Leading the Health System through Policy Development New Roles for Public Health

The Ten Essential Public Health Services Monitor health status Diagnose and investigate health problems Inform and educate Mobilize communities to address health problems Develop policies and plans Enforce laws and regulations Link people to needed health services Assure a competent health services workforce Evaluate health services Conduct research for new innovations The ten essential services are shown here on the screen and include: Monitor health status to identify and solve community health problems. Diagnose and investigate health problems and health hazards in the community. Inform, educate, and empower people about health issues. Mobilize community partnerships to identify and solve health problems. Develop policies and plans that support individual and community health efforts. Enforce laws and regulations that protect health and ensure safety. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public and personal health care workforce. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Research for new insights and innovative solutions to health problems These are the foundation of any public health activity. For example, any public health program needs data to operate. Essential Service #1 includes activities such as data collection, community health assessments and the maintenance of population health registries. As another example, Essential Service #7 includes personal health care services, transportation and other enabling services such as assuring the availability of culturally appropriate personnel and materials. Since the Ten Essential Services were released, numerous initiatives have explored the utility and feasibility of these services and have found them to be a good descriptor of public health practice.

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 Inform, Educate and Empower People About Health Issues This service involves: Making health information and educational resources accessible; Providing health information and education activities that shape attitudes and build knowledge necessary to reduce health risk and promote better health; Establishing health communication plans and activities that use media advocacy and social marketing approaches to shape attitudes and build knowledge; Enabling informed decision-making among individuals in making health choices and among leaders establishing health policies for the community. Maintaining health education and promotion program partnerships with schools, faith communities, work sites, personal care providers, and others to implement and reinforce health promotion programs that shape attitudes, knowledge, skills, and behaviors needed in a healthy community populations. These activities assist to empower people to make informed decisions regarding individual and community health matters.

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 Mobilize Communities to Identify and Solve Community Health Problems Community health improvement is a collaborative effort requiring: Skilled conveners and organizers, Social responsiveness (above self-interest) from community members, and System structures that link community assets and the public’s will to act. One person or organization can start community change but neither can make change alone. It is critical for public health system leaders to effectively convene and organize for community actions that can improve health. Actions within the public health system that demonstrate this service are: Convening and facilitating multiple community groups to undertake health improvement work. Convener should seek to include those that are not typically considered to be involved in health-related matters. Mobilized groups can undertake defined preventive, screening, and rehabilitation initiatives, or support other programs activities that influence health. The building of coalition is one form or system to facilitate collaboration. Other forms exist. The key however is that structures must be maintained to support the mobilization of the community in order to draw upon the full range of community assets including people, organizations, and the physical environment that can support the improvement of health. Many broadly focused processes of community action exist across the U.S. under names like Healthy Communities, Livable Communities, and Loveable Communities. An even greater number of issue specific processes exist and are addressed under names such as Healthy Mothers and Babies, Mother’s Against Drunk Driving, and many, many other collaborative groups taking action to address environmental, economic, historical, and other efforts that can improve community health and quality of life.

Develop Policies and Plans That Support Community Health Efforts 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 Develop Policies and Plans That Support Community Health Efforts Policies addressing specific health-related issues are public statements establishing directions individuals, organizations, or governments follow to protect and promote health. Policies are established by organizations and governments to identify consistent behaviors that are expected. Community and organization leaders have responsibility to articulate policies built on proven scientific finding and shaped by community values. Policies having negative or positive influences on health touch every aspect of community life. Safety standards that makers of automobiles and producers of electrical materials follow demonstrate policies that protect people from injury. Food handling guidelines protect people from illness. Other policy examples designed to encourage or support healthy behaviors can be identified in zoning rules. For example, zoning that requires sidewalks in new residential developments. This type of policy has influence on health by supporting the opportunity for physical activity as well as improving pedestrian safety. In addition, organizational leaders can influence health with policies that govern use of tobacco at company facilities, the availability of health insurance for employees, or facilities and time that allow for and promote physical activity. These are all examples of health-related policies that are important for community leaders to understand and apply. How well is health-related policy used to improve health in our community? Health plans provide strategic and operational guidance on how to improved health. Plans establish a set of objectives and related actions to make measurable health improve. Community health plans are more likely to be accepted and applied if the plans are made with the active participation of those the plans affect. Establishing a community health improvement plan builds on other essential services that result in development of good community health data, use of relevant public health science in decision-making, effective community education, establishment of supportive health-related policies, and mobilization efforts necessary to bring about health improvements. Community health improvement is not limited to issues classified within traditional public health or health services categories, but may include environmental, business, economic, housing, land use, and other community issues indirectly affecting the public’s health. This service represents decision-making and action to plan and measure general community health improvement. In addition, this essential service addresses more specific health plans like those that focus on preparation and response to disasters and all the human health and environmental implications resulting from disasters.

