Week 1 Lecture 1 - Google Docs PDF

Week 1 Lecture 1 Welcome to HS3400! What about Policy? A bit about the course ○ Structure ○ Content ○ Engagement Course Ops o Syllabus o Assignments o Etc. Welcome to Health Policy – 3400A “Absolute freedom is the right of the strongest to dominate,’ Camus wrote, while ‘absolute justice is achieved by the suppression of all contradiction: therefore it destroys freedom.’ The conflict between justice and freedom required constant re-balancing, political moderation, an acceptance and celebration of that which limits the most: our humanity. ‘To live and let live,’ he said, ‘in order to create what we are.” (Dresser, 2017) ○ Dresser, S. (2017). How Camus and Sartre Split up Over the Question of How to Be Free. Psyche.; URL: https://aeon.co/ideas/how-camus-and-sartre-split-up-over-the-question-of-how-to- be-free. Accessed August 11, 2020 Policy is often seen in a negative light A bit about me… Denise Grafton [email protected] Office Hours by Appointment (virtual, I don't have a campus office – but I do have an office at SJH) I am a health geographer & why this matters How I practice policy ○ Deal with legislation policy and rules Your Teaching Team We have 7 TAs this term representing 5.0 FTE Office Hours by Appointment, please see OWL for details Everyone will be assigned to a TA. This will be your point of contact for questions throughout the term All questions NOT of a personal nature should be posted to the Discussion Boards WHY is this a Mandatory Course? (...Or Death by 1000 cuts) You can't work in the health care profession without being influenced by policy! The more you know about policies, the more you can influence your job and influence working conditions All of these associations have their own policies, the places where these people work have policies, hospitals have policies, dental care policies, etc. Our idea in this course is to take policy to help us work toward a desired outcome What is Policy? Health Policy? 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" (Buse et. al., 2012) ○ Sometimes policies are written on paper or online, or sometimes unwritten ○ A lot of rules and social norms are policy but are not written down The Policy Process: ○ the way in which policies are initiated, formulated, developed, negotiated, communicated, implemented and evaluated ○ The policy process is what's important to understand ○ Ex: UWO CUPE Strike Why are they closing university traffic system? It is easy to get angry at policy But there are reasons for it, and the better you understand the policy process, why these decisions were made, and the factors considered, it will help you understand and work within it better and help facilitate change ○ Policy process is about why things have started, why have they developed, how are they negotiated, etc. Public Policy ○ government policy or policies of government agencies Who cares? Health is affected by the decisions that are made by policy makers and the relationship between these decisions/choices and health outcomes are critical Ex: Minnesota State Fair What policies do we see in the picture? (discussion) ○ Pedestrian friendly Changing what streets/roads are open so people can walk ○ Maximum capacity How many people can come in and what number is safe ○ Parking The cost of parking Who's allowed to park, who's allowed to drive Policy is everywhere ○ It doesn't matter what discipline you are in ○ All of these policies are negotiated and decided on Decisions for policies can be seen in a positive or negative light ○ A certain policy can be perceived as good or bad by different groups of people ○ Not everyone will ever agree on a policy Policy = Politics Ideology and worldviews are important – even if you don't share them Policy is strongly correlated to politics ○ People will agree and disagree with policy Political compass ○ https://www.politicalcompass.org/test/en?page=1#google_vignette ○ We all have to operate in the same space even though we don't fall on the same place on the compass ○ Where you fall on the graph will influence what kind of policies you support and disagree with What happens when we don't agree? With policy making, policy process you are looking at how policies are made and how well they work Always trying to find a balance between the benefits for the group/collective, and also the will/desires of the individual ○ Ex: To allow people their independence, autonomy, liberty to go to fair, eat a hotdog, park where they want to park, but ALSO what is good for the group Policy tries to balance these things ○ TRIES -- doesn't always succeed Ex: can now buy liquor at the cornerstone ○ Some agree, some don't ○ This decision took a long time to make, and it's all about balancing the factors listed