T
his section consists of three chapters that describe how health policy is made in the United States
and elsewhere in the world. Chapter 2 describes policymaking at the US federal level, and chapter
3 illustrates the process at the US state and local levels and in the private sector. Chapter 4 covers
health policymaking by international agencies such as the World Health Organization and provides
examples of the process in selected countries. The spectrum of health policymaking presented in these
chapters is intended to provide students with a broad perspective of health policy development. Such
knowledge is critical in preparing students to examine the specific health issues commonly addressed
by health policy in the United States and in other countries.
PA R T I I
H E A LT H P O L I C Y M A K I N G
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Account: s4264928.main.eds
L e a r n i n g O b j e c t i v e s
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3
L e a r n i n g O b j e c t i v e s
C H A P T E R 1
O V E R V I E W O F H E A LT H P O L I C Y
After completing this chapter, you should be able to
➤ define key terms related to health policy,
➤ appreciate the influence of health determinants,
➤ understand the framework of health policy formulation,
➤ identify the stakeholders in health policy,
➤ describe the major types of health policies, and
➤ discuss the importance of studying health policy.
I have never had a policy. I have simply tried to do what seemed best each day, as
each day came.
—Abraham Lincoln
The health and vitality of our people are at least as well worth conserving as their
forests, waters, lands, and minerals, and in this great work the national government
must bear a most important part.
—Theodore Roosevelt
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I n t r o d u c t i o n t o H e a l t h P o l i c y4
he a lt h C a r e re f O r m: hi l l a ry Cl i n t O n a n d Ba r a C k OB a m a
Two major healthcare reform initiatives have played out on the US political landscape since
the late twentieth century: the Health Security Act, developed by the Clinton administration
in the 1990s and spearheaded by First Lady Hillary Clinton, which failed to pass into law, and
the Affordable Care Act (ACA), drafted by the Obama administration, which became federal law
in March 2010.
The hallmark of the Clinton plan was its universal coverage mandate, which required all
employers to contribute to a pool of funds to cover the costs of insurance premiums for their
workers, with caps on total employer costs and subsidies for small businesses. Competition
among private health plans and a cap on the growth of insurance premiums were to have held
costs in check, and additional financing was to have been provided through savings from cuts
in projected Medicare and Medicaid spending and increased taxes on tobacco (Oberlander
2007; Pesko and Robarts 2017).
The Obama plan focused on reforming the private health insurance market, extending
insurance coverage to the uninsured, providing better coverage for those with preexisting con-
ditions, improving prescription drug coverage in Medicare, and extending the life of Medicare
trust fund accounts. The ACA was expected to be financed through taxes, such as a 40 percent
tax on “Cadillac” insurance policies (policies that offer the richest benefits) and taxes on
pharmaceuticals, medical devices, and indoor tanning services (KFF 2013), and through other
offsets or provisions of the law that reduce the overall cost of enacting legislation, such as
penalties on uninsured individuals.
The political landscape in 2009, as President Barack Obama’s healthcare reform initia-
tive was being debated, was similar to that in the early 1990s: Both the Clinton and Obama
administrations were affiliated with the Democratic Party, both chambers of the US Congress
were controlled by Democrats, and national opinion strongly favored healthcare reform (Sack
and Connelly 2009).
However, whereas the Obama reform initiative became law, the earlier Clinton healthcare
reform package was defeated in Congress. Although Americans supported healthcare reform
in theory, the Clinton plan was derailed by the heavy opposition of the medical and insurance
industries and by antitax rhetoric. The disenchantment of the electorate following that failed
effort helped Republicans gain control of the House of Representatives and Senate in the
1994 election (Trafford 2010), which all but guaranteed that any further Democratic-designed
proposal would fail due to increasing political polarization in Congress.
After Republican president Donald Trump took office in January 2017, the Trump admin-
istration and the Republican-controlled Congress put forth many efforts to “repeal and replace”
the ACA. However, as of mid-2018, none of these attempts had succeeded.
C a s e s t u d y 1
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C h a p t e r 1 : O v e r v i e w o f H e a l t h P o l i c y 5
he a lt h C a r e re f O r m af t e r t h e aCa
Healthcare reform continues to be a deeply partisan issue in US politics, and political gridlock
in Congress has made efforts at reform challenging. Since 2010, Republicans in Congress have
unsuccessfully attempted to repeal the ACA, voting more than 60 times to repeal or alter the
law (Cowen and Cornwall 2017). In January 2016, the Republican-controlled House and Senate
passed a bill that would have repealed the ACA, but President Obama, a Democrat, promptly
vetoed it. The Congressional Budget Office (CBO) review of the proposal concluded that the bill
would have canceled health insurance for 22 million people by 2018 (Cubanski and Neuman
2018). In the 2016 presidential election campaign, every Republican candidate vowed to “repeal
and replace” the ACA (Jost 2015). In January 2017, within hours of taking office, President Trump
issued his first executive order, moving to dismantle parts of the ACA (Davis and Pear 2017).
On March 7, 2017, Republicans introduced the two bills that constitute the original
American Health Care Act (AHCA) of 2017, H.R. 1628, to partially repeal the ACA. The Trump
administration announced its support for AHCA. On March 12, 2017, the CBO released its budget
analysis, projecting that 52 million Americans would be left uninsured under the AHCA and those
with insurance would have to pay higher premiums through 2020. On May 4, 2017, the House
narrowly passed the AHCA, by a vote of 217–213, and sent the bill to the Senate for delibera-
tion. On June 22, 2017, the Senate released a discussion draft for an amendment to the bill,
which would rename it the Better Care Reconciliation Act of 2017. On July 28, 2017, the bill was
returned to the calendar after the Senate rejected several amendments, including the Health
Care Freedom Act, or the “skinny bill,” that would have repealed the ACA’s individual mandate
retroactive to 2016 and the employer mandate through 2025.
Does this legislation point to a new phase of healthcare reform whose success hinges
on support from both major political parties? As Wilensky (2017) suggested, Republicans and
Democrats might need to find a way to work together to enact comprehensive healthcare
reform beyond the ACA.
Or, does it signal a new approach toward dismantling the ACA through the administrative
process, such as policy implementation? In reaction to Congress’s repeated failure to repeal
the ACA, on October 12, 2017, President Trump issued Executive Order 13813, directing federal
agencies to expand the use of association health groups—groups of small businesses that pool
together to buy health insurance (Trump 2017).
The Tax Cuts and Jobs Act of 2017, passed and signed into law in December 2017, effec-
tively repealed the mandate in the ACA that required all Americans to have health insurance.
Although the ACA was still the law of the land during the first year of the Trump administration,
many of its components were being modified in Trump’s second year.
C a s e s t u d y 2
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I n t r o d u c t i o n t o H e a l t h P o l i c y6
A
t 16.9 percent of the nation’s total economic activity—also known as the gross
domestic product—healthcare spending in the United States leads all countries
in overall and per capita measures (OECD 2018). Yet the US healthcare system
does not perform well compared with those of other industrialized countries. A 2010 World
Health Organization (WHO) report ranked the US health system thirty-seventh among 191
countries (Tandon et al. 2018). In addition, a Commonwealth Fund study on healthcare
performance ranked the United States behind ten other industrialized countries—Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland,
and the United Kingdom—on the basis of quality, efficiency, access, equity, and health
outcome measures (Davis, Schoen, and Stremikis 2014). The US healthcare system also
ranked last in a recent survey of eleven nations (Commonwealth Fund 2017).
Why have health policies tended to fail in the United States while they appear to suc-
ceed in other countries? The answer might be found in the context—the United States—and
the determinants of health and health policy in the country.
The main purpose of this chapter is to present a framework of health policy determi-
nants and discuss their impact in the United States. Understanding this framework will help
the reader appreciate factors that contribute to health policy development in general and in
the United States in particular. The chapter first defines key concepts related to health policy
and later discusses the importance of studying health policy, including an awareness of its
international perspective. The stakeholders of health policy are also presented and analyzed
as key parts of the policy context.
he a lt h de f i n e d
WHO (1946) defines health as “not merely the absence of disease or infirmity but a state
of complete physical, mental and social well-being.” This broad definition recognizes that
health encompasses biological and social elements in addition to individual and community
well-being. Health may be seen as an indicator of personal and collective advancement. It
can signal the level of an individual’s well-being as well as the degree of success achieved
by a society and its government in promoting that well-being (Shi and Stevens 2010). This
definition of health implies that issues such as poverty, lack of education, discrimination,
and other social, cultural, and political conditions found around the world are essentially
public health issues.
