Health Policy 3400 Lectures PDF

Week 1 Health Policy “Broad statement of the goals, objectives, and means that create the framework for activity. Often takes the form of explicit written documents but may also be implicit or unwritten” Policy process: ways in which policies are initiated, formulated, develop...

Week 1 Health Policy “Broad statement of the goals, objectives, and means that create the framework for activity. Often takes the form of explicit written documents but may also be implicit or unwritten” Policy process: ways in which policies are initiated, formulated, developed, etc Health is affected by decisions made by policy makers Health policy is a subset of public policy Policy Decisions try to Balance… 1. Individualism Independence, autonomy, liberty 2. Collectivism Group norms, common good, social justice and support 3. Policy goals Security, liberty, equity, efficiency Week 2 What is Policy? “Set of interrelated decisions taken by a political actor (s) concerning the selection of goals and the means of achieving them within a specified situation where these decisions should be within the power of these actors to achieve” Implications of this definition: policy is everywhere, not always written, can be deciding to do nothing, intent does not always = results Policy = politics (authoritative allocation of resources) Policy = intent, understanding, and process Public Policy “A strategic action led by a public authority in order to limit or increase the presence of certain phenomena within the population” Course of action/inaction chosen by public authorities that addresses a problem (s) Anchored in a set of beliefs about the best way to achieve goals Why Study Policy? Helps organize/manage modern societies Key in advocacy work and in allocating resources Understanding evidence and beliefs that guide policy Essential programs that work to change society Policy Rhetoric vs Reality What policymakers say they will do vs what they actually do Policy can be overgeneralized as: for or against? All or nothing?  Policy does not take place in a vacuum, its created in response to problems Should account for different ways problems are approached and understood Focusing events: episodes that catapult issues to the fore Existing Policies Are Based On… Political environment Economic environment Socio-cultural environment Administrative environment Actors, content, context, process Framework, tools, levers, belief systems Policy Failure Can Be Due to… Multiple or conflicting goals Multiple actors Key actors with different preferences or intensity Consensus Policy Theory Policy is made using rational consideration of alternative courses of action Choices are based on cost and benefits of evidence Focus on small improvements that can be made to improve existing services Emphasis on technical issues, not much about overall organization Neglects the importance of ideology, values, power, misses the big picture Ex. medical care Nuts and bolts lens Conflict/Critical Policy Theory Policy is influenced by social class, politics, and inequalities Considers broader issues in the organization and development of policy Acknowledges power differentials Who will be affected by this policy? Ex. health care Socio-cultural-economic lens Social Theory Applied to Policy Analysis Positivism - medical approach The only authentic knowledge is scientific Adheres to scientific method - hypothesis testing and identifying relationships Predict and control Bottom up approach Structural Functionalism - behavioural/lifestyle approach Apply positivist notions of knowledge and methodology  Society is viewed as an organism, a system of parts that function together to create effectiveness Shared norms and values, cooperation Interpretivism -socio-environmental approach Critique of positivism, emphasizes lived experience Hermeneutics: how people understand themselves through shared systems of meaning All views are equal Can remove important contexts that explain individual understandings and experiences Critical Theory - structural/critical approach Structures and processes that are usually hidden and ignored Critique and transformation of society as a whole Considers haves/have nots in society Nature and distribution of power, who has the ability to bring about change Ex. how political/economic structures shape the healthcare system Philosophy Cannot Be Ignored in Policy “Positions on key public policy issues are driven by largely implicit and unarticulated philosophical presuppositions that guide individuals’ notions of the nature of government, individuals’ moral obligations to each other, how society assesses quality of life, and what it means to be a community.” How knowledge is generated (ie our understanding of health) Basis for choosing interventions Reflects community and policy maker values Acceptable policy levers Epistemology = study of what knowledge is Ontology = study of existence Health WHO: physical, mental, social wellbeing, not merely absence of disease Lalonde report: biology, environment, lifestyle, health care organization Public health: art and science of preventing disease, prolonging life, and promoting health through efforts of society Also a social construct - some illnesses are embedded in cultural meaning Ableism = discrimination against those with disabilities Political Scientists: identify packages of positions often seen as consolidated in a single, preferred optimal state Why is Policy Challenging? 