11 May Review the World Health Organizations (WHO) definition of health in Chapter 7 of your textbook? ? Why is the definition of health important to
Review the World Health Organization’s (WHO) definition of health in Chapter 7 of your textbook
- Why is the definition of health important to health policy?
- Define the term “target population” as it relates to health policy.
- How do societal influences impact the identification and definition process of policy?
- Research a healthcare organization and highlight how their policies align or misalign with the WHO’s definition of health.
The Policy Analysis Process: Identification and Definition
In a December 1, 2005, talk at Duke University, Dr. Julie Gerberding, then director of the Centers for Disease Control and Prevention (CDC), suggested three important concepts to consider when looking at recent public health crises (e.g., epidemics, terrorist attacks, and natural disasters) and preparing for future threats:
She argued that we have to do a better job of imagining problems if we are to prepare for them. The connectivity issues—the ease and speed with which information, people, and diseases move around the world, bringing clusters of individuals into contact—are widely understood. These issues are often cited in descriptions of globalization (Friedman, 2005; Naim, 2005). Scale relates to the fact that when critical events happen, they happen on a scale of considerable magnitude. Citing the response to Hurricane Katrina in New Orleans, Dr. Gerberding noted that the lack of preparedness was not due to a failure of imagination. The tragedy was widely forecast. Connectivity worked favorably, as rescuers and support resources quickly arrived from all over the United States and Mexico. To her, much of the problem was one of scale. The governments involved were not prepared to deal with events of that scale. However, Admiral Thad W. Allen, the U.S. Coast Guard commandant who took over the federal response, reported at least one failure of imagination. There were procedures to deal with a hurricane and its storm surge, and there were procedures to deal with a flood; however, there were not procedures to deal with both occurring in the same place only a day apart.
When it comes to preparing for or responding effectively and imaginatively to any major health care event or pressing health policy issue, defining the problem is critical. Imagination involves calling on more than what is already known and experienced. There are a number of adages about how well generals are prepared to fight the last war. Learning from experience is a good thing, but only when it is relevant experience.
Identifying and defining the problem may be only the first steps. When experienced individuals who deal regularly with an issue are unable to resolve it, one or more of the following conditions likely pertain:
1. There is not a shared understanding of the nature of the problem.
2. There is a shared understanding, but it is not appropriate to the situation.
3. There is a realistic and relevant understanding, but it is not in some people’s interest to resolve it.
4. There is an appropriate understanding and a shared desire for a solution, but there are not sufficient resources to implement the solution:
a. There are inadequate facilitation and leadership skills to reach the necessary compromises.
b. There are inadequate levels of skilled personnel to implement the preferred solution.
c. There are insufficient financial resources to implement the preferred solution.
d. The implementers cannot focus the political process on the problem or the solution sufficiently to move ahead.
e. Some combination of the above.
In this chapter, we deal primarily with the first two conditions—making sure that there is an accurate and appropriate definition of the problem that is understood by all involved. The other conditions relate to technological assessments, political feasibility, economic feasibility, implementation, and leadership and are addressed elsewhere.
7.1 GETTING THE SCENARIO RIGHT
Assessing the Impact of a Health Policy
A World Health Organization (1999) report, the Gothenberg Consensus Paper, defines a health impact assessment as, “A combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population and the distribution of those effects within the population.” As we shall see later, the distributional effects may take these studies well beyond the population at immediate risk, especially in a market system like the United States.
If we are to reach agreement about the scope of potential and existing problems, possible alternatives, and desired outcomes, we have to reach some agreement on several key areas (University of Birmingham, 2003):
1. The relevant definition of health
2. Identification of the target population
3. The current or likely future status of the health of a targeted population
4. The factors that determine the health status of concern with that population
5. The methods realistically available to change that health status
6. The responsibilities of the various actors in dealing with the identified issues
7. The societal values that are to govern the selection of alternatives and the acceptability of alternative outcomes
A health policy analysis seldom starts with a clean slate. The starting point is usually a recent major event. Often that leads to overcorrecting for earlier mistakes, rather than taking a fresh look at the situation. Complex systems are full of problems in search of solutions, but they are also full of solutions in search of problems. A policy proposal is often put forward by someone with a specific solution already in mind. It is important, however, to ask whether a broader range of alternative solutions should be considered. One secretary of defense used to complain that the Joint Chiefs sent up the requisite three alternatives, two of which did not count. It is a waste of scarce resources to evaluate alternatives that do not count. Screening for additional alternatives, however, can be enlightening. The following box describes an actual situation in which this occurred.