below There will always be conflict when it comes to policy ○ Not always going to agree but try to understand better Policy decisions, particularly with respect to health try to balance: Individualism ○ Personal independence ○ Autonomy ○ Liberty Collectivism ○ Group norms ○ Common good ○ Social justice ○ Social support Policy Goals: ○Security ○Liberty ○Equity ○Efficiency Potentially in CONFLICT with each other and prone to DIFFERENT INTERPRETATIONS! Ex: Cost The least well off people find it harder to get healthcare they need ○ Depending on where you live this is important -- e.g. USA vs Canada Opportunity cost problem ○ It is also an opportunity cost problem ○ If you are making minimum wage it is harder to take time off from work and be able to pay for bills, etc. Also relates to social economic status, and social determinants of health Produced by OECD ○ OECD - Organisation for Economic Co-operation and Development ○ The organization has to mandate the mission ○ The mission and the mandate will show up in the things that they produce Produced by the Heritage Foundation Public vs. private spending infographic Use this kind of data to make lobbying, and advocate for different policy choices ○ E.g. we are already spending 31% of the money on private healthcare, why not expand it It is about cost, but there is also motive behind presentation of costs data Produced by the International Insurance company Map of USA showing the average premiums for healthcare coverage Why does it cost more in certain places to other? ○ Ex: more expensive in Wyoming and South Dakota vs. Michigan ○ What does the government do in those states and how do they fund their program? Why are they producing this information? Think about: ○ (a) the message it sends ○ (b) why they are sending it ○ (c) what happens on the ground to create these patterns? Future costs through cost benefits and cost effectiveness relevant to quality of life show up in things like who's smoking vs. who's vaping, etc. There might not be a health cost now, but 4 years later they probably will There will always be: ○ Information that is part of the policy process ○ A rationale for the presentation of that information ○ Information can be used in different ways Can take one specific data set and come up with 3 different policy alternatives and use it in different ways This is what is interesting about policy -- like a bunch of ingredients and you can put stuff together to get different outcomes Course Syllabus and Evaluation Items Course Textbook Case Studies in Canadian Health Policy and Management Raisa Deber and Catherine Mah University of Toronto Press, 2014 See the course syllabus for information on how to obtain a copy; the UWO Bookstore has ordered copies for this class Assigned Readings are provided in the Course Schedule in OWL Textbook structure overview Evaluations Midterm (30%) ○ October 29 ○ 8:30-10:30 Final (40%) ○ Non-cumulative ○ TBA 2 Briefing Notes (30%) ○ 5-6 students ○ Due Nov 17 (+ 3 day grace period) Asking Questions! All questions should be posted on OWL forums. Forums, or discussion boards, will be used regularly as a ‘first line’ for asking questions on course content. Students can expect questions to be answered within 48 hours, with the exception of weekends. The forums will be set up to include a separate space for questions and discussion on: (1) course content; (2) mid-term exam; (3) project/assignments; (4) final exam. The instructor can delete posts that are deemed to be inappropriate. Teaching assistants and course faculty will respond to posted questions. Students are also encouraged to respond to questions to facilitate learning and share their own insights on course content. Please be respectful of the teaching team and your peers! What's UP next? Class #2 this week: Introduction to Policy, Theory & a wee bit of Epistemology We need to consider WHY we make the decisions we make in health care policy and delivery This topic is NOT in the textbook On-line link to the Health Care Ethics dictionary (Internet Encyclopedia of Philosophy) has been provided in OWL ONLY review the first three chapters and the conclusion Week 2 Lecture 1 Philosophy and Policy – Why it Matters Roadmap Perspective matters What is Policy, anyway? ○ Policy is about making choices! The Policy Making Process and how can we examine policy? Influences on Policy ○ Environments and contexts ○ Actors and Process ○ Philosophy; Epistemology and Ontology ○ Beliefs, worldviews, ideology, biases, moral decision making, and ethical principles Learning Outcomes To develop an understanding of the policy process and the role of thoughts, values, and ideas in that process To differentiate between Consensus and Critical policy approahces To differentiate between