However, health is also the result of personal characteristics and choices. This con-
cept is the source of the fundamental tension in public health and has been a major topic
of discussion in the United States in the twenty-first century. Major debates continue over
whether people can be forced to take actions to ensure their own health, such as buying
health insurance (e.g., the “individual mandate” in the ACA), or be prohibited from perform-
ing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the
United States must attempt to balance the good of the public health with personal liberty,
gross domestic product
The value of all goods
and services produced
within a country for
a given period; a
key indicator of the
country’s economic
activity and financial
well-being.
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C h a p t e r 1 : O v e r v i e w o f H e a l t h P o l i c y 7
often a difficult compromise to make. Indeed, the conflict between the WHO definition of
health and many of the social, cultural, and political issues surrounding the US healthcare
system is one of the most important areas of debate for health policymakers.
Ph y s i C a l he a lt h
The most common measure of physical health is life expectancy—the anticipated number
of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest
in their population’s life expectancy as of 2015 and includes the US ranking for comparison.
Although good or positive health status is commonly associated with the definition
of health, the most frequently used indicators measure, instead, lack of health or incidence
of poor health—for example, mortality, morbidity, disability, and various indexes that
combine these factors. One such measure is quality-adjusted life years, which combines
mortality and morbidity in a single index. The Learning Point box titled “Measures of
Mortality, Morbidity, and Disability” lists categories by which each indicator is measured.
life expectancy
Anticipated number of
years of life remaining at
a given age.
mortality
Number of deaths in a
given population within
a specified period.
morbidity
Incidence or prevalence
of diseases in a given
population within a
specified period.
disability
A physical or mental
condition that limits
an individual’s ability
to perform functions
considered normal.
quality-adjusted life
years
A combined mortality–
morbidity index that
reflects years of life
free of disability and
symptoms of illness.
KEY LEGISLATION
What Is the Status of Healthcare Reform in the United States?
In the United States, healthcare reform typically denotes a government-sponsored program
that strives to make health insurance available to the uninsured. Heretofore, healthcare reform
has not quite addressed how healthcare should be delivered, such as in resource allocations
across preventive, primary, and tertiary care settings. Although universal health insurance is
a difficult goal to realize, incremental reforms have been successful when political and eco-
nomic environments were favorable. The first such program came in the form of the Old Age
Assistance program, which was enacted as part of the 1935 Social Security Act and provided
direct financial assistance to needy elderly persons.
Full health insurance for the elderly became available under the Medicare program, as did
health insurance for the indigent under the Medicaid program. Both programs were created in
1965 under the Great Society reforms of President Lyndon Johnson in an era when civil rights
and social justice had taken central stage in the United States. Later, authorized under the
Balanced Budget Act of 1997, the State Children’s Health Insurance Program—later renamed
the Children’s Health Insurance Program—was developed, whereby states can use federal
funds to cover children up to age 19 through their existing Medicaid programs.
One of the most significant healthcare reform efforts resulted in the Affordable Care Act
of 2010, designed to bring about major changes to the delivery of US healthcare. The key
objective of the ACA was to provide most, if not all, Americans with health insurance coverage.
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I n t r o d u c t i o n t o H e a l t h P o l i c y8
me n ta l he a lt h
In contrast to physical health, measures of mental health are limited. The major catego-
ries of mental health measures are mental conditions (e.g., depression, disorder, distress),
behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health
status), satisfaction (e.g., with life, work, relationships), and services received (e.g., counsel-
ing, drug treatment).
Mental illness ranks second, after ischemic heart disease, as a nationwide burden
on health and productivity (SAMHSA 2016). An estimated 17.9 percent of the US adult
population in 2014 had at least one diagnosable mental disorder, only 41 percent of whom
received any treatment (SAMHSA 2016). Serious mental illness costs the United States
$193.2 billion in lost earnings per year (SAMHSA 2016). Mental illness is a risk factor for
death from suicide, cardiovascular disease, and cancer. Mental health problems are frequently
associated with social problems. For example, with easy access to guns, mental health often
contributes to gun violence in both public and private settings.
sO C i a l we l l-Be i n g
The most commonly used measure of relative social well-being is socioeconomic status (SES).
An SES index typically considers such factors as education level, income, and occupation.
Quality of life is another common measure and may include the ability to perform various
roles (e.g., self-care, family care, social functioning), perceptions (e.g., emotional well-being,
Life expectancy at birth (years)
Rank Country (state/territory) Overall Male Female
1 Japan 83.9 80.8 87.1
2 Switzerland 83.0 80.8 85.1
3 Spain 83.0 80.1 85.8
4 Italy 82.6 80.3 84.9
5 Australia 82.5 80.4 84.5
6 Iceland 82.5 81.2 83.8
7 Norway 82.4 80.5 84.2
8 France 82.4 79.2 85.5
9 Sweden 82.3 80.4 84.1
10 Korea 82.1 79.0 85.2
26 United States 78.8 76.3 81.2
Source: Data from OECD (2018).
exhiBit 1.1
Top Ten Countries
with the Longest
Life Expectancy,
with the United
States as
Comparison
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C h a p t e r 1 : O v e r v i e w o f H e a l t h P o l i c y 9
pain tolerance, energy level), and living environment (e.g., pollution levels, crime preva-
lence). A third set of social well-being measures, often used by sociologists, is composed of
social contacts and social resources. Examples of social contacts include visits with family
members, friends, and relatives and participation in social events, such as membership
activities, professional conferences, and church gatherings. The social contacts factor can be
used as an indicator of social resources by determining whether an individual can rely on
social contacts for needed support and company and whether the people involved in these
contacts meet the individual’s needs for care and love.
Pu B l i C he a lt h de f i n e d
In the early twentieth century, Winslow (1920) defined public health as “the science and
the art of preventing disease, prolonging life, and promoting physical health and efficiency
through organized community efforts for the sanitation of the environment, the control of
social contacts
The frequency of social
activities a person
undertakes within a
specified period.
social resources
Interpersonal
relationships with social
contacts and the extent
to which the individual
can rely on the people
involved in these
contacts for support.
LEARNING POINT
Measures of Morbidity, Mortality, and Disability
Morbidity measures
• Incidence of specific diseases: number of new cases in a defined population within a
specified period
• Prevalence of specific diseases: number of instances in a defined population within a
specified period
Mortality measures
• Crude (unadjusted for any other factors) death rate
• Age-specific death rate
• Condition-specific death rate
• Infant death rate
• Maternal death rate
Disability measures
• Restricted activity days (e.g., bed days, work-loss days)
• Limitations in performing activities of daily living (i.e., bathing, dressing, toileting, get-
ting into or out of a bed or a chair, continence, eating)
• Limitations in performing instrumental activities of daily living (i.e., doing housework
and chores, grocery shopping, preparing food, using the phone, traveling locally,
taking medicine)
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I n t r o d u c t i o n t o H e a l t h P o l i c y1 0
community infections, the education of the individual in principles of personal hygiene, the
organization of medical and nursing service for the early diagnosis and preventive treatment
of disease, and the development of social machinery which will ensure to every individual in
the community a standard of living adequate for the maintenance of health.” It focuses on
prevention and involves the efforts of society as a whole. Public health is intended to protect
lives and improve the health of populations around the globe. Today, the Johns Hopkins
Bloomberg School of Public Health emphasizes the continued importance of public health
in its school motto, “Protecting Health, Saving Lives—Millions at a Time.”
Whereas healthcare is intended to treat, influence, and care for individuals, public
health operates on a larger scale. The field is described by the American Public Health
Association (APHA 2018) as one that “promotes and protects the health of people in the
communities where they live, learn, work and play.”
Public health has broad implications for a population. Successful public health activities
and initiatives can save money by promoting healthy living and prevention, thus reducing
healthcare costs and disease burden. In addition, these activities can improve quality of life, help
children thrive, and reduce the suffering caused by ill health in a population (APHA 2018).
The practice of public health leads to both direct benefits (e.g., healthier children, less chronic
disease, less need for acute care) and indirect benefits (e.g., fewer days missed from school
and work; increased funding available for other initiatives, such as education) for a society.
It is important to remember that public health, healthcare, and health policy are
interconnected areas of study and practice. All three have great influence on health.
wh at ar e t h e de t e r m i n a n t s O f he a lt h?