1. Worldviews Deeply held beliefs about how we interpret/experience the world What we think is true Schiff said it is: cognitive, affective, behavioural We connect our worldviews to our experiences of what is assumed to be right vs wrong Aspirational and acted upon Identifying yours identifies your greatest weakness 2. Decision theory A theory of beliefs and values and a theory of choice of how these meld together This amounts to a minimal account of rationality and the preferences that should be satisfied in any circumstance for someone 3. Bias People act on the basis of internalized schemas and engage in discriminatory behaviors without intent 4. Ideology Set of beliefs, especially one that can be used as a basis for a political organization What we think is right Can denote others beliefs and is used to wield power (political/socio-economic based) On a spectrum from left to right based on balance of individual vs societal rights Normative Ethics What is right and wrong (ie. What makes a good decision) Based on: justice (fairness, moral standing, procedural justice) and ethical choices and actions (deontology, consequentialism, virtue ethics) 1. Virtue Ethics - Aristotle Cultivating virtuous habits, good people make good decisions Person-based where character determines if someone is a good person In health care this means compassion, honesty, courage, thus doctors are trustworthy Antithesis: nuremberg trials 2. Consequentialism Ex. Utilitarianism by Mill: Moral decisions are identified based on extent to which they promote more happiness for the most people Often leads to further moral issues and conflict 3. Deontology - Kant Duty to do the right thing even if it produces a bad result Ex. hippocratic oath Ethical Principles They are prescriptive recommendations Permanent, universal and unchanging  1. Principlism Created in response to the failings of other theories Based on autonomy, justice, beneficence, non maleficence 2. Casuistry Case law of ethics Previous cases are a social construct that helps reflect how to handle new ones Path dependency 3. Feminist Approaches Skeptical towards traditional ethics Care and power focused Based on compassion, freedom, equality, distributive justice (equals should be treated equally and unequals should be treated unequally) Ethics of care is a sub field 4. Personalism Emphasis on human dignity and subjectivity Everyone should have access to choice treatment and information to make decisions Dr. Charlotte Blease Ted Talk 1. What is Blease’s main argument (e.g. George Clooney vs. Gerald Barnes)? -Barnes bedside manner well rewarded despite never going to med school -Barnes training was a TV show, and Clooney helped him learn how to act like a doctor -doctors lack professional insight, medicine needs outsiders 2. Genetics loads the gun, environment pulls the trigger. Are there bullets we have not really considered? -how one perceives their doctor and vise versa can influence health outcome -socioeconomic status, skin colour, age, weight, etc affects care -lead to diagnostic inaccuracy and inferior consultations 3. How do psychological (or worldview) issues affect patient outcomes? -if your doctor listens to you, you are more likely to listen to your doctor -racism/ageism problems persist because people do not admit to having these biases -Lake Wobegon effect, everyone thinks they are above average/better than everyone else -medicine is missing cognitive revolution, eg. we crave high calories because of past scarcity -medicine has to come to terms with this -medicine misconceives itself as science facts and softer/nice facts so the importance is undermined 4. “Art is anything you can get away with” shows us influences on decision-making. How can we improve this psychological problem? -digitization of medical care -enhanced doctor patient relationship -reflect on our implicit biases -put a premium on empathy, talk to doctors the way we want to be spoken to Thinking & Policy Development/Analysis How we see things determine what decisions we make Defining what health is Do we make a choice or do nothing? Selecting goals, for who and why? What will we choose and how will we choose it? Who are we choosing for and do we want to be choosing for them? What social theories of health are applicable to most people? What is the basis for these choices? Health Policy Analysis Multidisciplinary approach to public policy Explains interactions between institutions, interests, and ideas in policy process Understand past failures and successes to plan for future policy It is challenging and hard to measure resources, values, beliefs, power Canadian Public Health Ethics Framework - Making a Policy 1. Identify issue and gather facts to understand it (problem ID) 2. Identify and analyze ethical considerations and prioritize values/principles that will be upheld (agenda setting) 3. Identify and assess options in light of these values/principles (policy formulation) 4. Select best course of action and implement (policy legitimation/implementation) 5. Evaluate Normative Decision Making Is the problem related to duty Are decision makers good people Are there consequences of our decisions Key Ethical Principles Justice Autonomy Beneficence Non-maleficence Ethics of care Personalism Feminism Policy Analysis Triangle - stakeholders in the middle 1. Content  Policy objectives, operation, legislation, regulations, guidelines, actors, influential people, groups 2. Context Social, economic, political, cultural, and environmental conditions 3. Process Way in which policies are initiated, developed, negotiated, communicated, implemented, evaluated Canada’s First SSBT - 2022 Taxing sugar sweetened beverages to encourage healthier choices Aligns with recommendations from WHO, Canada Healthy Eating Strategy, etc Revenue will fund healthy living initiatives Includes ready to drink, dispensed, and concentrated drinks Excludes exports, deliveries to indian reserves, natural sweeteners, medical, yogurt, etc Calculation: (container size/litre) x tax rate Week 3 The Toronto TB Case 1999, 5 of 200 Tibetans asking for refuge in Canada came with active TB resistant to many meds, putting people at risk Sent to shelter Media