Discussion: Agenda Comparison Grids

Advocacy plays a key role in building strong health systems. It gives people a voice in the decisions that affect their lives and health and helps hold governments accountable for meeting the health needs of all people, including marginalized groups. Health policies developed with broad participation help governments and institutions provide better healthcare.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

In the fields of HIV, family planning and reproductive health (FP/RH), and maternal health, advocacy occurs throughout the policy process. Advocates detect problems and raise awareness of those problems. They participate in policy dialogue and contribute to designing policy solutions, then marshal support to adopt those solutions. Their work doesn’t end with the passage of policy measures. Instead, they help ensure equitable and effective implementation of health policies, monitor the impact of those policies, and identify gaps and challenges. To do all this successfully requires a specialized set of skills and knowledge.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

ORDER  A PLAGIARISM FREE PAPER  NOW

Advocacy has often been described as a key strategy for the achievement of health promotion aims, but multiple and conflicting definitions and usages exist. The concept itself may be unnecessarily intimidating. Advocacy work can take place at the level of both ‘cases’ and ‘causes’. Two main goals underpin health advocacy—protection of the vulnerable (representational advocacy) and empowerment of the disadvantaged (facilitation al advocacy). This paper attempts to integrate existing models and definitions into a conceptual framework for considering the role of advocacy in addressing health inequalities. It argues that we need to pay some attention to the diversity of values and goals of health promotion if we are to understand which models and approaches to health advocacy apply and in what context. This paper concludes that advocacy for health fulfills two functions: as a form of practice and as a useful strategy for a discipline which has to be self-promoting as well as health-promoting in order to survive in the competitive political environment of contemporary health work.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

What is public health advocacy?

The focus of this Discussion is on ‘policy-focused’ public health advocacy, i.e., activities that attempt to contribute to health promoting systemic change by influencing policy processes. While there are many available definitions of public health advocacy,2-4 these share key common elements, including: an emphasis on collective action to effect desired systemic change; a focus on changing “upstream factors like laws, regulations, policies, institutional practices, prices and product standards;”5 and an explicit recognition of the importance of engaging in political processes to effect desired policy changes. Public health advocacy is often defined as the process of gaining political commitment for a particular goal or program, and identified by some as a critical population health strategy.2,6Target audiences tend to be decision-makers, policy-makers, program managers, and more generally, those that are in a position to influence actions that affect many people simultaneously.4,7,8 Public health advocacy strategies espouse an upstream approach, recognizing that ‘individual’ and ‘personal’ problems are often reflective of social conditions. NURS 5050 – Policy and Advocacy for Improving Population Health. This approach involves situating ‘individual’ health issues within the broader context of social determinants external to individuals. It also recognizes the societal breadth of many public health problems, and the logistical and resource challenges inherent in approaching these challenges at the individual level.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper While downstream health promotion activities (such as primary or secondary smoking prevention, community-level interventions and provider education) play an important public health role and should be continued, “…to some they resemble fixing with a pick and shovel what is being destroyed with a bulldozer.”9Engaging in public health advocacy acknowledges the explicitly political aspects of public health, and the importance of addressing social determinants of health as a key component of a strategy for improving the health of populations. Put another way, public health advocacy is an important strategy for creating environments supportive of health.10 If the goal of public health is to reduce the societal burden of health problems, then effective interventions must “…alter the societal forces that foster these problems.”11 Ignoring the social and political dimensions of health has the effect of relegating public health practice to the “…prevention and promotion of individual risk factors.”