Numerous theories on the determinants of health have been proposed since the mid-
twentieth century. Blum (1974) offered a framework called Force Field and Well-Being
Paradigms of Health, which suggests four major influences—the force fields—on health:
environment, lifestyle, heredity, and medical care. According to Blum, the most important
force field is the environment, followed by lifestyle and heredity. Medical care has the least
impact on health and well-being.
Twenty-first-century models focus on socioeconomic context and health behaviors.
For example, the Dahlgren and Whitehead (2006) model divides factors that influence health
into two categories. Fixed factors, the first category, are unchangeable, such as age, sex, and
genetic makeup. The second category is composed of modifiable factors, such as individual
lifestyle choices; social networks and community conditions; the environment in which one
lives and works; and access to important goods and services, such as education, sanitation,
food, and healthcare. The factors in the second category form layers of influence around the
population, and modifying them positively can improve population health.
Ansari and colleagues (2003) proposed a public health model of the determinants of
health in which these factors are categorized into four major groups: social determinants,
determinants of health
Factors that influence
health status.
Typically, they include
socioeconomic status,
environment, behaviors,
heredity, and access to
medical care.
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C h a p t e r 1 : O v e r v i e w o f H e a l t h P o l i c y 1 1
healthcare system attributes, disease-inducing behaviors (see the Learning Point box titled
“Prominent Theories on the Causes of Disease”), and health outcomes.
A conceptual framework developed by the WHO Commission on Social Determinants
of Health (2008) focuses on socioeconomic and political context; structural determinants and
socioeconomic position; intermediary determinants, such as material circumstances, socioenvi-
ronmental circumstances, behavioral and biological factors, social cohesion, and the healthcare
system; and the impact on health equity and well-being measured as health outcomes.
LEARNING POINT
Prominent Theories on the Causes of Disease
Many of the historically dominant theories related to health focus on disease rather than
well-being. The three most prominent theories of disease causality are germ theory, lifestyle
theory, and environmental theory.
Germ theory gained prominence in the nineteenth century with the rise of bacteriology
(Metchnikoff, Pasteur, and Koch 1939). Essentially, the theory holds that every disease has a
specific cause, which should be identifiable. Knowledge of the cause allows for the discovery
of a cure. Microorganisms, the general causal agent identified by germ theory, are thought to
act independently of the environment. Furthermore, the individual who serves as the host
of the microorganism is the source of the disease, which may then be transmitted from one
person to another—a process known as contagion. Strategies to address the disease focus
on identifying people with symptoms and providing follow-up medical treatment. Much
of biomedical research is still based on germ theory. The traditional concept of the agent,
host, and environment as the epidemiological triangle—epidemiology is the study of factors
controlling the presence or absence of a disease—is also based on the single-cause, single-
effect framework of germ theory.
Lifestyle theory tries to isolate specific behaviors (e.g., exercise, diet, smoking, drinking)
as causes of a disease and identifies solutions on the basis of improving or changing these
behaviors. As with germ theory, lifestyle theory defines problems as they relate to individuals
and focuses solutions on individually tailored interventions.
Environmental theory considers the general health and well-being of individuals more
than it does disease. It maintains that health is best understood by examining the larger
context of community. Traditional environmental approaches focused on poor sanitation,
which was connected to certain infectious diseases. With industrialization and its by-products
of overcrowding and filth, contemporary environmental approaches examine the impact of
production and consumption on emerging health problems. Environmental theory consid-
ers disease to be influenced by environmental and social factors. It contends that solutions
should be developed through policy and regulation and focused on systems rather than on
individuals and medical treatment.
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I n t r o d u c t i o n t o H e a l t h P o l i c y1 2
Similarly, the US Department of Health and Human Services (HHS) publication
Healthy People 2020 embraced a holistic approach by considering the range of personal,
social, economic, and environmental factors that determine the health status of individuals
or populations (HHS 2010). Planning is now under way for the HHS Healthy People 2030
initiative and includes establishing a framework for the initiative (including the vision, mis-
sion, foundational principles, plan of action, and overarching goals) and identifying new
objectives (HHS 2018). In the first phase of the process, an expert advisory committee will
develop recommendations for the HHS secretary on the framework and implementation
of Healthy People 2030. Input from members of the public and relevant stakeholders will
guide the development of recommendations. During the second phase, a federal interagency
workgroup will use the advisory committee’s recommendations to establish objectives for
Healthy People 2030 (Haskins 2017). Exhibit 1.2 delineates the evolution of the Healthy
People initiatives and their respective overarching goals.
Exhibit 1.3 provides an overview of health determinants—environment, individual
characteristics, and medical care (discussed in greater detail in the sections that follow)—as
Target year
1990 2000 2010 2020
Overarching
goals
• Decrease
mortality:
infants to
adults
• Increase
independence
among older
adults
• Increase span
of healthy life
• Reduce health
disparities
• Achieve access
to preventive
services for all
• Increase
quality and
years of
healthy life
• Eliminate
health
disparities
• Attain high-quality,
longer lives free of
preventable disease,
disability, injury, and
premature death
• Achieve health equity;
eliminate disparities
• Create social and
physical environments
that promote good
health
• Promote quality of life,
healthy development,
and healthy behaviors
across life stages
No. of topic
areas
15 22 28 42
No. of
objectives/
measures
226 312 1,000 approximately 1,200
Source: Healthy People Initiatives of 1990, 2000, 2010, and 2020 (HHS 2010).
exhiBit 1.2
Evolution of
Healthy People
Initiatives
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…
7 0
l e a r n i n g O B J e C t i v e s
A policy is a temporary creed liable to be changed, but while it holds good, it has
got to be pursued with apostolic zeal.
—Mohandas Gandhi
One voice can change a room. And if one voice can change a room, then it can
change a city. And if it can change a city, it can change a state. And if it can change
a state, it can change a nation, and if it can change a nation, it can change the world.
Your voice can change the world.
—Barack Obama
C H A P T E R 3
H E A LT H P O L I C Y M A K I N G AT
T H E S TAT E A N D L O C A L L E V E L S
A N D I N T H E P R I VAT E S E C T O R
After completing this chapter, you should be able to
➤ describe features of the US state-level policymaking process and political system and
provide examples of state healthcare legislation,
➤ discuss features of the US local government policymaking process and local political
system and provide examples of local healthcare legislation,
➤ address the health policy–related activities of private health research institutes and
foundations,
➤ understand the implications for the US healthcare system of private industry policies
and practices, and
➤ appreciate the attributes of health policy development at the US state and local levels
and in the private sector.
00_Shi (2374) Book.indb 70 11/21/18 10:55 AM
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7 1C h a p t e r 3 : H e a l t h P o l i c y m a k i n g a t t h e S t a t e a n d L o c a l L e v e l s a n d P r i v a t e S e c t o r
ma s s a C h u s e t t s he a lt h C a r e re f O r m
In 2006, Massachusetts enacted landmark legislation to provide health insurance coverage to
nearly all state residents (KFF 2012). The legislation led to the creation of the Commonwealth
Care health insurance program to provide subsidized coverage for individuals whose income is
below 300 percent of the federal poverty level. It also developed a health insurance exchange
for individuals and small businesses to purchase insurance at more affordable rates than could
be obtained on the open market. The state’s Medicaid program was expanded and merged with
the Children’s Health Insurance Program (CHIP) to form MassHealth. Children from a family
whose income is up to 300 percent of the federal poverty level are covered by this program.
As part of this legislation, Massachusetts mandated that residents purchase health
insurance coverage or be charged a penalty of up to $912. In addition, employers with 11 or
more employees are required to contribute to health insurance coverage for their employees
or pay an annual fair-share contribution of up to $295 per employee.
As of 2012, the percentage of residents without insurance in Massachusetts had declined
to 6.3 percent, in comparison to the 2006 level of 10.9 percent uninsured (KFF 2012). Uninsur-
ance in Massachusetts was about one-third that of the rest of the United States (18.4 percent).
Employer health coverage remains the most common type of insurance, but MassHealth (the
public insurance plan) and Commonwealth Care (which provides subsidies for families and
individuals to purchase private coverage) have grown substantially (KFF 2012; Saluja et al. 2016).
Community health centers and safety net hospitals play a dominant role in caring for
those Massachusetts residents who now have health insurance as a result of the state healthcare
reform legislation. In addition, they continue to provide care for those who remain uninsured.
