1. Dr. Lisaann Gittner
Sept 2012

2. HEALTH AND POLICY
Where does the
money go?
US Health
Spending 2007

3. • Health is measured in life times with disease manifesting after many
years (decades)
• Policy is measured in election cycles with results necessary in 2-5
years
• Health outcomes are measured in terms of the absence of disease
states or the non manifestation of progressive deteriorating symptoms
• Policy outcomes are measured in active results that can be quantified
• HOW DO YOU QUANTIFY THE ABSENCE OR NON
MANEFESTATION OF A DISEASE????
INTERSECTION OF HEALTH AND
POLICY

4. POLICY CRASHES INTO HEALTH
Policy can effect Healthcare in a policy cycle but
can it effect Health?
 Policy for healthcare are quantifiable in a policy cycle
 Policy for healthcare does achieve measurable results
 Policy for health may not be quantifiable in a policy cycle or
may not even be quantifiable
 Policy for health especially prevention is difficult, how do you
measure “who didn‟t get sick??”

5. HEALTHY PEOPLE 2020
“The values of a nation are reflected in its willingness to secure
better health, well being, and vitality for all. “ (Secretary‟s
Advisory Committee on National Health Promotion and
Disease Prevention Objectives for 2020 7-26-2010)
Healthy People 2000, 2010 and now 2020 set the US public
health policies and goals for the decade.
All US health funding is supposed to be designed to meet the
Healthy People goals

6. Example from Health People 2010
According to the Healthy People 2010 Midcourse Review,
pediatric obesity increased and moved away from the target
by 5% (Healthy People 2010 Midcourse Review, 2007).
Rather than a reduction in obesity that was predicted, obesity
increased over and above the baseline threshold during the
measurement period (2000-2005).
WHY?
DOES HEALTHY PEOPLE WORK?

8. HEALTH
World Health Organization Definition
“Health is not only the absence of
infirmity and disease but also a
state of physical, mental and social
well-being.”

9. HEALTHCARE
The prevention, treatment, and
management of illness and the
preservation of mental and physical
well-being through the services
offered by the medical and allied
health professions

10. PUBLIC HEALTH: WHAT CAN HEALTH POLICY DO?
IS MEASURING HEALTH
DIFFERENT IF YOU LOOK AT IT
FROM AN INDIVIDUAL VS. A

11. HEALTH VS HEALTHCARE
Health is an individual state of
being
Healthcare is a provision of
service

12. When you design and evaluate
health policies?
What are the domains, factors,
variables?
What specifically can you measure?
HOW CAN YOU MEASURE
HEALTH VS. HEALTH POLICY?

13. WE MEASURE
SOCIAL DETERMINANTS OF
HEALTH

14. SOCIAL ECOLOGICAL THEORY
Urie OF HEALTH
Bronfenbrenner

15.  Each person is significantly affected by interactions among a number
of overlapping ecosystems. At the center of the model is the
individual.
 Microsystems are the systems that intimately and immediately shape
human development. The primary microsystems for children include
the family, peer group, classroom, neighbourhood, and sometimes a
church, temple, or mosque as well. Interactions among the
microsystems, as when parents and teachers coordinate their efforts
to educate the child, take place through the mesosystem.
 Surrounding the microsystems is the exosystem, which includes all
the external networks, such as community structures and local
educational, medical, employment, and communications systems,
that influence the microsystems.
 Influencing all other systems is the macrosystem, including cultural
values, political philosophies, economic patterns, and social
conditions.
SOCIAL ECOLOGICAL MODEL

16. Resource Restriction, Environmental Factors
Energy
Maintenance
Relative „Cost‟ of Growth
Growth and Development
Fetal
Development & Change in Mortality Death
Birth Development of
Disease
LIFESPAN
Theory of Developmental Origins of Adult Diseases (Barker 2001)
LIFECOURSE THEORY OF
David Barker HEALTH

17. • Proposed by David Baker in the late 1980s states that characteristics and
health of the infant and influences from the environment during infancy,
toddlerhood, and early childhood are associated with the development of
adult acute and chronic disease, disability and death (Barker, 1995b).
• Barker‟s theory has also come to be known as the Life-course Model of
Health (Forrest & Riley, 2004; Halfon & Hochstein, 2002; Hertzman, 1999).
• Thus, infancy and toddlerhood are critical periods for health status across
the life-span (Barker, 2001). The theory of Developmental Origins of Adult
Disease was developed using a geospatial model that pinpointed later life
heart disease in relationship to geographic areas that had high neonatal
mortality and low birth weight infants (Barker, 2003; Barker, Forsen,
Eriksson, & Osmond, 2002; Phillips et al., 2001; Robinson & Barker, 2002)
LIFE-COURSE MODEL OF
HEALTH