emphasized immigration system flaws in screening for disease, immigration policy, risk perception, and federal-provincial relations Media promoted fear and anxieties Public Health Health of populations, includes prevention and promotion Not addressed by Canada Health Act Services include: 1. Assess and monitor population health 2. Investigate, diagnose, and address health hazards/causes 3. Communicate effectively to inform and educate 4. Strengthen, support, and mobilize communities 5. Create, champion, and implement policies 6. Utilize legal and regulatory actions 7. Enable equitable access 8. Build a diverse and skilled workforce 9. Improve and innovate through evaluation/research 10. Build and maintain infrastructure for public health Population Health Approach that aims to improve health of a population and reduce its inequities Communicable Disease Transmission Direct (person to person, close proximity or touching) Indirect through a vehicle (contamination of an inanimate object ex. Water or food) Indirect through a vector (contamination by bridging species, ex. Covid, lyme disease) Airborne (droplets you breathe in/get inside your body) Tuberculosis Airborne bacteria, through coughs/talking Enters the lungs, progression occurs when bacteria multiplies (can happen right away or not at all) Can be treated when it is still latent Pulmonary TB = when it affects the lungs 1. Latent: not infectious, likely to develop if there are other risk factors 2. Active: infectious, deadly if not treated so be prompt 3. Multi drug resistant: resistant to isoniazid or rifampin, expensive, public health threat Framing Mental structures people use to categorize their thoughts, ie. how a policy is perceived and evaluated The same set of facts can be used to present different messages Framing helps determine how to influence an outcome/what stakeholders can participate in If the consequences of a problem are framed to only affect a few people, there will be less stakeholders involved Ex. Framing the Toronto TB Case 1. Illegal immigration 2. Infectious disease transmission/natural progression of disease 3. Public health risk 4. Cost, cost-benefit, opportunity cost 5. “Old disease” doctors have little training on Risk Identification/Perception All decisions/lack of decisions involve risk and media alters perceived risk Understanding risk (how many/who is exposed, extent to which it evokes dread) Less acceptable to leave alone if it is involuntary/catastrophic = a hazard and an exposure Prevalence Measure of how often a disease occurs in a population at a point in time Incidence Measure of the rate of occurrence of new cases of a disease in a specific time period in relation to the population which is disease free TB in Canada 2017 2.6% increase in cases Incidence rate increase from 4.8 to 4.9 Most cases among foreign born and indigenous peoples between 15-44 80.4% of cases treated successfully TB in Canada 2021 Increased by 50 people in 1 year Canada still one of the lowest rates in the world 1,055 foreign born In 2020, highest rate among Inuit people, people who travel, or live in endemic area Screening Mass screening (everybody) Selective screening (saves money) Multiphasic screening (looking for a condition that may not show up yet) Surveillance (looking for data that suggests condition is active in our environment) Case finding (find people with condition to determine root cause) Population surveys (status of health in population) Ethical Decision Making What is the right thing to do based on all the principles Based on: Risk, intervention effectiveness, costs, individual burden, fairness of policy Role of Government 1. Institutional Arrangements Policies we use to organize ourselves in society (levels of gov, ministries, etc) 2. Jurisdictional Issues Ex. Provinces responsible for healthcare under Constitution Act 3. Constitution Act 1982 Legislative act that created Canada Federal responsible for laws of peace/order/good governance, quarantine, and maintenance of marine hospitals Provinces responsible for education, hospitals, and healthcare Local are controlled by the province, therefore they vary widely across Canada Charter of rights and freedoms Repatriation of the constitution (rights of aboriginal, provincial jurisdiction over natural resources) 4. Canada Health Act 1984 Public administration, comprehensiveness, universality, portability, accessibility Right to publicly funded health insurance We should protect/promote wellbeing and give access to health services without barriers Has criteria provinces have to follow to be funded/what is funded (UPPAC)  5. Federal Government Controls spending power, power to pass laws for peace/order/good, and criminal law power Immigration Limited and temporary coverage of healthcare benefits to refugees (IFHP) 6. Provincial Government Hospitals and clinics Drug benefit plans Training of physicians/providers Long term care 7. Municipality Health Protection and Promotion Act 1983: discloses a list of diseases that must be reported to public health 1998 reducing number of public health units Vaccinations, communicable diseases, sexual health, etc Additional Stakeholders 1. TB specialists Understand drug resistance, symptoms vs screening, medical school, quality of care for tibetans, social, psychological, and pharmacological aspects 2. The media Timing, relevance, fame, human interest Often non representative of what is going on How the media frames it When is something newsworthy? In this case, it was probably a slow week and they wanted attention Effects and Implementation Framework Policy Options: questions to ask Who is at risk? Who must we work with? Who pays?  