Leading the Health System Leading the Health System through Policy Developmentthrough Policy Development

New Roles for Public Health

The Ten Essential Public The Ten Essential Public Health ServicesHealth Services

1. Monitor health status

2. Diagnose and investigate health problems

3. Inform and educate

4. Mobilize communities to address health problems

5. Develop policies and plans

6. Enforce laws and regulations

7. Link people to needed health services

8. Assure a competent health services workforce

9. Evaluate health services

10. Conduct research for new innovations

Essential Services: A Different ViewEssential 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 Health Issues Have Moved to the Forefront of Public AttentionForefront 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 Creating a Unique Window of Opportunity for Policy ChangeOpportunity for Policy Change

Educating & informing elected officials Mobilizing health professionals Engaging businesses/employers Building coalitions with community

organizations Empowering consumers to take action

0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

3 0 0 0

3 5 0 0

1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970

Tuberculosis

Whooping Cough

Measles

Death Rates 1860 – 1970Death Rates 1860 – 1970D

eath

s p

er 1

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Focusing on disease prevention Focusing on disease prevention has led to major achievementshas led to major achievements

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Rate if trend continued

Peak Rate

Actual Rate

Age-a

dju

sted D

eath

Rate

per

10

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Popula

tion

1955 1965 1975 1985

300

700

Year

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

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.

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/>.

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

14% increase

Leading Causes of Death, 1990Leading Causes of Death, 1990

1. Heart disease

2. Cerebrovascular disease

3. Cancer – lung, trachea

4. Lower respiratory infections

5. Chronic Obstructive Pulmonary Disease

6. Cancer – colon, rectum

7. Cancer – stomach

8. Traffic accidents

9. Self-inflicted injuries

10. Diabetes

Developed Nations

1. Lower respiratory infections

2. Heart disease

3. Cerebrovascular disease

4. Diarrheal diseases

5. Perinatal conditions

6. Tuberculosis

7. Chronic Obstructive Pulmonary Disease

8. Measles

9. Malaria

10. Traffic accidents

Developing Nations

Some important “drivers” of Some important “drivers” of population healthpopulation health

Globalization

Changes in the environment

A social and political environment that prioritizes health

Disparities in health status and access to care

Advances in biotechnology and

information technology

Infectious disease threats

Including MAN-MADE ONES!!

Political Theory 101Political Theory 101

Potential Solutions

Window of Opportunity

Window of Opportunity

Policy Change

Kingdon J.W. Agendas, Alternatives, and Public Policies (1984, 2003)

Perceived Problems

Political Dynamics

Our Challenge as Public Health Our Challenge as Public Health LeadersLeaders

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 SystemThe Health System

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

-Institute of Medicine

The Public Health System

MCOs

Home Health

Parks

Economic Development

Mass Transit

Employers

Nursing Homes

Mental HealthDrug Treatment

Civic GroupsCHCs

Lab Facilities

Hospitals

EMS Community Centers

Doctors

Health Department

Faith orgs

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Jails

Environmental Health

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Affected

PopulationwithDisease Developing

Complications

Population withComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

Demand for response

Public Health

Medical Care

Demand for response

Demand for response

Other Sectors

Source: Adapted from Bobby Milstein, CDC Syndemics Prevention Network

Health System Dynamics that InfluenceHealth System Dynamics that Influencethe Public’s Healththe Public’s Health

Spectrum of Action within the Health SystemSpectrum of Action within the Health System

SHORTmonths-years

INTERMEDIATEyears-decades

LONGdecades-centuries

Time Horizon

SECONDARY &TERTIARY

Physiological Change

Treatment Services

Focus on Disease

PRIMARY & SECONDARY

BehavioralChange

Focus on RiskDisease Prevention

INTERGENERATIONAL

Social Change

Focus on ConditionsHealth Promotion

Focus on Capacity for ActionCapacity Building or Empowerment

Policy & Infrastructure Change

Pol

icy

Dev

elop

men

t

Decision-making: the Interface Decision-making: the Interface of Policy & Leadershipof 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 Examples of Traditional Public Health PoliciesHealth Policies

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

What Policies and Policy-makers What Policies and Policy-makers are Relevant to Public Health? 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?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 What Policies and Policy-makers are Relevant to Public Health?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?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 ArkansasPolicy Leadership in ArkansasHealthy Arkansas InitiativeHealthy 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 ArkansasCurrent Approaches in ArkansasHealthy Arkansas InitiativeHealthy 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 ArkansasPolicy 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 ArkansasCurrent Approaches in ArkansasAct 1220 Child Obesity InitiativeAct 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 1220Policy 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 ArkansasCurrent Approaches in ArkansasUAMS Smoke Free Campus InitiativeUAMS 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 Policy Instruments in Smoke Free Campus InitiativeCampus 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 Policy Instruments in National Public Health InfrastructurePublic 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 ResearchThe 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 ResearchThe 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 The Future for Public Health Policy DevelopmentDevelopment

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