The Massachusetts experience with healthcare reform legislation provides a real-world
case study demonstrating the potential to significantly reduce the number of uninsured through
an individual mandate combined with affordable health coverage options. It illustrates the
state’s role in bringing about real healthcare reform affecting healthcare access and
delivery.
CO n n e C t i C u t OP i O i d re s P O n s e in i t i at i v e
According to the Connecticut Department of Mental Health and Addiction Services, admission
for heroin addiction has increased since 2011, and heroin has replaced alcohol as the primary
drug reported at admission for substance abuse treatment within the state, with heroin and
other opiates accounting for 42 percent of admissions in fiscal year 2016 (Giard 2017). Connecticut
C a s e s t u d y 2
C a s e s t u d y 1
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I n t r o d u c t i o n t o H e a l t h P o l i c y7 2
Governor Dannel P. Malloy charged the Alcohol and Drug Policy Council (ADPC), a statewide
stakeholder group, with comprehensively addressing Connecticut’s opioid crisis. The Connecti-
cut Opioid REsponse (CORE) team—a partnership among academic, medical, and public health
organizations and state agencies—supports the work of the ADPC by using evidence-based
strategies to achieve measurable outcomes that have a prompt impact on the number of opioid
overdose deaths in Connecticut (Fiellin et al. 2016). The CORE initiative has two main functions:
(1) to serve as a means to convey strategies and methods likely to immediately treat opioid
use disorder and reduce overdose events, and (2) to provide metrics and measures that may
be used to monitor and track progress over time (Fiellin et al. 2016). Namely, CORE identifies
strategies and associated metrics to address the opioid crisis in Connecticut.
The strategic plan involved a multistage process of data gathering from Connecticut
stakeholders, evaluation of evidence-based practices, and stakeholder engagement (Fiellin
et al. 2016). First, a three-month data-collection process led by Yale University’s Schools of
Medicine and Public Health sought recommendations from stakeholders throughout the state.
In addition, the team evaluated evidence-based practices from other states and countries.
Review and integration of these data helped identify Connecticut’s specific data needs and key
questions. Recommendations were further reviewed with regard to scientific strength, potential
three-year impact on overdose mortality, and availability of a measurable outcome that could
be monitored to determine strategic priority.
These efforts resulted in the following six strategies (Fiellin et al. 2016):
1. Increase access to high-quality treatment with methadone and buprenorphine.
2. Reduce overdose risk, especially among those individuals at the highest risk.
3. Increase adherence to opioid prescribing guidelines among providers, especially those
providing prescriptions associated with an increased risk of overdose and death.
4. Increase access to and track use of naloxone.
5. Increase data sharing across relevant agencies and organizations to monitor and
facilitate responses, including rapid responses to outbreaks of overdoses and other
opioid-related events.
6. Increase community understanding of the scale of opioid use disorder, the nature of
the disorder, and the most effective evidence-based responses to promote treatment
uptake and decrease stigma.
Based on the evolving nature of the opioid epidemic, and an evolving evidence base,
the CORE initiative team plans to evaluate its strategies, tactics, and metrics annually and
adjust as needed.
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7 3
A
lthough US health policies are developed primarily at the federal level, state and
local governments and industries in the private sector (nonfederal arenas) also
engage in health policymaking. This chapter focuses on health policymaking in
these arenas. First, state-level health policymaking is presented; that discussion is followed
by sections covering local government and private-sector health-related policy influencers.
The attributes of health policymaking in these sectors are also summarized.
stat e gO v e r n m e n t st r u C t u r e
The federal and state sectors share a common government structure composed of the legis-
lative, executive, and judiciary branches. However, each state also has its own constitution
and bill of rights, which together define the structure and function of the state government
and the local governments within the state’s boundary (Longest 2016). Following is a brief
discussion of the typical state political system.
PO l i t i C a l sy s t e m
State governments are modeled after the US federal government in that each is composed
of executive, legislative, and judicial branches (exhibit 3.1). States are bound by the US
(federal) Constitution to maintain a republican form of government, although they are not
specifically required to adhere to the three-branch system. The executive branch of the state
government is headed by the governor and other state executives, such as the lieutenant
governor, the attorney general, the secretary of state, auditors, and commissioners. All state
republican
A type of democratic
government in which the
head of state is not a
monarch; governmental
activities and affairs are
open to all interested
citizens.
state executives
Officials in the
executive branch of
state government.
Examples include the
governor, who is the
chief executive of a
state or territory, and
the attorney general,
who serves as the main
legal adviser to the state
government and has
executive responsibility
for law enforcement.
C h a p t e r 3 : H e a l t h P o l i c y m a k i n g a t t h e S t a t e a n d L o c a l L e v e l s a n d P r i v a t e S e c t o r
exhiBit 3.1
The US State
Political System
State government
Executive branch
Governor
Lieutenant governor
Attorney general
Secretary of state
Auditors
Commissioners
Legislative branch
Senate
House of representatives/
assembly/house of
delegates
Judicial branch
Supreme Court
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I n t r o d u c t i o n t o H e a l t h P o l i c y7 4
governors are directly elected by the people, as are most other positions in their executive
branch. The exact structure of the executive branch varies from state to state.
The state legislative branch is the main lawmaking body of the government; it also
approves the state budget and fulfills other functions of government. As in the federal gov-
ernment, the state legislature consists of two chambers: a house of representatives—known
in some states as the assembly or house of delegates—and a senate (except Nebraska, which
has only one chamber in its legislature). In most states, senators are elected by the state’s
voters to four-year terms, and members of the house are elected to two-year terms.
A state’s judiciary is generally headed by its version of the US Supreme Court (with
exceptions; for example, New York’s Supreme Court is actually the trial-level court, and the
state’s highest court is referred to as the Court of Appeals). This highest state court hears
appeal cases from lower-level state courts; no trials are held in state supreme courts. Decisions
made by a state supreme court are binding unless they do not adhere to the US Constitution,
in which case its decisions may be appealed in the US Supreme Court. The exact structure
of the courts and the rules governing judicial appointments and elections are determined
on a state-by-state basis, either through state legislation or by the state constitution.
PO l i C y m a k i n g Pr O C e s s at t h e stat e le v e l
The policymaking process at the state level can vary substantially from state to state. In
general, however, states apply the same legislative system as the federal government does
(see, e.g., Maryland General Assembly 2006; State Legislature of Alaska 2018; West Virginia
Legislature 2018). The idea for a new law can come from an elected representative, a group
of elected representatives, the governor, or any other concerned citizen or interest group.
The proposed law is drafted into a bill, which is then sponsored by an elected member of
either the state’s senate chamber or its lower chamber (e.g., house of representatives, general
assembly). Although a bill must be introduced into the legislature by a representative or
senator, both legislators and interest groups draft significant amounts of legislation.
Bills can be introduced in either chamber of the legislature, where they are reviewed
by committees. Many states require that the bill also be accompanied by a financial projec-
tion showing the budgetary impact of the potential law. The bill goes through three readings
before being voted on by the elected representatives. Often, amendments are made after
each reading, and the merits of the bill are debated among the members.
After it passes one chamber, the bill proceeds to three readings in the other chamber.
The same process of debates and amendments is followed. After both houses have agreed
on and passed a final version of the bill, it goes to the governor to be signed into law. In
many states, the governor has the authority to veto a bill that is passed by both chambers
so that it does not become law. In other states, the governor’s veto can be overridden by a
favorable vote of two-thirds or more of the members in both houses so that the bill becomes
law even without the governor’s support.
state legislature
The legislative body of
a US state, also called
the general assembly or
legislative assembly.
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7 5
ex a m P l e s O f stat e he a lt h C a r e le g i s l at i O n
The power and responsibility of states to establish laws that protect the public’s health and
welfare derive from the US Constitution. The focus of healthcare legislation can range from
promoting health (including environmental protection, occupational health, safe food
services, and injury prevention) to providing health services (such as public health nursing,
communicable disease control, family planning and prenatal care, and nutritional counsel-
ing). See exhibit 3.2 for examples of state health policies, review the Learning Point box
titled “Illustration of State Involvement in Health Policy Development” for a description
of health policy activity in Oregon, and read the Learning Point box titled “State Initiatives
on Health Promotion and Disease Prevention” to understand state involvement in health
promotion and disease prevention activity as well as efforts to address the healthcare needs
of its vulnerable citizens.
exhiBit 3.2
Examples of State
Responsibilities
Through Health
Policy
• Serve as a major payer of healthcare services; an average of 28.2 percent of all
state expenditures were Medicaid related in 2015 (Medicaid and CHIP Payment and
Access Commission 2016).