Advocacy strategies draw from a range of tactics. These can involve “…creating and maintaining effective coalitions, the strategic use of news media to advance a public policy initiative and the application of information and resources to effect systemic changes that change the way people in a community live. It often involves bringing together disparate groups to work together for a common goal.”13 It can also involve gathering and presenting an evidence-base for desired changes, although it is worth noting that scientific evidence alone is rarely enough to achieve desired political support for public health goals. Evidence is often a necessary – but rarely sufficient – factor for influencing policy processes. The Ontario Health Promotion Resource System categorizes advocacy activities as low, medium, and high profile.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper Low profile activities could include quiet negotiation, meetings with civil servants, sharing information, and the development of non-public briefs. Medium profile activities include on-going negotiation, development of public briefs, ‘feeding’ the opposition, giving deputations at committees, participating in meetings with elected officials, forming strategic alliances with other groups, and writing letters to elected officials or newspapers. High profile activities include public criticism, public relations activities, advertising campaigns, information distribution, letter writing, and participation in demonstrations and rallies.14Within this categorization system, many activities (e.g., meeting civil servants, sharing information) may fall within any of these categories, depending on the nature of the activity and its intended result. There are many examples of successful public health advocacy efforts, and “…every branch of public health can point to the critical role of advocacy in translating research into policy, practice and sea changes in public opinion.”15 To date, public health advocacy has been used to advance policies in several public health areas, including gun control, injury prevention, and tobacco control.13 In spite of the importance of this work, Chapman argues that “…advocacy remains a Cinderella branch of public health practice. Advocacy is often incandescent during its limited time on stage, only to resume pumpkin status after midnight. Routinely acknowledged as critical to public health, it is seldom taken seriously by the public health community, compared to the attention given to other disciplines.”16 The lack of attention paid to public health advocacy is reflected in the limited body of research literature on public health advocacy research or practice. Advocacy skills Engaging in policy advocacy requires a diverse set of skills. Comm et al. identify three core skills required for successful public health advocacy: 1) the ability to work collaboratively with multiple stakeholders, 2) strategic use of media, and 3) ability to conduct strategic analysis.17This latter skill requires a focus on three central questions (what is the problem? what is the desired solution? who is the target for change?) Although sometimes overlooked as a skill, being able to identify a policy solution is as important as being able to identify the problem in public health advocacy.18The ability to frame issues effectively is identified as a key component of public health advocacy. Chapman argues that “.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

What is Population Health Advocacy? Advocacy represents the strategies devised, actions taken and solutions proposed to influence decision-making on a particular cause/issue. The purpose of advocacy is to create positive change for people and their environments. Individuals, organizations, businesses and governments can all engage in advocacy activities. As seen in Appendix 1, advocacy efforts range from those on behalf of an individual to efforts directed at bringing about policy change. Population health advocacy is directed at actions to improve the overall health of a population. Generally, this is done through addressing the many social conditions that impact the health of populations, such as early child development, income, education, gender, etc. These conditions are often referred to as the non-medical or social determinants of health . NURS 5050 – Policy and Advocacy for Improving Population Health

The Enhancing the Role of Hospitals in Improving Population Health (EHPH) Learning Center was established to support the Robert Wood Johnson Foundation’s (RWJF) efforts to expand the number of hospitals and health systems active promoting healthy communities and committed to a Culture of Health. The EHPH Learning Center is focused on learning systematically across the field and is exploring ideas to transform health and health care and advance community health and well-being.

The EHPH Learning Center is located at the NYU Langone Department of Population Health and staffed by Leora Horwitz, MD MHS, Jim Knickman, PhD and Carol Chang, MPH MPA. Leora is an associate professor and director of the Center for Healthcare Innovation and Delivery Science. Her recent research has focused on better coordination of hospitals and communities during the patient discharge process. Jim is the Derzon Chair in Health and Public Affairs with appointments at the Department of Population Health and NYU Wagner. He has many years of philanthropy experience, most recently as the president of the New York State Health Foundation. Carol is directing the EHPH project and is a former RWJF staff member who developed early grant making focused on population health including overseeing the Foundation’s Health and Society Scholars Program.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

Public policy frameworks for improving population health

Four conceptual frameworks provide bases for constructing comprehensive public policy strategies for improving population health within wealthy (OECD) nations. (1) Determinants of population health. There are five broad categories: genes and biology, medical care, health behaviors, the ecology of all living things, and social/societal characteristics. (2) Complex systems: Linear effects models and multiple independent effects models fail to yield results that explain satisfactorily the dynamics of population health production. A different method (complex systems modeling) is needed to select the most effective interventions to improve population health. (3) An intervention framework for population health improvement. A two-by-five grid seems useful. Most intervention strategies are either ameliorative or fundamentally corrective. The other dimension of the grid captures five general categories of interventions: child development, community development, adult self-actualization, socioeconomic well-being, and modulated hierarchical structuring. (4) Public policy development process: the process has two phases. The initial phase, in which public consensus builds and an authorizing environment evolves, progresses from values and culture to identification of the problem, knowledge development from research and experience, the unfolding of public awareness, and the setting of a national agenda. The later phase, taking policy action, begins with political engagement and progresses to interest group activation, public policy deliberation and adoption, and ultimately regulation and revision. These frameworks will be applied to help understand the 39 recommendations of the Independent Inquiry into Inequalities in Health, the Sir Donald Acheson Report from the United Kingdom, which is the most ambitious attempt to date to develop a comprehensive plan to improve population health.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

