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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

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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)

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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”
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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


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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
“Health Care Policy” 9

Palfrey
Health Sciences:
Basic sciences
Clinical medicine
biostatistics

Epidemiology< >Health Services Research< >Health Policy

Social policy

Public Policy

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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)
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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.”
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Key findings:

• 24% of papers had a “policy pronouncement”

• 55% concerned public health practices and 28%


clinical practice

• 30% of papers by authors from government or public


health had policy statements, 20% from universities

• 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 6 71

Feldman et al. Annals of the Royal College of Physicians &


Surgeons of Canada c.1999
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Sources of Knowledge
Decision-Makers Physicians

Documents produced with my own Original studies published in scientific journals


organization
Management of staff of my organization Information from specialists

Internet Searches Computerized literature search (e.g.,


MEDLINE)
Documents produced by other government Information from colleagues
agencies, RHAs, or healthcare facilities
Evaluation reports for a project that you were Publications that focus on evidence-based
personally involved with medicine
Databases (e.g. CIHI, cancer registries, Child Presentations and seminars
Health Survey)
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.
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Affinities and Barriers

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

 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

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Schematic of the Policy Process

INPUTS WITHINPUTS OUTPUTS OUTCOMES

Imperatives
Policy
Constraints Political
Levers for Results
Uncertainties Administrative
implementation
Pressure

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

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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 27
THE POLICY PROCESS

Other Mgmt. Leg.


Gov’t. Ministry
Mins Board Counsel

Agencies Other Policy &


Branch Brs Legislat.
Priorities

Public Legal Cabinet Committe


Analyst

IMPLEMENT Branch LAW Legislat


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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.”

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The Core Of Policy
Analysis

Evaluation
Goal Objectives Options
Criteria

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A Basic Framework for Policy Analysis [“GOCO”]
Goal Objectives Criteria Option #1 Option #2 Option #3
statement of #1 concrete a. standards assessment of
a general targets which to judge how well each
principle or together will attainment of option
broad intent, achieve the objective, achieves each
e.g., improve broader goal plus data and criteria
the health of sources
Canadians

b.

c.

#2 a.

b.

c.

#3 a.

b.

c.

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CONSTRUCTING A POLICY
ANALYSIS

Goals
Objectives
Evaluation Criteria

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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
[CIHI 2006] 34
Criteria for Each Objective

GOAL OBJECTIVES EVALUATION


CRITERIA

to enhance the health of assuring access to 1. entitlement documents


homeless persons primary health care not required for care or
through the provision of through a regular for ancillary services
optimal primary care primary health care
provider 2. service available at
venues likely to suit
homeless persons
enhancing the 1. collaboration with
population orientation public health authorities
of primary health care on harm reduction
strategies
providing 1. multidisciplinary team
comprehensive whole care
person care
2. established referral
routes for specialty
services

3. social work assistance


available for benefit
entitlement, housing
enhancing an 1. service available at
integrated approach times likely to suit
to 24/7 access homeless persons

2. evidence of reduced
emergency room use
strengthening the 1. special expertise in
quality of primary areas germane to the
health care clinical conditions of
homeless persons, e.g.
substance abuse,
sexually transmitted
diseases.
building patient- 1. user involvement in
centered care service planning and
operation
promoting continuity 1. appropriate access to
through integration electronic medical
and co-ordination 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]

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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
#6: presenters responsible for directing class discussion 39