• Fund CHIP, health insurance benefits for state employees and other public-sector
workers, and stand-alone state programs that provide health services to the
uninsured.
• Regulate the state healthcare system (e.g., licensing and monitoring health
professionals and health-related organizations, regulating the state private health
insurance industry).
• Establish and monitor compliance with quality standards for environmental
protection.
• Provide safety net facilities through support of local health departments and
community-based healthcare organizations and through programs that provide
charity care to low-income populations.
• Provide subsidies for graduate medical education and support large-scale
educational campaigns.
LEARNING POINT
Illustration of State Involvement in Health Policy Development
Known as a leader in state healthcare reform (Health Care for All Oregon 2017), Oregon’s
Legislative Assembly passed House Bill 2009 in 2009, which established the Oregon Health
Authority (OregonLive 2018). The legislation created an insurance exchange—a federal subsidy–
eligible set of standardized healthcare plans regulated by the state from which individuals
( c o n t i n u e d )
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I n t r o d u c t i o n t o H e a l t h P o l i c y7 6
LEARNING POINT
Illustration of State Involvement in Health Policy Development (continued)
may purchase health insurance—through the Oregon Health Authority for individuals and
small businesses that do not have group health insurance (Oregon Legislative Assembly 2009).
The law also expanded the Oregon Health Plan to cover low-income working families and
allocated an additional $5 billion to the Medicaid plan over the following ten years. The Oregon
Health Plan is the Medicaid program for Oregon and is overseen by the Oregon Health Author-
ity. Its purpose was to make healthcare more accessible to the working poor while rationing
insurance benefits. President Bill Clinton approved the plan in 1993 but required a revision to
ensure access for people with disabilities. In 2011, Oregon House Bill 3650, which contained
the proposed revision, was passed by the state legislature, and Oregon Senate Bill 1580 was
signed into law, establishing Coordinated Care Organizations (CCOs). A CCO is a network of
all types of healthcare providers who care for people covered under the Oregon Health Plan.
CCOs integrate physical, mental, and dental care for better care and better health outcomes
at lower costs. CCOs focus on preventing illness and disease, improving quality of care, and
managing existing health conditions to keep patients healthy.
Other provisions contained in House Bill 2009 called for expanding the use of electronic
health records through the Oregon Health Authority, establishing quality standards for hospi-
tals and healthcare providers, and mandating that health insurance companies disclose their
administrative costs and executive salaries to maintain transparency and accountability. As with
the federal reforms included in the Affordable Care Act (ACA) of 2010, lifetime maximum limits
on health benefits were eliminated, insurers were prohibited from taking health coverage away
from those already enrolled in a plan, and children who were unmarried could stay on their
parents’ health insurance plan until age 26 (Oregon Legislative Assembly 2009). The ACA was
also expected to provide some financial support for the reforms in Oregon’s House Bill 2009.
The state’s efforts were largely successful. A report by the Oregon Health Authority (2017)
showed that by 2017, about 94 percent of people in Oregon had health insurance coverage.
LEARNING POINT
State Initiatives on Health Promotion and Disease Prevention
All US states and the District of Columbia receive federal grants to initiate their own health
promotion and disease prevention programs (CDC 2018a). These programs focus on a variety
of health problems, such as promoting wellness culture in the workplace, increasing access
to healthy food, and improving physical activity. These programs have the common goal of
improving environments to make healthy living easier. Four examples of these programs are
provided here.
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7 7
LEARNING POINT
State Initiatives on Health Promotion and Disease Prevention (continued)
Exercise and Dietary Modification to Combat Obesity in Michigan
Strong evidence indicates that physical inactivity and excess calorie intake are the primary
causes of obesity, not only for adults but also for young children (CDC 2017b). To address this
public health concern, Michigan has worked on various activities such as partnering with the
local Farmer’s Market Association to accept Supplemental Nutrition Assistance Program cards
(formerly known as food stamps) and providing funding to local health jurisdictions to promote
physical activity with walking campaigns. One highly successful project involved working with
school districts and community organizations to enhance physical activity standards and
healthy eating habits in early care and education settings (i.e., licensed childcare centers and
in-home childcare settings) across the state. As a result of this five-year project, 226 centers
and homes improved children’s physical activity through activities such as 60 minutes of
adult-led playtime every day, and 194 centers and homes made children’s diets healthier by
adding more fruits and vegetables to meals or encouraging parents to bring healthy snacks for
children. To sustain the program, Michigan is making efforts to expand these improvements
in every childcare center and in-home childcare setting in the state (CDC 2016b).
Healthier Retail Environments in Rural Wisconsin
A 2013 study found that In Wisconsin, about 38 percent of adults consumed fruits and 26
percent of adults ate vegetables less than once a day (Young et al. 2017). In addition, rural
residents often have limited access to nutrient-dense, fresh produce because most corner
stores—small retail shops that sell groceries and other household items—in rural Wisconsin
lack a variety of fruits and vegetables. To make healthy options more convenient for local
residents, the Wisconsin Division of Public Health (DPH) partnered with the University of
Wisconsin Extension and 11 community-based organizations in 2015 to promote and expand
the Wisconsin Corner Store Assessment tool for corner stores across the state. The tool guides
corner stores through an assessment of areas for improvement, informing them on factors
such as placement and shelf space of healthy foods in the store (Young et al. 2017).
This state program achieved the most desirable results in rural Lincoln County. Many corner
stores in Lincoln County now offer much healthier food and drink options in their communities
through multiple strategies, including coupons for healthy foods, point-of-purchase promo-
tions, and displays of healthy products. To build on this success, the DPH decided to expand this
program to gas stations in Lincoln County (CDC 2014; Young et al. 2017). Milwaukee County also
launched a similar initiative to encourage corner stores to sell healthy foods by using such strate-
gies as fresh produce signage, in-store demonstrations, and store redesign (Young et al. 2017).
Dietary Interventions in Philadelphia Healthcare Settings
In the state of Pennsylvania, the Philadelphia Department of Public Health launched the Good
Food, Healthy Hospitals (GFHH) initiative, a healthy food and beverage option promotion
( c o n t i n u e d )
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I n t r o d u c t i o n t o H e a l t h P o l i c y7 8
In some instances, an initiative instigated by a private-sector group to address an
urgent public health problem may garner support from the state. For example, see the case
in the Learning Point box titled “West Virginia’s Drug-Free Moms and Babies.”
LEARNING POINT
State Initiatives on Health Promotion and Disease Prevention (continued)
targeting patients, staff, and visitors in local hospitals (Bartoli 2018). Providing hospital patients
suffering from chronic diseases with a healthy diet is a key component of chronic disease
management, the department found, and many of the hospitals in Philadelphia serve residents
of low-income areas where few fresh and healthy food options are available. The Common
Market (a nonprofit organization) and the American Heart Association partnered with the
Philadelphia Department of Public Health in 2014 to implement the GFHH initiative. Specifi-
cally, they encouraged hospitals to adopt five GFHH food standards that applied to purchased
foods and beverages, cafeteria meals, patient meals, catering, and vending machines. Each
standard came with specific guidelines. For example, the patient meal standard prohibited
deep frying as a method of food preparation (Bartoli 2018).
As of June 2017, 15 hospitals had signed a pledge and committed to adopt GFHH standards.
In their first year of implementation, all of these hospitals had met the minimum guidelines
for at least one of the five GFHH standards, and half of them had achieved this goal for mul-
tiple standards. Most hospitals reported increased sales of healthy items even in their first
year of implementation. One local medical center’s cafeteria reported increased sales of
unsweetened waters by 83 percent compared with the previous year, after following a GFHH
price reduction guideline. Most important, these hospitals credited the GFHH standards with
helping to shape hospital policies around healthier food and beverage options (Bartoli 2018).
Bike Share Program in California
Considering that the obesity rate for adults in Sacramento County, California, increased dra-
matically, by nearly 29 percent from 2001 to 2011, the California Department of Public Health
(CDPH) collaborated with five state agencies to initiate a bike share program that motivated
state employees to use free bicycles for business and personal trips during weekdays (Rosenhall
2018). The initial results were encouraging: From May 2015 to May 2016, 235 CDPH employees
had enrolled and made more than 900 trips, biking a total of more than 3,000 miles (CDC 2016a;
Rosenhall 2018). The program thus accomplished the dual benefits of improving employee fit-
ness and decreasing environmental pollution from cars. City officials, taking notice of the CDPH
program’s success, worked to establish a bike share program for the Sacramento metropolitan
area. The new bike rental service, called Social Bicycles, debuted on May 17, 2018, with a fleet
of several dozen bicycles available in downtown Sacramento and along the West Sacramento
waterfront and with plans for an increase to about 900 bikes by the end of the year (Bizjak 2018).