Surveillance? Quarantine? Future screening protocol? Possibilities Test all Test high risk Do not screen or test, contact trace Screening Looking for disease in population that does not have risk factors Testing Confirming diagnosis or aiding in monitoring/treatment Resulting Policy Changes Toronto public health: TB x ray and skin test Ontario ministry of health: TB services for uninsured people Federal government: cancelled health insurance for refugees, then reinstated Canadian charter of rights and freedoms guarantees freedoms for all in Canada Healthy Public Policy Improves living conditions Includes housing, education, nutrition, information, child care, transportation, etc Before making a Policy Decision 1. Inform a decision maker about adopting a certain public policy 2. Promote the adoption of a public policy 3. Compare public policies Analyzing a Policy Determine whether the policy should be prolonged or a weaknesses that can be fixed Ask evaluation questions  1. Effectiveness Does it achieve its objective Distal Effects Long term Immediate Effects Can help determine root causes of the problem by deconstructing chain of events 2. Unintended Effects 3. Equity How the program affects different groups 4. Costs Actual, relative, hidden, opportunity Whose costs? Opportunity Costs Cost of something is what you give up to get it Ex. how much good health would be lost if we allocated more money to obesity interventions? 5. Feasibility Resource availability, pilot programs, is there cooperation, etc 6. Acceptability Do stakeholders think it will work, are there alternatives Monkeypox (Mpox) Zoonotic infection characterized by prodrome, fever, malaise, lymphadenopathy and lesions Epidemic in 2023/2024 High risk (direct exposure to lesions or fluids) = avoid sexual/intimate contact for 21 days, monitor symptoms, avoid vulnerable groups, and exclude from work if necessary Medium risk (indirect exposure or proximity) = passive monitoring, avoid sexual/intimate contact, and refrain from international travel for 21 days Low risk (protected exposure) = no specific actions required Public health recommendations including vaccination to reduce risk Week 5 - Obesity Trimming the Fat Hybrid example of policy that is proactive and reactive  Preventing others from becoming obese and responding to those that already are Making “Healthy Canadians” via Policy starts with… 1. CIHI (Canadian Institute for Health Information) Helps us understand the nature of health problems/where we need to make adjustments 2 systems: discharge abstract database (health record created for every patient admitted to hospital) and national ambulatory care reporting system (health record created for patients treated but not admitted) 2. ICD-10 (worldwide standard of diagnoses) Collected in a standard way so we can have an idea on the prevalence of conditions Also CCI code (what was done if you had a surgery) 3. Life Expectancy Can also use HALE (health adjusted life expectancy - years in complete health) 4. PYLL (potential years of life lost - looks at burden of illnesses) Problem with Family Medicine There is no standard database All kept in office medical records Nature of the Problem Obesity has contemporary and future health implications Good research has been done that links it to other conditions and lots at risk Doing work now will prevent future financial burdens Leading Causes of Death (HALF RELATED TO OBESITY) Malignant neoplasms Heart disease COVID Accidents Cerebrovascular disease Chronic lower respiratory disease Diabetes Influenza/pneumonia Alzhimers Liver disease Obesity Measured by BMI (ratio of height and weight) A health problem and a risk factor Associated with immediate and long term effects (heart disease, stroke, diabetes, cancer, bone/joint issues, poor mental health) Today 30% of children 5-17 are overweight/obese Understanding ages, other countries, and costs helps us understand what to do Framing Obesity Examples 1. Obesity is genetic and lifestyle based 2. Obesity is related to the environment people live in (climate, mobility, access to food) 3. Obesity is related to SDH (availability of food, income, economic conditions) 4. Obesity as different types of burdens (individual, population, cost, risk factor) Strategic Lenses - how we can solve Who do we target? Resolution often needs multiple approaches and levels of support Scope of conflict is important in defining this Scope of Conflict The importance of understanding who is involved in deciding about policies Related to elements such as who is involved, what are the terms, and what issues are on the table Helps determine the outcome of a problem in addition to framing When analyzing the scope of conflict for a particular policy issue, it is important to determine why groups do or do not participate in the policy process Influenced by: visibility (information about the policy), direction (the agenda of stakeholders/agreement of stakeholders and whether it important enough to be involved), and intensity (how attached a groups is to a policy) Stakeholders: government, health promotions, associations, media, food industry, etc Obesity Policy Considerations Scope of conflict Population health Built environment influence (some areas may be worse than others) Health promotion models Effects and implementation Population Health & Public Health A type of strategic lens Obesity is a population burden, therefore we must inform everyone Demography and Population Geography Demography: study of the human population, its structure, and relationships with environment, social, and economic change Includes size, rates of growth, fertility, life expectancy, mortality Helps us understand trends/predict future trends (ex. need for long term care beds) Key ways to study: population pyramid (barrel = aging, triangle = growth) Healthy Community Design How we design/plan communities has direct impacts on physical and mental health 1. Decrease dependence on automobiles  2. Provides opportunities to be active 