This bar chart will also be included in the automated report to respondents. With just a quick glance, the responding system can see that Essential Services 2 and 6 have the highest performance and the most improvement may be needed in Essential Services 5, 7, and 9.

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 Deaths per 100,000 Tuberculosis Whooping Cough Measles Deaths per 100,000 Here are some big picture examples of what happened to the public’s health in the past 150 years. More charts and graphs at: http://www.healthsentinel.com/Vaccines/DiseaseAndRelatedData.htm

Focusing on disease prevention has led to major achievements Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 700 Rate if trend continued 600 500 Peak Rate 400 Age-adjusted Death Rate per 100,000 Population 300 200 Actual Rate CHD accounted for 460,000 deaths in 1998. It would have accounted for 1,144,000 if the rate had remained at its 1963 peak. 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) 14% increase 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 Heart disease Cerebrovascular disease Cancer – lung, trachea Lower respiratory infections Chronic Obstructive Pulmonary Disease Cancer – colon, rectum Cancer – stomach Traffic accidents Self-inflicted injuries Diabetes Lower respiratory infections Heart disease Cerebrovascular disease Diarrheal diseases Perinatal conditions Tuberculosis Chronic Obstructive Pulmonary Disease Measles Malaria Traffic accidents This contrasting list of developed versus developing nations points to how the challenges to American public has changed since the turn of the century. Lifestyle is now one of the largest threats to public health. Monitoring health status of the community is an essential PH service, which will be examined in detail in module 2. Chronic Obstructive Pulmonary Disease=COPD

Some important “drivers” of population health Changes in the environment Disparities in health status and access to care Infectious disease threats Including MAN-MADE ONES!! Globalization A social and political environment that prioritizes health Advances in biotechnology and information technology

Political Theory 101 Potential Solutions Perceived Problems Political Dynamics Window of Opportunity Policy Change Kingdon J.W. Agendas, Alternatives, and Public Policies (1984, 2003)

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 MCOs Home Health Parks Economic Development Mass Transit Employers Nursing Homes Mental Health Drug Treatment Civic Groups CHCs Lab Facilities Hospitals EMS Community Centers Doctors Health Department Faith orgs Philanthropist Elected Officials Tribal Health Schools Police Fire Jails Environmental Health A Public Health System is Complex This illustration has been referred to as “the eggs” or “the web” – it is a cluttered representation of the complexity of a public health system and examples of organizations and groups that make up the system network. As you can see, there are many partners and groups represented who contribute to health and delivery of the EPHS. These include: Healthcare providers like hospitals, physicians, community health centers, mental health, labs, nursing homes and others who provide preventive, curative, and rehabilitative care. Public safety such as police, fire and EMS. Their work is focused on preventing and coping with injury and other emergency health situations. Human Service and Charity Organizations such as food banks, public assistance agencies, transportation providers, and others that assist people to access healthcare and receive other health-enhancing services. Education and Youth Development Organizations like schools, faith institutions, youth centers, and others groups that assist with informing, educating, and preparing children to make informed decisions and act responsively regarding health and other life choices and to be productive contributors in the community. Recreation and Arts-related Organizations who contribute to the physical and mental well-being of the community and those that live, work and play in it. Economic and Philanthropic Organizations such as employers, community development and zoning boards, United Way, community and business foundations that provide resources necessary for individuals and organizations to survive and thrive in the community.

Health System Dynamics that Influence the Public’s Health Society's Health Response Dying from Complications Tertiary prevention General protection Adverse Living Conditions Targeted protection Primary prevention Secondary prevention Demand for response Demand for response Demand for response Safer, Healthier Population Becoming Vulnerable Becoming no longer vulnerable Population with Disease Developing Complications Population with Complications Vulnerable Population Becoming Affected Public Health Medical Care Other Sectors Source: Adapted from Bobby Milstein, CDC Syndemics Prevention Network

Spectrum of Action within the Health System SECONDARY & TERTIARY Physiological Change Treatment Services Focus on Disease PRIMARY & SECONDARY Behavioral Change Focus on Risk Disease Prevention INTERGENERATIONAL Social Change Focus on Conditions Health Promotion Focus on Capacity for Action Capacity Building or Empowerment Policy & Infrastructure Change Policy Development 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 Effective public health policy development therefore requires working across boundaries with stakeholders we cannot compel or control.

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.” Source: Institute of Medicine. 2003. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy Press. —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