Towards the end of the last century, health improvement strategies (such as the World Health Organization’s seminal Health for all by the year 2000) tended to use phrases like ‘protecting and promoting health’. In more recent years, the vocabulary has broadened out to place an emphasis on well being as well as health. Today the phrase ‘population health’ is used to convey a way of conceiving health that is wider still. It includes the whole range of determinants of health and well being – many of which, such as town planning or education, are quite separate from health services.

Referring to ‘population health’ rather than the more traditional phrase ‘public health’ also helps avoid any perception that this is only the responsibility of public health professionals. Population health is about creating a collective sense of responsibility across many organizations and individuals, in addition to public health specialists.

Confusingly, the phrase ‘population health management’ is also widely used, with a specific meaning that is narrower in focus than population health. Population health management refers to ways of bringing together health-related data to identify a specific population that health services may then prioritize. For example, data may be used to identify groups of people who are frequent users of accident and emergency departments. This way of using data is also sometimes called ‘population segmentation’.

Throughout all these changes in vocabulary, one element has consistently been essential: an emphasis on reducing inequalities in health, as well as improving health overall. This continues to be important in population health NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

Medicalization And Health Policy

A century ago, policy interventions addressing health vulnerability often reflected a broad view of the causes of vulnerability and the conditions that needed to be addressed through public action. The specific etiology of most illnesses and diseases was poorly understood. However, given the large and obvious statistical association between poverty and illness, health status vulnerability was readily seen as a consequence of socioeconomic vulnerability. ³ As a result, public health activities in the late nineteenth and early twentieth centuries focused on “upstream” causes of poor health, including poor sanitation, overcrowded and squalid housing conditions, work-related hazards, food security, and nutrition. ⁴ Interventions in these realms are believed responsible for sharp mortality declines across age groups in the United States. ^{5NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper}

Concurrent with these public health improvements, a sea change was under way in biomedical science, with an increasing focus on individual causes and manifestations of illness and disease. This increasingly individualized perspective fostered a tendency to medicalize health and illness. ⁶ Irving Zola defines medicalization as the expansion of medicine as an institution and the use of a medical lens to view human processes and behavior. ⁷ A medicalized perspective tends to define health problems as the result of individual failures of biology, hygiene, and behavior, with the implicit or explicit belief that the primary strategy for addressing these problems is through biomedical treatments delivered to individuals by physicians and other providers. ⁸

Multiple economic, social, and political factors fueled the growth and dominance of individualistic, medicalized perspectives regarding public health, although a detailed analysis of this topic is outside of the scope of this essay. ⁹ Michael Katz argues that individualized accounts of illness and vulnerability strongly resonated with Americans’ historic ambivalence toward disadvantaged individuals and groups, with accompanying moral and ideological distinctions between citizens deemed worthy and unworthy of assistance. ^{10NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper}

As health status and health vulnerability became more medicalized throughout the twentieth century, discourse and decisions regarding policy priorities changed as well. Given an increasingly medicalized view of health vulnerability, public policy became focused on expanding access to individualized medical care. ¹¹ The federal government was providing personal health services to certain populations (such as merchant seamen and Native Americans) before 1900. However, as the problems of vulnerable populations became more medicalized, policies and initiatives focusing on health care access proliferated across populations and across a range of pertinent medical services. NURS 5050 – Policy and Advocacy for Improving Population Health