3. Allow people to age in place 4. Improve air quality 5. Reduce risk of injuries 6. Increase social connection and community 7. Reduce contribution to climate change Natural Environment Ex. greenspace Built Environment Anything human built (ex. Neighbourhoods, work, schools, shops, parks, food systems, waste disposal, etc) Built form: design element of the built environment, how we decide to build things Ex. Big garages promote automobile use/not seeing neighbours whereas backyard garages promote better walking space Opportunity Structures: socially constructed features of the physical and social environment which affects health (all examples above) Ex. food systems: higher income neighbourhoods had less access to junk food than low income Ex. some parks can be rented so lower income people may have restricted access Food Desert: limited access to healthy and affordable food Food Swamp: unhealthy foods more readily available than healthy Important Considerations of Urban Planning of Built Environment Population Density Urban Sprawl Land use Patterns Pedestrian & Cyclist safety Climate Access to Food: Deserts and Swamps Noise Crime Gentrification Social Environment Ex. peers, family Key Considerations for Obesity Policy Implementation Cost State Political ideology Government turnover (government is short sighted and you will not see results for years) Individual and societal rights (how far can we go/interfere with them) Institutional arrangements Resources Resistance from political leaders Policies 1. Redistributive: impose costs or provide incentives to encourage behaviours (ex. Taxing or rebates, speeding tickets) 2. Regulatory: impose restrictions or inducements on behaviours, can involve money if it is not intended to be redistributed to someone specific (ex. SSB tax, building code standards) 3. Allocational: fund activities to produce health benefits (ex. Free admission to recreational activities) Policy Considerations Trade offs: between protecting health and controlling the expenses/cost effectiveness Ex. Chronic disease can increase need for care but also lower life expectancy (dead people do not use healthcare) Policy Instruments 1. Material instruments (more likely to result in changes) Exhortation: government encourages stakeholders to act in a way through information Expenditure: government funding for specific purposes (ex. Giving tax breaks) Regulation: rules are established to encourage or penalize actions Public ownership: government directly runs an activity 2. Economic instruments (puts a cost on intangible things) Ex. Incentives for investments in improved technology Ex. Raise taxes to achieve health objectives Authority Based Rules 1. Laws 2. Regulations 3. Directives Chances a policy will work depends on… Synergy with other policies Feasibility Equity/equality  Political commitment Resource based Long-range policy Impact assessment Policy Options Obesity 1. Changing the Built Environment 2. Taxing Sugar Sweetened Beverages 3. Subsidizing Healthy Foods 4. Restricting Marketing of Unhealthy Foods/Drinks 5. Intensifying Nutritional Labels 6. Education on Physical Activity 7. Invest in Healthcare Services 8. Incentives that promote physical activity The Black Box Problem Often there is an unknown in between an intervention and how it leads to its outcome Eg. Nutrition labelling leads to reduced obesity but what responses are in between? Logic Model The chain of effects that link a policy to a health problem it aims to solve Understanding how a policy works through proof of: planned work, goals of the program, key elements and outcomes of the program Helps identity the core elements of an evaluation strategy Forward Logic Model (for bigger budget) 1. Inputs: resources that are needed to operate the program 2. Activities: using resources to accomplish planned activities 3. Outputs: delivering the amount of product/service that you intended 4. Outcomes: participants will benefit in the ways you planned 5. Impact: certain changes in organizations, communities, or systems might occur Integration of Evidence When deciding what outcomes/outputs are, you need to look at the evidence Complexity of policy formation before starting a model National and global forces exist which is why context matters ○ Can you do this everywhere? Intermediate Effects Nutritional label example Inputs Techniques, tools, and actions of the planned program Activities What you do with the inputs Products (promotional/educational material) Services (education, counselling, screening) Infrastructure (relationships, structure, and capacity used to bring results) Contextual Conditions Resources/barriers which enable or limit program effectiveness Resources include funding, partners, staff, time, etc. Barriers include attitudes, lack of resources, policies, laws, regulations, and geography Outputs Direct results of activities Was it delivered to the intended audience at the intended “dose” Outcomes Changes in attitudes, behaviours, and knowledge at the organizational, community, or individual level Short, intermediate, and long term Benefits of Logic Model Stakeholder understanding, reference point, monitoring, asking questions, identifying external factors that can affect program, etc Week 6 Trouble on Tap  Walkerton outbreak of E.coli and campylobacter bacteria in water in 2000 Due to manure run off into well 7 dead, 2300 ill Public judicial inquiry to figure out what caused the illness and how to ensure future safety of water Chlorine levels were not being measured, falsified tests on water People drunk on the job or off sick Hard to trust government Regulation and public ownership 2 main problems Environmental Health Assessing, correcting, controlling, and preventing factors in the environment that can adversely affect health of present/future generations Environmental Stewardship