Transcript No Slide Title

Leading the Health System
through Policy Development
New Roles for Public Health
The Ten Essential Public
Health Services
1.
2.
3.
4.
5.
Monitor health status
Diagnose and investigate
health problems
Inform and educate
Mobilize communities to
address health problems
Develop policies and
plans
6.
7.
8.
9.
10.
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
Deaths per 100,000
Tuberculosis
3000
Whooping Cough
2500
Measles
2000
1500
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
Age-adjusted Death Rate
per 100,000 Population
700
Rate if trend
continued
600
500
Peak Rate
400
300
200
Actual Rate
100
50
1950 1955
1960 1965 1970
1975 1980 1985 1990
1995
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.
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 <http://apps.nccd.cdc.gov/HRQOL/>.
Leading Causes of Death, 1990
Developed Nations
Developing Nations
1.
Heart disease
1.
Lower respiratory infections
2.
Cerebrovascular disease
2.
Heart disease
3.
Cancer – lung, trachea
3.
Cerebrovascular disease
4.
Lower respiratory infections
4.
Diarrheal diseases
5.
Chronic Obstructive Pulmonary
Disease
5.
Perinatal conditions
6.
Tuberculosis
7.
Chronic Obstructive Pulmonary
Disease
6.
Cancer – colon, rectum
7.
Cancer – stomach
8.
Traffic accidents
8.
Measles
9.
Self-inflicted injuries
9.
Malaria
10.
Diabetes
10.
Traffic accidents
Some important “drivers” of
population health
Changes in the
environment
Infectious disease
threats
Including MANMADE ONES!!
Advances in biotechnology
and information technology
Disparities in health status
and access to care
Globalization
A social and political
environment that
prioritizes health
Political Theory 101
Perceived
Problems
Potential
Solutions
Window of
Opportunity
Policy Change
Kingdon J.W. Agendas, Alternatives, and Public Policies (1984, 2003)
Political
Dynamics
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
Faith orgs
Home Health
Jails
Health
Department
Parks
Schools
Doctors
Elected
Officials
Hospitals
Philanthropist
Civic Groups
CHCs
Nursing
Homes
Environmental
Health
Tribal Health
Lab
Facilities
Drug
Treatment
Mental Health
Employers
Mass Transit
Fire
Economic
Development
Health System Dynamics that Influence
the Public’s Health
Society's Health
Response
General
protection
Targeted
protection
Primary
prevention
Demand for
response
Secondary
prevention
Demand for
response
Becoming no
longer vulnerable
Safer,
Healthier
Population
Becoming
Vulnerable
Vulnerable
Population
Becoming
Affected
Population
with
Disease
Tertiary
prevention
Demand for
response
Developing
Complications
Population with
Complications
Dying from
Complications
Adverse Living
Conditions
Public Health
Other Sectors
Medical Care
Source: Adapted from Bobby Milstein, CDC Syndemics Prevention Network
Policy Development
Spectrum of Action within the Health System
SECONDARY &
TERTIARY
PRIMARY &
SECONDARY
INTERGENERATIONAL
Focus on Disease
Focus on Risk
Focus on Conditions
Treatment Services
Disease Prevention
Health Promotion
Physiological
Change
Behavioral
Change
Social
Change
Focus on Capacity for Action
Capacity Building or Empowerment
Policy & Infrastructure Change
Time Horizon
SHORT
months-years
INTERMEDIATE
years-decades
LONG
decades-centuries
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 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?

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




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



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


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
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 new
policies and measure their impact!!
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