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7 9
lO C a l gO v e r n m e n t st r u C t u r e
Local US governments typically fall into one of two levels: county or municipality (e.g.,
cities, towns, villages). Counties—called boroughs in Alaska and parishes in Louisiana—may
LEARNING POINT
West Virginia’s Drug-Free Moms and Babies
In 2015, West Virginia led the nation in drug overdose mortality among US states, with a rate
of 41.5 deaths per 100,000 people (Mullins 2017). High rates of drug addiction, including but
not limited to opiates, were also believed to affect neonatal outcomes and child health. To
address this growing problem, a group of West Virginia neonatologists and pediatricians met
with members of the Perinatal Partnership and coders in 2014 to address neonatal outcomes
for infants being born to opioid-addicted mothers (Mullins 2017). Specifically, the group sought
to “develop a standardized definition for neonatal withdrawal and guidance on documenting
exposure and withdrawal among newborns” (Mullins 2017).
The group examined how the Drug Free Moms and Babies Project—a medical and behavioral
health program for women during and after pregnancy—leveraged collaborative relationships
to achieve positive outcomes for mothers and babies through a comprehensive, integrated
approach including prevention, early intervention, addiction treatment, and recovery sup-
port services (Mullins 2017; West Virginia Department of Health and Human Services 2018).
The three-year project was supported through funding from the West Virginia Department of
Health and Human Resources; the Division of Behavioral Health and Health Facilities; the West
Virginia Office of Maternal, Child and Family Health; and the Claude Worthington Benedum
Foundation (West Virginia Department of Health and Human Services 2018). …
PA R T I I I
H E A LT H P O L I C Y I S S U E S
P
art III consists of three chapters that provide examples of health policy issues. Chapter 5 focuses
on health policies for US healthcare delivery and financing. Chapter 6 discusses health policy
concerns for people with special needs and other vulnerable populations. Chapter 7 illustrates
health policy concerns in the international community, including both developed and developing
countries.
The broad health policy issues presented in this part of the book should help students under-
stand how health policy is applied in the context of healthcare delivery and other determinants of
health. Knowledge of policy applications prepares readers to examine how health policies are studied
and evaluated—the focus of part IV.
00_Shi (2374) Book.indb 129 11/21/18 10:55 AM
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AN: 1989456 ; Leiyu Shi.; Introduction to Health Policy, Second Edition
Account: s4264928.main.eds
L e a r n i n g O b j e c t i v e s
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CHAPTER
375
HEALTH POLICY DESIGN
Suzanne Babich, DrPH, Irene Agyepong, DrPH, Egil Marstein,
PhD, and Francisco Yepes, MD, DrPH
Chapter Focus
This chapter is designed to help health managers develop the knowledge and
skills needed to understand, effectively influence, and adapt to global health
policies. It focuses on key concepts in the design of health policies around the
world that are of particular importance for health managers and organizational
leaders.
Learning Objectives
Upon completion of this chapter, you should be able to
• discuss the relevance of global health policy design and analysis for
health managers,
• describe key concepts in global health policy design and analysis,
• explore the implications of sociocultural factors on global health policy
and management practice, and
• apply knowledge of these issues to managerial decision making and
actions.
Competencies
• Advocate for and participate in healthcare policy initiatives.
• Interpret public policy, legislative, and advocacy processes within an
organization.
• Describe the roles and relationships among the entities influencing
global health.
• Analyze context-specific policymaking processes that influence health.
11
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AN: 1985979 ; Michael Counte.; The Global Healthcare Manager: Competencies, Concepts, and Skills
Account: s4264928.main.eds
T h e G l o b a l H e a l t h c a r e M a n a g e r376
Key Terms
• Allocative or redistributive
policies
• Global health policy
• Policy
• Policy analysis
• Policymaking
• Regulatory policies
• White paper
Key Concepts
• Global health policy
• Government policy
• Health policy analysis
• Health policy circuit
• Health policy design
• Sociocultural context
• Step method for policy analysis
• Transnational health policy
Introduction
Global health policy can be described as a complex web of rules, both formal
and informal, that police vested interests in the attainment of the highest level
of health possible for all people (World Health Organization [WHO] Regional
Office for South-East Asia 2016). This description acknowledges the role of
various stakeholders as key players in these systems that determine who gets
what health services and with what level quality, length of wait, and cost. The
description also goes beyond personal health services to include policies that
directly or indirectly affect health—whether those policies are rules that allocate
or reallocate important resources (e.g., food, medicines) or regulations that
control the behaviors of individuals and organizations (e.g., food companies,
drug and device manufacturers, coal-burning power plants).
The health policy landscape includes macro-level, transnational policies;
country-level government policies; and micro-level policies in smaller units of
governance or in individual organizations. Examples of macro-level, transna-
tional policies include the doctors’ directive in the European Union (EU),
which aims to promote the free movement of healthcare professionals, as well
as EU laws targeting issues that directly or indirectly affect health or health
services delivery (e.g., bovine spongiform encephalopathy, genetically modi-
fied foods). Often, different levels of health policy overlap. Some country- or
local-level policies, for instance, have a global reach and should therefore be of
vital interest to health managers globally. Examples might include policies to
limit the spread of Zika virus, H1N1/avian influenza, chikungunya, or Ebola.
Although national health policies often focus on domestic health services
allocation, they may also call for specific actions in response to global health
global health
policy
The complex
web of rules,
both formal and
informal, that
police vested
interests in the
attainment of the
highest level of
health possible for
all people.
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C h a p t e r 1 1 : H e a l t h P o l i c y D e s i g n 377
issues, including transnational initiatives on such topics as climate change or
the treatment of refugees and migrants. Policies also exist at the organizational
level, of course, with organizations located all over the world. An organiza-
tion might prescribe health services for employee groups in conjunction with
country-specific national health services.
The professional arena for many health managers today includes opportu-
nities in global organizations, where significant cultural differences require new
knowledge, skills, and abilities. Competent managers need to be knowledge-
able and flexible enough to adapt to these organizational differences. Chapter
6 focused on the leadership principles necessary for managers undertaking that
challenge; this chapter, meanwhile, focuses specifically on the health policies that
are relevant in today’s global context. This chapter focuses not on the policies
that exist at the organization level but rather on the politically structured, insti-
tutionalized frameworks that govern the allocation of health resources for popu-
lation groups. Such policy frameworks are largely shaped by national, regional,
and transnational interest groups, and they come about through a process of
stakeholder intervention, with each group representing a stake in the outcome,
to determine health services procurement practices and distribution. Stakeholder
interest groups include powerful corporations, nongovernmental organizations,
charitable foundations, and competing political institutions seeking to safeguard
their capacities to influence the impact and outcomes of health policies.
Making sense of any health policy issue requires an understanding of
the social and political factors that dictate a policy’s shape, pace, and direc-
tion. Many health managers possess extensive knowledge and experience in
the country in which they work, and a high level of insight into many of the
factors that influence health policies close to their locus of control and practice.
They often have great familiarity with environmental conditions, including
the social, political, economic, and organizational factors that provide the
backdrop for the development and implementation of local policies. However,
given the increasing interdependence of health systems and policies around the
world, today’s health managers—regardless of where they practice—must be
proficient in analyzing and understanding health policies that span geographic
boundaries and cultures.
Key Concepts in Health Policy Design and Analysis
Policies are rules that can be either formal or informal, written or unwritten.
Policymaking is the process of creating those rules. Policy analysis involves
examining those rules, the problems the rules are meant to address, the goals
of the rules, and the criteria used to evaluate the efficacy of the rules. Typically,
policy analysis also assesses alternatives to current policy and, based on results
of the comparisons, makes recommendations from among the alternatives.
policy
A rule, whether
formal or informal,
written or
unwritten.
policymaking
The process of
creating the rules
of policy.
policy analysis
The act of
examining rules,
the problems the
rules are meant
to address, the
goals of the rules,
and the criteria
used to evaluate
the efficacy of the
rules.
