ONES!!

Advances in biotechnology and information technology Disparities in health status and access to care Globalization A social and political environment that prioritizes health

Perceived Problems

Political Theory 101

Potential Solutions Political Dynamics Window of Opportunity Policy Change

Kingdon J.W.

Agendas, Alternatives, and Public Policies

(1984, 2003)

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

The Health System

The full complement of individuals and institutions whose actions influence the public’s health -Institute of Medicine

The Public Health System

Police EMS Community Centers MCOs Health Department Faith orgs Home Health Jails Parks Doctors Lab CHCs Facilities Schools Hospitals Drug Philanthropist Treatment Civic Groups Elected Officials Nursing Homes Environmental Health Tribal Health Mental Health Employers Mass Transit Economic Development Fire

Health System Dynamics that Influence the Public’s Health Society's Health Response

General protection

Safer, Healthier Population

Targeted protection

Demand for response Becoming no longer vulnerable

Vulnerable Population

Becoming Vulnerable

Primary prevention

Becoming Affected Demand for response

Secondary prevention

Population with Disease

Developing Complications

Tertiary prevention

Demand for response

Population with Complications

Dying from Complications

Adverse Living Conditions Public Health Medical Care Other Sectors

Source: Adapted from Bobby Milstein, CDC Syndemics Prevention Network

Spectrum of Action within the Health System SECONDARY & TERTIARY Focus on Disease

Treatment Services

PRIMARY & SECONDARY Focus on Risk

Disease Prevention

INTERGENERATIONAL Focus on Conditions

Health Promotion

Physiological Change Behavioral Change Social Change SHORT months-years Focus on Capacity for Action

Capacity Building or Empowerment

Policy & Infrastructure Change Time Horizon INTERMEDIATE years-decades LONG decades-centuries

Decision-making: the Interface of Policy & Leadership

 Decisions that determine the current and future

structure

system and its and

operation impact

of the health on the public’s health  Decision-makers: government, health professionals, employers, industry, consumers

→ communities

Examples of Traditional Public Health Policies

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

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

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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

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



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

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

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

Policy Leadership in Arkansas Healthy 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

Current Approaches in Arkansas Healthy 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.

Policy Instruments in Healthy Arkansas

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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

Current Approaches in Arkansas Act 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

Policy Instruments in Act 1220

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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

Current Approaches in Arkansas UAMS 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

Policy Instruments in Smoke Free Campus Initiative

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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

Policy Instruments in National

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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

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

policies and

measure

their impact!!

new

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 nation’s 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 nation’s health.” —Institute of Medicine, 2003

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 change…while it lasts