18. LIFECOURSE MODEL OF
INDIVIDUAL AND COMMUNITY
Glass and McAtee
2006 HEALTH

19. • Health is measured in life times with disease manifesting after
many years (decades)
• Policy is measured in election cycles with results necessary in 2-
5 years
• Health outcomes are measured in terms of the absence of
disease states or the non manifestation of progressive
deteriorating symptoms
• Policy outcomes are measured in active results that can be
quantified
• HOW DO YOU QUANTIFY THE ABSENCE
OR NON MANEFESTATION OF A
DISEASE????
INTERSECTION OF HEALTH AND
POLICY

20. • Public Health Service originated with an Act of Congress “Act For
The Relief Of Sick And Disabled Seamen” that was signed into law
by President John Adams on July, 16, 1798
• Creating a system to provide care to merchant seamen, Marine
Hospital Fund to be administered by the Treasury
Department. Twenty cents a month was deducted from the pay of
each seaman to fund a system of hospitals in major port cities to
treat sick and injured seamen.
WHAT WAS THE FIRST US
HEALTH POLICY?

21. • Responsibility for quarantine for infectious diseases originally rested
with the states
• In1877 yellow fever epidemic that spread from New Orleans up the
Mississippi River resulted in the passage of the National Quarantine
Act of 1878, which began a process of transferring responsibility for
quarantine from the states to the Federal Government utilizing the
Marine Hospitals.
• US Federal Health Policy for ~ 100 years was
only for the military.
HEALTH POLICIES WERE THE
JURISDICTION OF THE STATES

22. • Under the immigration act of 1891, the Marine Hospital Service was
assigned the responsibility for the medical inspection of arriving
immigrants.
• Immigration legislation prohibited the admission of individuals
suffering from “loathsome or dangerous contagious diseases,” those
who were insane or had serious mental deficiencies, and anyone
likely to become a public charge (because of a medical disability).
EXPANDED TO VETTING
IMMIGRANTS

23.  The name was changed in 1902 to the Public Health and
Marine Hospital Service and also defined increased
cooperation between Federal and state health authorities,
including directing the Surgeon General to prepare and
distribute to state health officers forms for the uniform
compilation of vital statistics.
 Another law passed in 1902, the Biologics Control Act,
extended the Service‟s reach in yet another direction, giving
it regulatory authority over the production and sale of
vaccines, serums, and other biological products.
 Another name change in 1912; “Marine Hospital” was
dropped from its title, and the organization became simply
the Public Health Service (PHS).
CHANGES AT THE TURN OF
THE 19TH CENTURY

24. • World War I changed the scope of the PHS; it was responsible to work
with local health departments to keep the areas around military training
camps in the United States free from disease.
• The threat of venereal disease (VD) to servicemen and essential war
workers was of particular concern to the military, and a Division of
Venereal Disease was created in the PHS in 1918 to help control the
spread of VD.
• The influenza pandemic that emerged in 1918 led to increased funding
and staff for the PHS to fight the flu.
US HEALTH POLICIES

25. • In the period between the two world wars, the PHS assumed
responsibility for the care of lepers when it converted the state
leprosy facility in Carville, Louisiana into a national leprosy
hospital; responsibility for the health of American Indians and
Alaska Natives (1928); health of Prisoners (1930).
• Veteran Health was split off and the VA established (1921).
• As a result of a government reorganization
in 1939, the PHS was taken out of the
Treasury Department and given a new
administrative home in the Federal Security
Agency.
US HEALTH POLICIES

26. • The PHS expanded significantly during WWII, doubling its
personnel between 1940 and 1945.
• The war also increased the involvement of the PHS in
international affairs, leading to the creation of an Office of
International Health Relations.
• A 1943 law reorganized the Service, consolidating its
programs into four subdivisions:
1. the Office of the Surgeon General,
2. the National Institute (later Institutes) of Health,
3. the Bureau of Medical Services
4. the Bureau of State Services.
Finally US Health Policies were consolidated/ Coordinated
by an agency that was solely responsible for the health
of the Nation.
US HEALTH POLICY

27. Another expansion of PHS grew out of a wartime program to control
malaria in areas around military bases.
The PHS-administered Malaria Control in War Areas program, based in
Atlanta, expanded its responsibilities over the course of the war to
include the control of other communicable diseases such as typhoid
fever, dengue, and typhus.
By the end of the war, the program had demonstrated its value in the
control of infectious disease so successfully that it was converted in
1946 to the Communicable Disease Center (CDC).
The mission of the CDC expanded over the succeeding decades to
include areas such as nutrition, chronic disease and occupational and
environmental health.
US HEALTH POLICIES

28. US HEALTH POLICY
• The other 1946 law that had an influence on the activities of the
PHS was the Hospital Survey and Construction Act, more
commonly referred to as the Hill-Burton Act. It authorized the PHS
to make grants to the states for surveying their hospitals and public
health centers, for planning construction of additional facilities, and
to assist with construction costs.
• The establishment of a National Institute for Mental Health, as a
part of the PHS happened in 1949.