Positivist, Structural Functionalist, Interpretivism, and Critical theory policy approaches To understand and explain the importance of epistemology and ontology in policy making To establish what elements are necessary for "good policy" To identify the characteristics of health that are cultural constructs To differentiate between worldview, ideology, bias and decision theory To identify and evaluate different methods of normative ethics To identify and explain key ethical principles in health policy formation To be critical and thoughtful of what influences our decision making What is this lecture about? While today's topic may seem to be a hodge-podge of ideas and structures, the overall goal is to understand why and how we make decisions when it comes to policy AND why there are often competing interests and disagreements. ○ Healthcare is people-centric and people are different, so there will be variation in what people want to see in HC and health policy ○ Therefore, a big consideration is what is the morally correct action Non-protest policy (Western) ○ Would have had to seek permission to protest ○ Why is it not morally correct? Publicly funded, place for public and free speak Policy is about making positive changes and the most morally correct choice ○ But people are different Key consideration in any HP decision: what is the morally right action? ○ It is hard to get people behind a policy if you can't convince them it's morally correct ○ End goal is to make the morally correct choice -- this is what makes policy fun but also challenging What is Policy? Policy: “A set of interrelated decisions taken by a political actor or group of actors concerning the selection of goals and the means of achieving them within a specified situation where these decisions should, in principle, be within the power of these actors to achieve.” (Jenkins, 1978) ○ A set of decisions that people in power make with an end goal in mind Everywhere ○ Policy is everywhere Not written down, necessarily ○ Ex: walking on one side of the hallway Can be “No” decision ○ Doing nothing is a policy choice Intent doesn’t always = results ○ Might have the intent of doing something good but might not work out ○ Can have a good policy that doesn't do what you wanted it to do ○ Good policies undergo evaluations to change for the better Difference in power can change the results of the policy 3 main components of policy: ○ Structures The frameworks in which you can build policy Actors, stakeholders Where you are is important for context i.e. making policies in Ontario is different from Italy ○ Process Is it top down? Or do we involve the people who it will affect? ○ Outcomes Does the intention equal the results What is Public Policy? Public Policy: a course of action or inaction CHOSEN by public authorities ○ Choices and decisions created by public authorities ○ Are often ideologically driven and anchored in a set of beliefs Addresses a given problem Addresses inter-related sets of problems Anchored in a set of beliefs about the best way to achieve those goals (Bryant, 2016) ○ i.e. different parities in government have different goals grounded in their set of beliefs Health Policy is a sub-set of Public Policy ○ Who has power and who does not have it to influence policy and outcomes? Who benefits/does not benefit? Why study policy? Central instrument for helping to organize and manage modern societies Often key in advocacy work ○ Relevant for non-profit work, advocacy work, etc. Not just why and how to act, but also the allocation of resources Policy can be thought of as ‘intent’, and, also as ‘understanding’ and ‘process’ Understanding the evidence that guides policy AND the beliefs that guide what we do/do not do Essential programs that work to change society Can’t work in HC and not be influenced by policy Understanding how it works helps you with advocacy Policy "Rhetoric" vs. Reality Policies are often seen as good or bad ○ But policy doesn't take place in a vacuum and shouldn't be distilled inro goodness vs. badness Policy as two choices: for or against? All or nothing? Or more nuanced? ○ Good choices vs. bad choices ○ But policy choices shouldn’t be distilled down to good voices or bad choices Policy does not take place in a vacuum Course of action created by actors in response to public problems Accounting for different ways problems are approached and understood Focusing events: episodes/experiences that catapult issues to the fore ○ Something that happens in the world around us that draws attention and needs fixing ○ Brings public attention ○ Often event causes outrage and need to make changes to existing policies ○ Can also be an issue that creates a policy or bring attention to an existing policy What do we already know about