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T h e G l o b a l H e a l t h c a r e M a n a g e r378
Health policies have many sources, with governance structures that vary
depending on where in the world the policies originate. Policies may be made
at the federal, state, provincial, or local levels via legislative or elected bodies,
administrative agencies, boards, commissions, courts, and so on. Health poli-
cymakers may include legislators, elected officials, agency members, board or
commission officials, judges, and the like.
The forms that health policies take also vary. They may be set out in
national, state, or provincial constitutions, or they may be put forth in doctrines,
statutes, ordinances, rules and regulations, operational or judicial decisions,
and other forms specific to the governance structure of the country in which
they were created. As a general rule, federal or country-level policies tend to
wield the most power, state or provincial policies have somewhat less power,
and local-level policies have the least amount of strength or authority. As a
result, top-level policies tend to be the slowest and most difficult to change,
whereas local-level policies tend to be the easiest to influence.
Health policies can serve any number of purposes, but most fall into
one of two broad categories:
1. Allocative or redistributive policies are policies that determine the
way public goods or resources are shared. Such policies typically give
more resources to some groups and less to others. Examples include
policies that provide free or reduced-cost services only to people who
fall under a specified income level.
2. Regulatory policies are policies that are designed to affect the behavior
or actions of others through rules that dictate what can and cannot be
done.
The Global Health Policy Circuit
The model in exhibit 11.1 provides a visualization of the complexity of global
health policy processes. The model highlights the following:
• The interconnectedness of public health policy, starting from the point
of policy inception (political initiative)
• The shaping of rules and regulations (governance policies), perhaps
establishing a new policy/reform paradigm
• The introduction of policy premises subsequent to implementation and
sector administration
• Renewed stakeholder initiatives, perhaps engaging in strategic ploys,
drawing attention to a preferred revision, potentially with the result of
new political initiatives—completing the policy circuit
allocative or
redistributive
policies
Policies that
determine the
way public goods
or resources are
shared.
regulatory policies
Policies that are
designed to affect
the behavior or
actions of others
through rules that
dictate what can
and cannot be
done.
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C h a p t e r 1 1 : H e a l t h P o l i c y D e s i g n 379
Governing structures vary among countries. In a social democracy, like
those common in Western nations, policy initiation and implementation emerge
following some level of national debate. Emerging policies commonly reflect
the paradigm that governs knowledge development at a given time. Policies
that break with established epistemology or generally accepted philosophy
about a given topic may be seen as radical proposals, setting the stage for
intensified policy debates.
In a top-down approach to policymaking, policies are formalized at the
more central health system levels and then passed down to peripheral gover-
nance structures responsible for implementation. The ultimate performance
or output of any policy will be shaped by how these peripheral governance
structures actually translate the policy into programs. Their actions and inac-
tions—decisions and nondecisions—can effectively shape the public face of
the policy. Whatever public service or good a policy is intended to govern, the
relevant sector stewards promote that policy.
Ministries of health in many countries may have a hierarchical structure,
with a central or national-level ministry responsible for agenda setting, policy
formulation, and health sector coordination and more peripheral levels, espe-
cially district level and below, responsible for policy implementation. Plans,
budgets, and programs for health services, education, and other areas may
or may not completely reflect the established policy premises, depending on
the extent to which centrally designed policies are modified peripherally in
implementation.
Political
initiative
Governance
policies
Sector
administration
Stakeholder
initiatives
Policy
circuit
Paradigm
I
Premises
II
Ploy
IV
Promotion
III
EXHIBIT 11.1
The Global
Health Policy
Circuit
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T h e G l o b a l H e a l t h c a r e M a n a g e r380
Regardless of how complete and well-intended policies may be, they may,
over time, be contested. A policy might not work as well as hoped, stakeholders
might become unhappy, or public opinion might shift. Changing conditions
in the policy environment might favor a new paradigm that prompts review of
the policy. The discourse that subsequently takes place includes the ploy sec-
tion of the exhibit—when actor agents might mask their actions for whatever
gains may be sought. The potential for new political initiatives at this point
illustrates the circular nature of the policy circuit.
In societies that lack well-functioning governance and legal structures,
policy development and execution practices might be significantly different from
what the model describes. In general, the practices of corrupt or incomplete
policy development are beyond the scope of this chapter. However, in seeking
to understand the policymaking contexts of those situations, the identification
of key stakeholders and their policy goals and practices is critical.
Analyzing Health Policy
Health policy design and analysis are inherently social and political exercises.
The environmental context in which policies play out may be shaped by a variety
of changing conditions, including such factors as the economy, public opinion,
election and budget cycles, and organizational interests. All of these factors can
influence the shape, pace, or direction of a particular policy at a given time.
Throughout the world, the conditions shaping policy environments, including
governance structures and the power of stakeholder influences, vary widely.
At the top levels—the national, state, or transnational levels, such as
within the EU—policy initiatives are approached systematically, often calling
for complex structures and decision-making processes. At these levels, groups
seeking to promote trade and regional development—such as the Association
of Southeast Asian Nations (ASEAN), the European Free Trade Association
(EFTA), the Latin American Free Trade Association (LAFTA), and the South-
ern African Development Community (SADC)—play an important role in
determining how health policies are shaped and how they work once approved.
In Western countries, policy papers known as “white papers” are often
drafted by governments as a first stage in a parliamentary process for establish-
ing a future policy. White papers provide policy analysis as depicted in exhibit
11.2, with an emphasis on the following:
1. Formulating a problem statement and underscoring its relevance
2. Recognizing budgetary implications; identifying financial options
3. Identifying all resources considered necessary to determine a capacity to
enact, following an assessment of critical prerequisites
white paper
A comprehensive
yet concise report
that summarizes
a position on a
complex and often
controversial or
difficult issue; it
aims to increase
stakeholders’
understanding
of the issue to
support the
development of
policy.
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C h a p t e r 1 1 : H e a l t h P o l i c y D e s i g n 381
4. Reflecting on the policy’s presumed credibility with regard to key
stakeholders (constituency acceptance)
5. Concluding its analysis of the policy initiative as summarized in a model
acceptance
Despite this complexity—or, indeed, in recognition of it—health manag-
ers should put forth the effort to understand the basic concepts and steps of
policy analysis, because such knowledge can foster better organizational decision
making and strategic planning. Performing a thorough analysis of a complex
health policy can be extremely time consuming, however, and organizations
will often be limited by time and other resources. Therefore, in organizational
settings, analyses of health policies may be limited to relatively quick reviews
or abbreviated studies, with certain steps in the process skipped or addressed
in only a cursory way.
Given the time-consuming nature of policy analysis, it may be practical
for analysis to be conducted by individuals who have prior knowledge of the
policy in question. Even though such individuals might not be as objective as
an analyst who has no prior knowledge of the case, the amount of time and
energy needed for a newcomer to get familiarized with the necessary back-
ground may be too great (Patton, Sawicki, and Clark 2012).
No single, correct approach exists for conducting a policy analysis; in
fact, the activity is as much an art as a science. Nevertheless, a number of
approaches have been described in the literature, each attempting to apply a
Budgetary
implications
Relevance
Capacity
to enact
Constituency
acceptance
Policy
circuit
Financial
options
(I)
Critical
prerequisites
(II)
Model
acceptance
(IV)
Credibility
(III)
EXHIBIT 11.2
Analysis of
Health Policies
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T h e G l o b a l H e a l t h c a r e M a n a g e r382
structure to a complex, multidimensional situation that typically evolves even as
it is being studied. One of the most popular approaches—the step method—is
widely taught in university courses, in part because it is easy to explain and
intuitive to grasp.
The Step Method for Health Policy Analysis
The step method for the analysis of health policies follows a systematic sequence
of logical activities that comprehensively examine a problem, the policy designed
to address it, the intended consequences of the policy, the policy’s outcomes,
and the variants of the policy that could potentially improve the results. The
analysis may include a recommendation for a “best choice” from among the
suggested alternatives, plans for advocating for the preferred variant, and plans
for evaluating the outcomes of the policy alternative.
The number of steps included in the model can vary depending on
the source, but it typically includes five to eight steps. The core of the analy-
sis—without including advocacy or evaluation plans—generally includes the
following five activities:
1. Defining the problem and its corresponding policy. Think of the old
adage, “There ought to be a law.” This step consists of several linked
components: A problem has to be identified; it has to be deemed
sufficiently significant in magnitude, scope, cost, or some other criteria;
and it has to draw the attention of policymakers. Once the problem has
met these requirements, a policy may be created to address it.