29. FINALLY, in 1953, the Federal Security
Agency was elevated to cabinet status
as the Department of Health, Education,
and Welfare (DHEW), but this change in
status had little direct impact on the PHS
at the time.
US HEALTH POLICY

30. • The PHS continued to expand in the 1960s. Two agencies that
were also housed in DHEW were incorporated into the PHS in this
decade.
• St. Elizabeths Hospital, which had begun in 1855 as the
Government Hospital for the Insane, in 1967.
• The Food and Drug Administration, whose predecessor
organization dates back to 1906, was made a part of the PHS in
1968, thus involving the Service much more heavily in the area
of regulation.
US HEALTH POLICY

31. As You Can See US Health Policy bas been
addressed since the beginning of the Nation but it
is difficult to characterize the FOCUS of the Policy
Stream
“IN AN IDEAL WORLD,
H E A LT H P O L I C Y W O U L D
B E F O R M U L AT E D I N A
R AT I O N A L , L I N E A R
PROCESS, MOVING FROM
D ATA C O L L E C T I O N , T O
I N T E R P R E TAT I O N , T O
SCIENTIFIC CONSENSUS.”
(SOMMERS 2001)

32. “By definition, health policy is made in the public
arena. The process is, therefore, subject to a
complex array of considerations and influences,
only some of which, sometimes none of which,
have anything to do with data or with the
public’s health.” (Sommer 2001)
FORMULATION OF US HEALTH
POLICY

33. Who are the stakeholders?
Which stakeholders are named?
Who are the un-named stakeholders?
What is the power structure of the stakeholders?
Which if any stakeholders have veto power?
What are the stakeholder‟s agenda? (Is there a
hidden agenda?)
How vested is each stakeholder in the program?
US HEALTH POLICY

34. • Policies are made up of numerous programs
• Programs form the bulk of the activities when policies are
implemented
• The failure of one program does not mean the policy is a failure
• It gets even more complicated in health because many policy
streams develop health programs so you need to be aware that
there could be programs from other policies that could interfere
with the program you are working with
• Health care policy determines the institutional framework but not
the direct provision of health care
• As you move up the public health pyramid you shift from policies
to programs to individual interactions
POLICY VS. PROGRAM

35. Health Policy Direction
“WHAT DO WE NEED TO DO IN THE
FUTURE TO ENSURE THE HEALTH OF
OUR SOCIETY.”

36. Health Program Direction
“WHAT DO I NEED TO DO RIGHT NOW
FOR THIS SPECIFIC PATIENT TODAY TO
MAINTAIN HEALTH.”

38. POLICY STREAMS
• How is knowing the history of a policy stream
helpful?
• What can it tell you?
 Who controls the agenda
 What type of evaluation/ analysis is necessary for change or
termination
 How you should frame the debate and your recommendations

39. FEDERAL AGENCIES THAT CONTROL POLICY
STREAMS
Department of State Department of Commerce http://www.energy.gov
http://www.state.gov http://www.commerce.go
v Department of Education
Department of the http://www.ed.gov
Treasury Department of Labor
http://www.treasury.gov http://www.dol.gov Department of Veterans
Affairs
Department of Defense Department of Health and http://www.va.gov
http://www.defenselink. Human Services
mil http://www.hhs.gov Department of Homeland
Security
Department of Justice Department of Housing http://www.dhs.gov
http://www.usdoj.gov and Urban Development
http://www.hud.gov Environmental Protection
Department of the Interior Agency
http://www.doi.gov Department of http://www.epa.gov
Transportation
http://www.dot.gov

40. LOOK AT EACH DEPARTMENT’S STREAMS
•Look at the websites for the different agencies and write a brief
list of what they oversee
•Especially note, any policies that might affect HEALTH
•You will find this very interesting and it will give you clues about
why some policies seem illogical
•Then try to classify what type of policy model (Bureaucratic,
Political, Social Movement, Collaborative) each agency operates
under
•Sometimes policy streams mature and change as their agency
matures
•You have ½ hour and your group will be presenting your findings