Model Environment Public — disease –- death People harm the environment, the environment harms us back If you want to make a change in the environment, tag it to the health impacts Encourages people to care for their environment, so environment cares for them, prevents disease Swiss Cheese Model for Risk Management Different layers of policy problems The more layers, the more likely to have a problem Framing Examples Budgetary restrictions, relying on privatized water testing “Bad apple” theory Framing is about symbolism and policy stories Ex. Exhortation Encourage people to boil water  If nobody follows it, won't work, so have to create a regulation Choosing a Policy When Dealing with Reactive Situations 1. Ideology: Common Sense Revolution PC party passed bills that reduced regulatory oversight and allowed more pollution/construction Defunding, privatization of service, local municipality had no independent authority 2. Nature of public goods (PUBLIC GOOD DOESN’T = GOOD FOR THE PUBLIC) Public good: collective goods (clean water, clean air), defined by rivalry and excludability Non-Rivalry: when consumed it doesn’t reduce amount available for others Non-Excludability: it is impossible to provide a good without it being possible for others to benefit from it Free rider problem: avoid paying for public goods knowing you will still benefit from others paying 3. Production characteristics of public goods Contestable: how easy it is to get into the market Measurability: precision in which it can be measured, makes monitoring easier Complexity: do goods stand alone or require coordination (ex. Water testing) External Costs of Production Characteristics Side effects/health effects Loss of trust Days of work lost Externalities Un‐priced, unintentional and uncompensated side effect of one agents’ action, that directly affects the welfare of another Costs imposed on society and the environment that are not accounted for by the producers or consumers (ex. pollution) Private costs of production tend to be lower than its “social” cost Polluter/user-pays principle: prompts households and enterprises to internalise externalities in their plans and budgets Public-Private Apply to financing and delivery Public can apply to many levels of government, dominant for water service Private can apply to for profit corporations and small businesses involved in water service delivery, lab work Quasi Public: legally private but regulated Not for profit Privatization Types 1. Terminating public programs and disengaging the government from responsibility  2. Transfer of public assets to private ownership (ex. 407) 3. Public financing of private service delivery (ex. Life labs) 4. Deregulation of entry into activities previously public Privatization of Public Goods Contracting out and defining what constitutes good performance, lots of planning Can fall apart without good planning eg. walkerton case neglected specifying that tests should be conducted by someone who understood what they meant Obligation to maximize their profits, not to go beyond terms of contract Accountability Responsible to its stakeholders for decisions made and policies implemented Can be before or after (ex. impose taxes/tariffs) Transparency: encourages stakeholder participation in its decision making process, processes are open to the public Precautionary principle: obligation to protect populations against reasonably foreseeable threats Street Level Bureaucracy People who work on the front lines who have direct interactions with the public and have leeway in how they do their job (ex. Teachers change curriculum) Public Inquiries Act Inquiry will be made concerning any matter concerning the good government of Ontario or conduct of public business that is of public concern Public Inquiries Are episodic, often demands a public response that is specific about the past, future, cost efficient, and speedy Commissioner may act as a number of roles Canada is a heavy user of these O’Connor Report 2002 (KNOW THIS) Pt 1: 28 recommendations for more public health units, communication, boiling water, inspections, training, MOE business processes Pt 2: 93 recommendations on a multi-barrier approach, what is needed to reduce risk at every stage (ex. Looking at the swiss cheese model) Multi-Barrier Approach to Source Water Protection 1. Source water protection 2. Water treatment 3. Inspection 4. Testing 5. Distribution  6. Drinking Wendy Blunt Language has Meaning Is informed by culture, social environments, and context More than a tool to exchange information Analyzing Language in Policy 1. What is the problem represented in this policy? 2. Where are the silences? 3. What is the effect of this representation of the problem? Diabetes Mellitus Insulin production is impaired or non existent Insulin ensures glucose is properly stored and used in the body Without insulin glucose passes through organs increasing risk for morbidity and mortality Type 2 Diabetes Most common, impacting 462 million worldwide Contributor to other illnesses Causes: behavioural, environmental, metabolic, genetic Terms associated: prediabetes, preventable, stigmatizing, inherited, silent, remission, epidemic, etc Diagnosing Type 2 Diabetes Oral glucose tolerance test (blood-sugar levels after eating) Fasting plasma glucose (blood-sugar levels after fasting) Glycosylated haemoglobin A1c (blood-sugar levels over time?) Prediabetes Potential to prevent type 2 diabetes A1c of 6-6.49% 5-10% of people with this will progress each year 31% will regress Study for Diabetes 1. Interviews with family physicians, nurses, dietitians, pharmacists 2. Focus groups and interviews with patients told they were at risk 3. Policy analysis of the National Framework for Diabetes in Canada Addressing Risk for Type 2 Diabetes from Primary Care Providers Patient centred practice: