1 ENHANCING HEALTH POLICY THROUGH EPIDEMIOLOGY R.A. Spasoff, MD University of Ottawa University of Ottawa

2 Policy A set of principles guiding decision-makingA set of principles guiding decision-making Public Policy: policy of governmentsPublic Policy: policy of governments Health Policy: health promotion, health protection, health services (plus…)Health Policy: health promotion, health protection, health services (plus…)

3 Healthy Public Policy From health promotion movementFrom health promotion movement Use of policy in all sectors to promote healthUse of policy in all sectors to promote health Policy can also contribute to disease prevention and treatment at all levelsPolicy can also contribute to disease prevention and treatment at all levels

4 Policy Instruments Legislation and regulationsLegislation and regulations Taxation and financial incentivesTaxation and financial incentives Information and coordinationInformation and coordination Provision of direct serviceProvision of direct service

5 The Basis of Policy ValuesValues IdeologyIdeology PoliticsPolitics EvidenceEvidence –Not usually the main influence on policy, but worth fighting for –The main contribution of epidemiology

6 Premise of this presentation Decisions must be made, regardless of the quality of the supporting evidenceDecisions must be made, regardless of the quality of the supporting evidence Some evidence is better than no evidenceSome evidence is better than no evidence Epidemiology can provide much of the important evidenceEpidemiology can provide much of the important evidence

7 Policy Analysis The process of predicting the impacts of possible policies and evaluating past policiesThe process of predicting the impacts of possible policies and evaluating past policies Epidemiology can make a major contribution to both stepsEpidemiology can make a major contribution to both steps

8 Tugwell’s Iterative Loop 1. Burden of illness1. Burden of illness 2. Aetiology or causation2. Aetiology or causation 3. Community effectiveness3. Community effectiveness 4. Efficiency4. Efficiency 5. Synthesis & Implementation5. Synthesis & Implementation 6. Monitoring of Program6. Monitoring of Program 7. Reassessment7. Reassessment

9 Policy Cycle 1. Assessment of population health1. Assessment of population health 2. Assessment of potential interventions2. Assessment of potential interventions 3. Policy choices3. Policy choices 4. Policy implementation4. Policy implementation 5. Policy evaluation5. Policy evaluation

10 1. Assessment of population health Demography, population dynamicsDemography, population dynamics Descriptive epidemiology:Descriptive epidemiology: –Measure the health of the population –Identify trends and patterns –Assess health risks –Assess health needs –Identify priority targets for policy development Analytical epidemiologyAnalytical epidemiology –Individual-level and population-level causes

11 2. Assessment of potential interventions Identify potential policy interventionsIdentify potential policy interventions Synthesize existing knowledge regarding their effectivenessSynthesize existing knowledge regarding their effectiveness Contribute relevant new researchContribute relevant new research Assess the potential of each approachAssess the potential of each approach

12 3. Policy choices Project impact of potential interventions on the health of the populationProject impact of potential interventions on the health of the population –Computer simulations of different interventions Assist the process of consensus developmentAssist the process of consensus development

13 4. Policy implementation Help to set targets for the chosen policiesHelp to set targets for the chosen policies Inform needs-based resource allocation for health servicesInform needs-based resource allocation for health services Guide development of information systemsGuide development of information systems

14 5. Policy evaluation Assess the impacts of policiesAssess the impacts of policies Monitor future healthMonitor future health

15 Epidemiology & Health Policy: three examples Healthy People 2010 (and Health 21)Healthy People 2010 (and Health 21) –goal-setting, targets Global Burden of DiseaseGlobal Burden of Disease –ethical basis, DALYs Public Health Status and Forecasts in the NetherlandsPublic Health Status and Forecasts in the NetherlandsPublic Health Status and Forecasts in the NetherlandsPublic Health Status and Forecasts in the Netherlands –integrated process