2. Collecting evidence. In this step, a policy analyst becomes educated—
often quickly—on as many facets of the problem as possible within
time and other resource constraints. Evidence includes information
from diverse sources, potentially including reports, news articles,
governmental proceedings, published papers, financial records, scientific
data, and input from stakeholders, including opinions and anecdotes.
The evidence may be objective or subjective.
3. Determining the policy goals and evaluation criteria. The goals and
evaluation criteria are often one and the same. In other words, once an
analyst determines what the policy is meant to accomplish, assessment
of how well the policy is working can be done by comparing the actual
and intended outcomes.
4. Laying out the alternatives. The next step includes brainstorming several
evidence-based variations of the current policy that might reasonably
be expected to yield improved results. A “do nothing” option should
be one of the alternatives, with the status quo serving as the standard
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C h a p t e r 1 1 : H e a l t h P o l i c y D e s i g n 383
against which other alternatives are compared. The alternatives should
be sufficiently diverse that meaningful differences can be discerned
among them. Once several alternatives have been identified, the list
should be culled to the three or four strongest options.
5. Playing out the options and picking one. For each potential policy
alternative, the analyst extrapolates the likely results, assigning scores for
each of the evaluation criteria. Matrixes, spreadsheets, grids, and charts
can help illustrate the comparisons among the alternatives. This step
should lead to the selection of the best option.
After the best option has been selected and the recommendation com-
pleted, the analysis may end, or it may continue with development of an
advocacy plan or a plan for evaluating the new policy, should it be adopted.
Policy analyses are iterative. At any point in the analysis, if the results
are unclear, the analyst can and should return to earlier steps and repeat the
processes until the results enable a move to the next step.
Given the complex and time-consuming nature of policy analysis, most
analyses, in reality, are incomplete or at some point deemed to be “good
enough for now.” Analysts may be forced to cut short or skip entire steps in
the process if faced with time or resource constraints, meaning that a decision
has to be made based on information that is less than ideal.
Exhibit 11.3, using an example from a major capital city in Western
Europe, illustrates one way in which a policy analysis might be set up. In this
example, the problem is that the city’s hospitals are receiving large numbers
of pregnant migrant women who present for delivery without having received
adequate prenatal care, resulting in costly complications and adverse outcomes
for infants and mothers. The policy alternatives represent ways in which the
hospitals might provide prenatal care free of charge for pregnant migrant women
who come to on-site outpatient clinics. Based on the comparison presented in
the exhibit, the fourth policy alternative appears to be the best choice among
those presented.
As noted in chapter 6, cultural competence is a crucial aspect of effective
leadership, but the concept is equally important in the context of global health
policy. Policies that do not take into consideration the community’s unique
social and cultural needs and characteristics risk underperforming or failing to
meet their goals. Policies that are culturally incompetent might, for example,
result in intended beneficiaries losing interest in a program or failing to use
services intended to help them.
Background about the sociocultural factors pertinent to a particular
policy context can be collected during the evidence-gathering phase of policy
analysis. In many cases, it can be acquired through document reviews or discus-
sions with stakeholders. Ideally, though, health policies should be conceived
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T h e G l o b a l H e a l t h c a r e M a n a g e r384
and constructed with the active involvement and leadership of representatives
of the community at which the policy is aimed. Participatory approaches to
community engagement that are considered standard for health services research
are equally relevant to the design and analysis of health policies. Policies are
most valuable when they respect and respond to the health beliefs, practices,
and cultural needs of the diverse populations being served.
Summary
Global health policy is a complex web of rules that police vested interests to
promote the attainment of the highest level of health possible for all people.
Health policies can be either formal or informal, and either written or unwrit-
ten. The health policy landscape includes macro-level, transnational policies;
country-level government policies; and micro-level policies in smaller units of
governance or in individual organizations. Health policies come from a variety
of sources and take a variety of forms, but they typically can be divided into
two broad categories: (1) allocative or redistributive policies, dealing with the
way goods or resources are shared, and (2) regulatory policies that dictate what
can and cannot be done. Health policy analysis involves examining the various
rules, the problems the rules are meant to address, the goals of the rules, and
the criteria used to evaluate the efficacy of the rules. One of the most popu-
lar approaches for health policy analysis is the step method, which follows a
systematic sequence of activities to comprehensively examine a problem, the
Criterion 1:
Cost
Criterion 2:
Time to
Implement
Criterion 3:
Effectiveness
Alternative 1:
Maintain status quo
Poor Good Poor
Alternative 2:
Increase the number of hospital-
based outpatient prenatal clinics
Poor Good Fair
Alternative 3:
Provide free transportation to hos-
pital outpatient prenatal clinics
Fair Good Fair
Alternative 4:
Move clinics to community-based
sites in migrant neighborhoods
Good Good Good
EXHIBIT 11.3
Comparing
Projected
Effectiveness
of Policy
Alternatives
Based on
Evaluation
Criteria
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C h a p t e r 1 1 : H e a l t h P o l i c y D e s i g n 385
policy designed to address it, the policy’s intended consequences, the policy’s
outcomes, and the variants of the policy that could potentially improve the
results.
Discussion Questions
1. Define global health policy.
2. Identify the steps in the policymaking process. How does the process
differ from one country to another? How is it similar?
3. Analyze the impact of sociocultural and political factors on the
establishment and implementation of health policy. How does national
health policy affect organizational management practice?
4. Describe the health policy process in your country. Analyze the
impact that redistributive policy and regulatory policy have on
your organization. How does this affect your approach to strategic
planning?
5. As a healthcare leader or manager, what steps could you take to
influence national health policy? How open is your ministry of health,
or similar organization, to policy analysis emanating from the grassroots
level? How can you work through the national political process to
influence policy?
Case Study: The Global Policy to Immunize Against Human
Papillomavirus
Human papillomavirus (HPV) is a necessary cause, though not the only
cause, of several sex-related cancers, capable of leading to cancers of the
uterine cervix, anus, penis, and pharynx. Of the more than 150 types of
HPV, 15 are carcinogenic, and two are responsible for 70 percent of cases
(Tomljenovic, Spinosa, and Shaw 2013).
After completing phase I, II, and III studies, three HPV vaccines have
been approved by the US Food and Drug Administration (FDA), with the
first—Gardasil—having been approved in 2006. The HPV vaccine has been
endorsed by several major health authorities worldwide, including the World
Health Organization (WHO), the European Medicines Agency (EMA), the
US Centers for Disease Control and Prevention (CDC), and the ministries of
health of more than 100 countries. However, despite its effectiveness and
safety assurances, growing scientific controversy surrounds the use of the
(continued)
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T h e G l o b a l H e a l t h c a r e M a n a g e r386
HPV vaccine, with a number of case reports suggesting serious adverse
effects (Nicol et al. 2016; Brinth et al. 2015). The global health policy support-
ing HPV vaccination meets the generally accepted criterion of having a basis
in a preponderance of scientific evidence. However, debate focuses on the
potential for overestimation of vaccine effectiveness and the underestimation
of vaccine safety risks. In addition, some have raised ethical concerns related
to possible conflicts of interest on the part of scientists who have vested
economic interest in …
5
Progressive Learning Discussion for Week 3
Topic of Interest Posting: Initial Post Due by Friday 9.am. Pick a topic from the list and discuss it in terms of the concept analysis and evaluation. Support your statements with credible evidence and offer an example. (Note: Select a topic that will allow you learn something new and is of interest to you.)
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· 1.Affordable Care Act (ACA): Impact, Defining Value, and Healthcare Reform
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· 2. Federal Health Policy: Legislation, Regulations, and Rules
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· 3. Global Health Policy: Assessment, Engagement, Partnerships, and Priorities
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· 4. Organizational Policies and Procedures in Healthcare Settings: Legal Aspects, Regulatory Compliance, and Managerial Decision Making
You will provide a response to at least two peers for the Initial Discussion by Saturday 10am, sharing information that may help them better understand their selected topic of interest. (Help them answer their question of interest> offer guidance to better topic understanding)
Lessons Learned Posting by Monday at 9am EST: You will
share the information that you learned
from your course readings, your peers, and your own research
.
Assess how your initial understanding of the topic differs from your present views. Define the lessons (minimum 1) learned and provide an outstanding questions (minimum 1) that you still may have on the topic.
A minimum of two APA references with correlating in-text citation(s)
are required from the week content