patient knowledge, age, weight, time, symptoms, prediabetes Prediabetes: attending to it, family history, co-existing discourses, resistance to it Policy Analysis of Risk for Type 2 Diabetes in Federal Policy 1. Background Framework for diabetes released in Oct 2022 to provide a common policy direction to address diabetes Informed by stakeholder engagement activities such as surveys, interviews, etc Stakeholders were health providers, researchers, people with lived experience, etc 2. Data collection Explored how the solutions proposed represent the problem of risk for diabetes Sample of 8 documents 3. Analyze the language with 3 questions 4. Policy framing examples Make people aware of their risk Individual has to change on their own Absence of primary care 5. What can we do? Support primary care providers Prioritize built environment so people have space to be active Policies to address risk for this disease Week 7 - Genetic Screening and Testing in Infants The Case Many diseases have genetic components If they are detected early they can be treated Policy Issues of this Case 1. Screening 2. Insurance 3. Individual vs societal rights (including autonomy, privacy, and risk of discrimination) Public Policy Implications 1. Autonomy 2. Confidentiality (people are given information to be held in confidence) 3. Privacy (right to confidentiality, the actionable term) 4. Equity 5. Ethics 6. Policy - consensus and critical Genetic Screening Performed in general population for early detection and monitoring risks Purpose: preventing birth of individuals with certain conditions, early detection and treatment, identifying carriers Genetic Testing Tool that can help identify individuals at high risk for disease/vulnerability to environmental chemical hazards Implications regarding when these tests should be required, who has access to results, and what can be done with the info 2 scenarios: screening for reproductive decisions, screening for insurance and employment Testing applies to individuals who have higher probability of having a condition Profession 1. Possess specialized knowledge through training programs/certification 2. Provide services to the public 3. There is a risk to the public if the services are not done properly 4. Clients who receive services are not in a position to judge quality Evaluating Screening 1. Specificity Ability of a tool to correctly rule out disease Ability to obtain normal range or negative results for a person without a condition SpPIn (A highly Specific Positive test rules In the disease) 2. Sensitivity Ability of a tool to correctly pick up positive cases Proportion of true positive tests out of all patients with a condition Excellent at detecting disease (high true positive rate) but can produce false positives because they are tuned to catch as many cases as possible, even at the risk of mistakenly flagging some negative cases. SnNOut (A highly Sensitive Negative test rules Out the disease) 3. Disease Prevalence Affects predictive positive and negative value Highly prevalent disease = use test that is better at ruling in and worse at ruling out 4. Costs and consequences of false results Predictive Value - what is most economical to do the best job 1. Positive predictive value Ratio of true positives (numerator) relative to the true + false positives (denominator) 2. Negative predictive value Ratio of true negatives (numerator) relative to true + false negatives (denominator) The Concept of Normality  Determining what is normal/abnormal and who decides this Has to exist for a test to exist Once determined you have implications regarding it (ex. Eugenics - do we prevent the birth of abnormal children?) When is Screening Justified? - WHO Condition is an important health problem (costly? increase disability in the population?) There are accepted treatments for patients with recognized disease Facilities for diagnosis and treatment Recognizable latent or early symptomatic stage Suitable test or exam (has to be reliable) Test is acceptable to the population (ex. is it invasive?) Natural history of the disease is known Agreed on policy to who can be treated Case finding is economically balanced in relation to the possible expenditure on care Case finding is a continuing process Early Success in Genetic Screening Tests Guthrie Test by Dr. Robert Guthrie for Phenylketonuria - PKU (brain damage caused by inability to metabolize Phenylalanine in food) “Heel Prick” test - replaced by mass spectroscopy Prenatal tests for PKU as well Criteria to Choose Screening Methods in Ontario 1. Identity objective (reason for genetic screening) 2. Feasibility (needs to be done in an integrated program) 3. Propensity (high risk individuals should be screened by a simple/inexpensive test that is specific and sensitive) 4. Significance of disease 5. Benefit of treatment 6. Consent 7. Regulation (outcome of screening should be monitored) 8. Values 9. Cost When do we Screen? Prenatal Newborn Among various members of population Once symptoms appear Under-writing (evaluating the riskiness of an insurance policy) Propensity and availability of treatment As a condition of employment? Employment Screening Legally can be done to prevent certain employees from being onboarded Prevent work-related injury and disease Examples: hemoglobinopathies, sickle cell disease, beta-thalassemia, lipid disorders, alpha-1-antitrypsin deficiency, adult onset gaucher disease, huntington disease What we Screen for In Ontario 1. Prenatal Downs syndrome (trisomy 21) Edwards syndrome (trisomy 18) Patau syndrome (trisomy 13) - non invasive Sex chromosomes 2. Newborn (always changing) Congenital Hypothyroidism (thyroid gland absent or does not produce enough thyroxine) Sickle Cell Anemia (severe type of anemia) Krabbe Disease (neurodegenerative disorder - body does not make enough