16 Why epidemiology has had a limited influence Our faultOur fault –Emphasis on aetiologic research –Grime avoidance –Focus on individual-level risk actors Not our faultNot our fault –Different backgrounds from policy- makers –Different values –Different time scales –Lack of credibility (often not “real MDs”)

17 Towards a larger role: relevant expertise Policy and its formation Descriptive epidemiology Population health data Social determinants of health Health and disease modelling Geographical information systems Multilevel modelling Population dynamics

18 Towards a larger role: a developing discipline Teaching (see course description)Teaching (see course description) Professional societiesProfessional societies Broadened role for journalsBroadened role for journals Policy-relevant researchPolicy-relevant research – Inequalities in health –Measuring health needs –Multilevel analyses of health –Health and disease modelling Communication skills, research transferCommunication skills, research transfer Working with policy-makersWorking with policy-makers

19 Epidemiology for Health Policy: Objectives To provide students with:To provide students with: 1. knowledge of how health policy is developed and used;1. knowledge of how health policy is developed and used; 2. knowledge of epidemiologic methods relevant to the development of health policy; and2. knowledge of epidemiologic methods relevant to the development of health policy; and 3. the skills to use that knowledge, in collaboration with policy-makers3. the skills to use that knowledge, in collaboration with policy-makers

20 Epidemiology for Health Policy: Topics (1) Policy and Health PolicyPolicy and Health Policy Policy FormulationPolicy Formulation Ethics, Politics & CommunicationEthics, Politics & Communication Measuring Population HealthMeasuring Population Health Health Burden and Health NeedsHealth Burden and Health Needs Assessing CausationAssessing Causation Assessing InterventionsAssessing Interventions

21 Epidemiology for Health Policy: Topics (2) Disease ControlDisease Control Disease ModellingDisease Modelling Priority-settingPriority-setting Impact Assessment & Goal- settingImpact Assessment & Goal- setting Resource AllocationResource Allocation Policy EvaluationPolicy Evaluation

22 Policy-relevant thesis topics Small-area estimation of healthSmall-area estimation of health Adapting “Prevent” to OntarioAdapting “Prevent” to Ontario Small-area variations in health careSmall-area variations in health care Evaluating a restricted driver licensing policyEvaluating a restricted driver licensing policy Modelling mammographic screening beyond age 69Modelling mammographic screening beyond age 69 Economic burden of breast-feedingEconomic burden of breast-feeding Income inequality and health (two theses, one using multilevel analysis) Income inequality and health (two theses, one using multilevel analysis)

23 Relevant resources: Books Spasoff, Epidemiologic Methods for Health Policy, 1999Spasoff, Epidemiologic Methods for Health Policy, 1999 Brownson/Petitti, Applied Epidemiology, 1998Brownson/Petitti, Applied Epidemiology, 1998 Young, Population Health, 1998.Young, Population Health, Petitti, Meta-Analysis, Decision Analysis, and Cost-effectiveness Analysis (2 nd ed), 2001Petitti, Meta-Analysis, Decision Analysis, and Cost-effectiveness Analysis (2 nd ed), 2001 Gray, Evidence-based Healthcare, 1997Gray, Evidence-based Healthcare, 1997

24 Relevant resources: Journals International Journal of EpidemiologyInternational Journal of EpidemiologyInternational Journal of EpidemiologyInternational Journal of Epidemiology Journal of Epidemiology and Community HealthJournal of Epidemiology and Community HealthJournal of Epidemiology and Community HealthJournal of Epidemiology and Community Health British Medical JournalBritish Medical JournalBritish Medical JournalBritish Medical Journal Journal of Public Health PolicyJournal of Public Health PolicyJournal of Public Health PolicyJournal of Public Health Policy Public Health ReportsPublic Health ReportsPublic Health ReportsPublic Health Reports American Journal of Public HealthAmerican Journal of Public HealthAmerican Journal of Public HealthAmerican Journal of Public Health