Given this policy emphasis on medical care, a piecemeal, categorical, and separatist approach to providing health care services to vulnerable populations emerged. Throughout the twentieth century, the making and buying of health care services through government policy created facilities, systems, providers, financing arrangements, and bureaucracies that exist outside the mainstream health care delivery system and operate specifically for vulnerable populations. Examples abound, including community and migrant health centers, Title X family planning clinics, local public health clinics, Medicaid managed care, Medicaid expansions for pregnant women, the National Breast and Cervical Cancer Early Detection Program, and the State Children’s Health Insurance Program (SCHIP).NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

The Limits Of Medicalized Policy Responses

Current public policy responses to health vulnerability focus primarily (although not exclusively) on the procurement of medical care services, with a reduction in access barriers proffered as the central benchmark for success. Although policies that address financial and geographic barriers to health care bring important services to populations in need, many such policies establish and reinforce a two-tier “safety-net” system in which vulnerable populations primarily go to separate institutions or providers for their health care.

These separate programs are viewed as necessary as a result of the dominant system’s failure to provide adequate access for those who are marginalized and vulnerable. These programs, however, are not well funded, and the services provided are neither adequately paid for nor completely covered. ¹² This leaves safety-net providers and programs plagued by financial pressures and often unable to deliver high-quality medical care to the populations they serve. ¹³

A second, less noticed consequence of medicalized perspectives is a conflation between health status disparities and health care disparities. Medicalization encourages the view that one can solve socioeconomic and racial/ethnic health status disparities through initiatives and policies that reduce disparities in health care access, use, and quality. This conflation, for example, can be seen in some aspects of the Health Disparities Research Plan of the National Institutes of Health (NIH) and also in the National Action Agenda of the Department of Health and Human Services (HHS) Office of Minority Health. ^{14NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper}

In turn, when health vulnerability and disparities are medicalized, health care access becomes overvalued and overemphasized as the most promising policy path. It is also an easier path, politically, than are fundamental social and economic reforms. The result is our current situation, in which an estimated 95 percent of U.S. health services spending goes toward direct medical services, and only 5 percent is invested in population or community approaches for prevention and health status improvement. ¹⁵

Medicalized framing of health vulnerability can be an effective strategy to defend policy benefits/transfers to the disadvantaged by sidestepping social and political debates over the deservingness or worthiness of vulnerable populations. The Supplemental Security Income and Social Security Disability Insurance programs are examples of how a medicalized approach to complex social problems can bring valuable income support and other benefits to people living with disabilities. ¹⁶ Similarly, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides housing and social services that extend beyond the domain of medical care to people living with HIV and AIDS. In addition, Medicaid provides a funding umbrella under which many states finance expanded services and social supports that extend beyond medical treatment and care. Nonetheless, these types of social services and interventions tend to become available only after a person is diagnosed as sick or disabled, and they focus on individuals and families rather than on the social and economic conditions of communities that are the fundamental drivers of poor health over the life course.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people.

National health policies, strategies, plans

National Health Policies, Strategies and Plans play an essential role in defining a country’s vision, policy directions and strategies for ensuring the health of its population.

The development of National Health Policies, Strategies and Plans is a complex and dynamic process. Its precise nature varies from State to State according to the political, historical and socio-economic situation prevailing in the country.
There is a renewed focus on strengthening countries’ capacity to develop robust

National Health Policies, Strategies and Plans that can

• respond to the growing calls for strengthening of health systems and the renewal of Primary Health Care: universal coverage, people-centered care, emphasis on public health and health in all policies;
• serve to guide and steer the entire, pluralist health sector rather than being command-and-control plans for the public sector;
• go beyond the boundaries of health systems, addressing the social determinants of health and the interaction between the health sector and other sectors in society.NURS 5050 – Policy and Advocacy for Improving Population Health Assignment Paper

WHO has a long track record of supporting Member States in to develop National Health Policies, Strategies and Plans through country-level technical cooperation, facilitation of national policy dialogue and inter-country exchange, as well as through normative work and high level international policy frameworks.

Health policy can be defined as the “decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society”.^[1] According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people.^[1]

There are many categories of health policies, including global health policy, public health policy, mental health policy, health care services policy, insurance policy, personal healthcare policy, pharmaceutical policy, and policies related to public health such as vaccination policy, tobacco control policy or breastfeeding promotion policy. They may cover topics of financing and delivery of healthcare, access to care, quality of care, and health equity.^[2