Finding an Alternative Definition
The administrators and the board of trustees of a large academic medical center were at an impasse over the design of their new facility. At issue was whether to purchase a new and relatively untried monorail system for the distribution of supplies, laboratory samples, paperwork, and so forth. The investment would be large, and the risk was relatively high. Finally, one of the senior medical staff asked a consultant to meet with them. After listening to the arguments on both sides, the consultant asked, “Why are you in a hurry to make a decision now?” They replied, “The architect for the first building needs to know how big to make the passageways and utility channels in the plans which are nearly complete.” After listening to the various concerns, the consultant asked, “How much additional would it cost to design the building to take either the new or the old technology?” Here was a new alternative. It turned out the additional cost was not much when compared with the uncertain gamble on the new technology. Both sides quickly agreed on that new alternative.
Table 7-1 presents the view of health and health care espoused in the constitution of the World Health Organization. Although the United States is a U.N. member state, one would be hard put to find consensus in the United States on a number of the points that it cites as basic principles.
Asking people in the United States if health is more than the absence of illness or infirmity could produce a host of different responses. Some respondents might come down on the side of physical and mental well-being but have a problem with trying to address social well-being under the heading of health. Indeed, the fact that we have millions of uninsured and do not provide mental health care to a large proportion of the population would seem to indicate a lack of commitment to physical and mental well-being.
Those analyzing or deciding on a policy need to understand the differences in the operational definitions of health that are represented around the table. In the best of all possible worlds, those seated at the table would agree on that definition and move on, but sometimes the art of politics depends, in part, on knowing when to try to agree on principles, or on actions, or on both, and whether to use limited political capital to try to bring them into alignment publicly.
Table 7-1 Excerpts from the Preamble of the Constitution of the World Health Organization
… the following principles are basic …
• Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
• The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic or social condition.
• The health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest cooperation of individuals and States.
• The achievement of any state in the promotion and protection of health is of value to all.
• Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.
• Healthy development of the child is of basic importance, and the ability to live harmoniously in a changing total environment is essential to such development.
• The extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.
• Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.
• Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.
Source: Reproduced from: Constitution of the WHO, Basic Documents, 45th Ed. Supplied 2006, October at www.who.int/governance/eb/who_constitution_en.pdf
Defining the Target Population
Just what population are we talking about? The history of community mental health centers illustrates how difficult—and critical—it can be to answer this question. A system designed to help the developmentally disabled and severely and persistently mentally ill morphed into a general mental health treatment system in which many practitioners avoided the original target group and concentrated on the more rewarding (professionally and financially) cases (Torrey, 1997). As more and more states now focus more intently on the original target population, many of those previously served must rely more on private payment or insurance or go without.
An analyst in charge of developing a maternal health program policy who wanted to determine the health status of the target population might start by looking at the health of all females of childbearing age. But what constitutes childbearing age when 8-year-old girls and women in their 50s can give birth? An analyst would have to put both an upper and a lower limit on the age range in order to get a count of the target population.
Identifying the Health Status of the Target Population
The next step after defining the target population is to assess its health status. Many data sources are available for this task, but sometimes they do not match up exactly with the target population that has been identified. The CDC demonstrated the complex connection between defining the target population and assessing its health status using available data in 2000 when it reported on changes in serum foliate levels in noninstitutionalized women ages 15–44 who participated in the National Health and Nutrition Examination Surveys from 1991 to 1994 and in 1999 (CDC, 2000). It did not conduct a special study of pregnant women or women of childbearing age, the recommended target group. Instead, it segmented the data in the existing surveys and analyzed that. There certainly are women bearing children after age 44, before age 15, and in institutions; however, the age range covered most of the potential recipients, and the differences in outcomes were so great that the analysts did not feel the need for further refinements.