making policy? Ex: don't put blueberry filling in a jelly donut ○ We know the problem ○ But WHY don't we want to put blueberry filling in a jelly donut? There are many ways to frame it E.g. ppl don't like it, it doesn't sell, etc. ○ Only saying don't do something is not enough, need to frame it Steps: ○ Problem ID ID the problem How are you framing the problem? What is your view of the problem? How we frame the problem dictates the rest of the policy steps What is your stance ○ Agenda Setting Who do you have to consult, involve, etc. Who are we affecting, when will it be in effect? The things you would like to do that are theoretical or evidence based that will solve the problem ○ Policy Formulation What are we going to do? Will be different based on geographical location -- i.e. Alberta vs. Ontario, etc. Geared toward where policy will take place ○ Policy Legitimation How do we move forward in making this a thing Have to tell people that this is happening and that there is a ban on blueberry jelly donuts Tell people that there is a new policy -- it may be a focusing event ○ Policy Implementation How will we put this into action? Policy lever: what do you have that you can wield to make changes Steps can go on forever and can start anywhere + evaluation Ex: obesity ○ Problem ID Have to frame obesity (problem ID) There are multiple factors of obesity so there can be many policies So you need to pick one How did we end up with existing policies? What will they look like in the future? Policies are due to: ○ Political Environment ○ Economic Environment ○ Socio-cultural environment ○ Administrative Environment ○ Look at these environments when analyzing an existing and forming a new policy Actors, Content, Context, Process ○ Actor -- stakeholders Frameworks, tools, levers, "belief" systems Always dealing with people who are happy and unhappy Ways of Thinking About Public Policy Policy theory analyzes policies to try to find common themes and elements to simplify and generalize them ○ One way is to sort the analysis of policy decisions into two buckets One way is to sort policy analyses into two large buckets: ○ Consensus ○ Conflict/critical Both assume policy choices are based on rational consideration of alternatives Each has own place in explaining development/implementation Both are important! Obesity -- sugar tax ○ Consensus: focuses on the nuts and bolts What are the taxation amount? What are we going to do with the revenue from the tax? How much will it cost to implement the policy? Etc. Consensus Policy Theory Policy - made using rational consideration of alternative courses of action choices are based on cost and benefits and evidence Focus on small improvements that can be made to improve existing services Emphasis on technical issues such as day-to-day organization, financing, delivery – not much about the forces (economical, political social) that shape overall organization Often neglects importance of ideology, values and power and misses the ‘big picture’ ○ Doesn't really consider the people part of it AKA: "nuts and bolts" lens Conflict / Critical Policy Theory Consider broader issues in the organization and development of policy ○ Looks at the societal dimensions, such that it acknowledges that policies affect people and that people are different Policy debates are influenced by social class politics and inequalities in influence and power including gender, race, class, disability, etc. Acknowledges power differential ○ Acknowledges that policy is for the people and there are factors that influence power ○ Even with public participation, not everyone will participate ○ So looks at power differentials -- who's voice? WHO will be affected – for better or for worse – by policy decisions AKA: "socio-cultural-economic" lens Another is to apply Social Theory to Policy Analysis Approaches to health and HC that can be used to analyze and develop policies Critique: science is traditionally white and male Take social theory and apply it to policy analysis Important to realize that these are all happening at the same time Positivism Only authentic knowledge is scientific Strict adherence to the scientific method Hypothesis testing and identifying relationships Predict and control Bottom up (a posteriori) approach In health and HC policy ○ Ex: Ozempic to reduce obesity problems (use of science) ○ Looks at people as strictly biological creatures e.g. biological and physical science, much of health sci Structural Functionalism Apply positivist notions of knowledge and methodology Behavioural/lifestyle approach Views society as an organism, a system of parts whose function together creates overall societal effectiveness ○ View people as part of a community ○ Society as a system Shared norms and