galactosylceramidase to create myelin for nerves) Duchenne Muscular Dystrophy (slowly progressive muscle disease) Cystic Fibrosis (chronic progressive lung disease and intestinal malabsorption) 3. Other Colon Cancer Check Ontario Breast Screening program Ontario Cervical Screening Program Ontario Lung Screening Program Amniocentesis: needle into amniotic sac to collect fluid, done at 15-20 weeks Chorionic Villus Biopsy: catheter through cervix/abdominal wall to obtain sample of embryonic placenta, done at 10-12 weeks Maternal Screening 1. Age Older = greater risk for chromosomal abnormalities 2. Serum screening Detect compounds suggesting disease 3. Midtrimester ultrasound Screening Context Rights 1. Right to remain ignorant But genetic information doesn’t just affect the person tested… 2. Right of privacy and the right to know Research - Screening “Wiggle Room”  Incidental findings: discovery about participants during research but not included in the study objectives - can also affect non participants Material: welfare implications for the participant Incidental findings more probable due to technology advancements, lots of data, innovation Ex. unexpected mass on CT scan When do I Report Something? 1. Valid (accurate finding) 2. Significant (important to the participant, affects welfare) 3. Actionable (participant can use this info for action - ex. treatment or research) Minimizing Harm has Downsides Test interpretation (hard to interpret for healthy high risk people since many conditions are multifactorial) Lack of options to treat Danger to employment and insurance Psychological impact (survivor’s guilt, anxiety, fear of discrimination) Moral Hazard Insulating people from risk may make them less concerned with negative consequences of that risk (keeping info away from people) Copay or deductible or refusal to provide policies for high risk People use healthcare resources inappropriately and do high risk things and that makes cost go up Prospect Theory People react differently to gains than to losses (more risk averse) People are willing to take risks to win the lottery but not for their health for example People make decisions based on assessments of probabilities which may be different than the truth Discrimination and Confidentiality People are treated differently by their employer/insurance because they have a genetic condition that increases risk of inherited disorder To counteract these problems, USA has GINA and Canada has GNDA GINA: prevents health insurers from using genetic info to determine eligibility/cost GNDA: protects Canadians from discrimination based on genetic characteristics, amendments made, does not apply to family history, diagnosis of manifested disease, or symptoms Direct to Consumer Genetic Testing Important to understand privacy risks and transparency from providers GNDA prohibits organizations to collect, use, or disclose without consent  Research is a separate consent Contemporary Applications of Genetic Medicine Dr. Kim assesses ability to metabolize different drugs (ex. Opioids, chemo) London Health Sciences Medical Genetics Program Centre for Precision Medicine at Vanderbilt To Screen or Not Screen Importance of autonomy, privacy, and risk Cost-benefit Cultural, situational, and structural contexts Gene Disorders 1. Single gene disorders - called mendelian conditions Can be dominant or recessive If it is on sex chromosomes, males are more susceptible 2. Multifactorial 3. Chromosomal Often more severe with autosomal chromosomes Genetic Diagnostic Technology 1. Biomedical testing Showing accumulation of a compound as a result of a genetic defect Simple, low cost, rapid analysis 2. DNA testing Requires knowledge of exact nature of nucleotide sequence changes associated with the defect Specific mutation analysis (know specific mutation) or genetic linkage analysis (know the mutation is close to a specific gene) 3. Chromosome analysis Patients karyotype can be compared with a normal one Through collecting tissue and stimulating it to divide Genomics and Genomics England - Sim Baker Finding policies that maximize equity and accessibility Genomics Takes genome and tells us patterns between genes Spots variants within genetic code by comparing people’s data Genomics England Operate as a national database for genome sequences (national genomics library) Free access to these genetic services that can be returned to your family physician to interpret and prevent/treat diseases early  Can compare this database to others around the world to find more patterns 4,000 researchers, work with 7 top pharma companies and tech companies such as amazon for lab technology Funded by department of health, uk research, and cancer charities Cancer vaccinations to prevent relapses National health service - clinicians and patients can send in their genome to be analyzed Newborn Screening Program - the Generation Study Government supported Aims to find out the extent to which newborn diseases affect life and provide treatment Media coverage of this program reached approximately 1.33 billion Start at newborn stage and continue across a lifetime for predictive and preventative care AI in Genomics 1. Better health Machines can look through data quickly, increased volume of diagnosis and treatment Find predictive models for disease 2. Driving innovation Tooling that links patients to clinical trials and treatments Partner with industry 3. World leading research Investigate models to accelerate discoveries Get though larger volumes of data faster AI Project Examples Go back to slide - can’t see in person Foundation of Trust - every data point belongs to an individual Engagement Ethics Communications Diverse data - 3 year program that looks how we target conditions in non white groups, aiming to broaden these data sets Equity and inclusion Accessibility Data protection