Looking at the health status of the target population in the aggregate can often obscure differences between subgroups. One frequently hears about the millions of people in the United States who lack health insurance. Does their health status suffer because they lack insurance? Sometimes and sometimes not. Historically, many of the uninsured have been young people who have made a calculated trade-off between the cost of health insurance and the fact that they are young and healthy (a group sometimes referred to as “the young immortals”). Yes, they are more likely to have severe auto accidents than an older population, but until one happens they are not part of the 20% of the population that accounts for 80% of health care costs. They are transferring the risk of low-probability events to the public at large because they would probably receive care anyway. Others may want insurance and need it, but are simply unable to afford it. The point is that there is plenty of room to talk at each other rather than solve problems. One can talk about the issue by discussing the uninsured as a bloc or about the needs of specific segments. The important thing is that analysts define clearly whom they are talking about.
Identifying the Factors Determining the Health Status of Concern Within That Population
Causation is the bane of the policy world. Politicians and polemicists would have us think that the right policy is certainly this or definitely that. If it were that simple, however, there would be little need for analysis. The conclusions of studies seeking causation are seldom as clear as obvious results of taking the handle off the local water pump and watching the cholera epidemic stop. Most policy problems support the characterization by the Danish mathematician and poet Piet Hein, who wrote, “Problems worthy of attack prove their worth by hitting back.” Inference is one thing, and causation is another.
If we return to our historical population of uninsured individuals as a target (it will take years to understand the full impact of the ACA), we find that they have poorer health than the average population, and data show that they are more likely to postpone care and not fill a prescription because of cost and have an avoidable hospitalization. One might counter that some lack coverage because they are in poor health and cannot find employment. Also, when one deals with a policy issue of uninsured populations, one probably needs to address issues of the underinsured as well. Problems of definition and causation are also thornier because so many studies and analyses rely on information entered into the claims data bank, which does not include information on the underinsured because they do not generate claims.
Identifying Methods Realistically Available to Change Health Status
With all the alternative solutions being offered for health policy changes, the analyst needs to identify the few that are most realistic economically and politically. By politically realistic, we mean acceptable to those who are likely to fund and use the analysis and implement its findings. Many potential actors may express a preference for specific alternatives a priori. The analyst must respect these preferences and still keep the process simple enough that decision makers are not likely to ignore the work or be confused by it.
Defining the Methods Operationally and Optimally
In an industry with a recognized high degree of waste like health care, one has to add the step of defining the alternatives operationally by answering the following questions:
1. Has the alternative been in use?
a. If so, determine how it could be improved prior to applying it in this context.
b. If not, define it in more detail to establish operational feasibility.
2. For the more promising, feasible, and relevant alternatives, determine optimal methods and procedures for delivery.
3. Use these optimal processes to determine costs and effectiveness where relevant.
7.2 HIDDEN ASSUMPTIONS
Other assumptions, often dealing with values, can impinge on an analysis. They may get addressed, or they may be left implicit or tacit to maintain organizational civility or political compromise. They include professional perspectives and personal conceptions of equity, due process, decision-making methods, and rights. This is not an exhaustive list. It does not include many value issues, such as the value of a human life.
If the group doing the analysis seems to be agreeing on most things but cannot reach closure, look for hidden assumptions that might be holding up the process. If the problem persists, it may be necessary to bring in a skilled process observer who will listen carefully to what people are saying and identify the stumbling blocks. It is unlikely that the team’s leadership can push successfully toward closure until hidden assumptions have been addressed.
Social science disciplines have built-in assumptions about how societal and personal decisions are made, and these underlie known differences between each discipline’s jargon, research methods, and notions about things such as cognitive processes, equity, and appropriate governance. These assumptions also support aggregate assumptions (sometimes called visions) of institutional roles and how effective change takes place in a society.
Each discipline appears to redefine issues in its own terms and research approaches. MacRae (1976, pp. 109–110) used his background in public policy research to characterize how social science disciplines approach decision making. He noted that disciplines talk to themselves, try to emulate th