values; cooperation e.g. herd immunity Ex: obesity ○ Policy solution may be create more infrastructure that promotes exercise ○ Like creating more walkable streets Interpretivism Critique of positivism Hermeneutics – how individuals understand themselves through shared systems of meaning ○ interpretation All views considered equally valid Can lead to removal of important contexts that help explain individual understandings and experiences e.g. experience of an individual with health conditions Socio-environmental approach as it emphasizes lived experience Ex: the BMI scale ○ Science says one is obese, but you know you are healthy This is all about interpretation ○ Subjective interpretation ○ Policy should consider the way that people operate within the community and how they are affected by it, lived experiences Critical Theory Structures and processes that are usually hidden and ignored by positivists Critique and transformation of society as a whole Considers haves and have-nots in society Nature and distribution of power Who has the ability to bring about social and political change ○ e.g. Enviro and Social Determinants How political and economic structures shape the health care system Who has the power? Ex: is it the doctors who should tell obese people what is best for them? Program logic model Theory of change, map out plan, policy structures, what you're going to do, the outcomes, and then evaluate it Ask: Regardless of HOW we look at Policy, we are typically asking the following questions: ○ What Do We Value? ○ What Do We Need? ○ How Do We Know? ○ How Do We Decide? ○ How Do We Decide Who Knows? ○ How Do We Decide Who Gets To Decide? ○ How Are People Important? ○ Which people are Important? Martsolf and Thomas, 2019 “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.” ○ You cannot separate decision-making and policy issues from underlying philosophy Philosophy Cannot be Ignored in Policy How knowledge is generated ○ studies in biology, epidemiology, and social science , etc. ○ Philosophy looks at social sciences of how knowledge is generated and what we know Our understanding of health ○ Our understanding of the world is a cultural construct Basis for choosing and undertaking interventions ○ Policies have to be equivalent to the problem ○ Philosophy helps choose the right solution Reflect community values Reflect policy maker's values, worldviews and philosophies Acceptable policy levers The lever has to be appropriate to the problem, then the philosophical part is what is the morally correct choice to solve the problem Epistemology and Ontology Epistemology: ○ “Episteme” = “knowledge” or “understanding”; ○ “logos” = “account” or “argument” or “reason”. ○ What is knowledge? How is it created and understood? ○ Creation of knowledge is the product of the society in which one lives ○ Decisions about what we know are not created in a vacuum ○ Is universal for the most part Ontology is the study of existence ○ What exists, what kinds of things exist, and what it means for something to exist ○ The simple nature of identifying a policy problem is ontological ○ Not always universal, practiced differently by different people Ex: Mary Wilcox - Witchcraft ○ An epistemology of 1870s A way of understanding the world and explaining why certain things happen ○ Modern epistemology Afflictions could have been caused by hysteria, anxiety, ergotism or encephalitis ○ Ontologically we can ask do witches exist? If so, what power do witches have? Is a witch a person? Is it a spirit? Is it a power? Epistemology of anything can change ○ How can we apply this to health? HEALTH - What is it, exactly? Epistemologically ○ Epistemology is our knowledge of health ○ What is health? Ontologically ○ Ontology is our interpretation of health ○ Different between different people ○ What are the different health states, forms of health Health is... WHO (1948) - "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." ○ How we frame health epistemologically ○ But does it exist? (ontological) Lalonde Report (1974) ○ identifies two main objectives: the health care system; and prevention of health problems and promotion of good health. ○ Considers the "Health “Field” (more broad view of health than in the past – determinants); Human biology Environment (physical and social) Lifestyle Health care organization Public Health ○ "the combination of science, practical skills , and values directed to the maintenance and improvement of the health of all people” (Last, 1988) ○ the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society (WHO, 1988) Medical Care vs. Health Care Medical Care ○ Identify and understand disease ○ Biological ○ Often Consensus Health Care ○ Health Status ○ Socially constructed Different experiences, subjective natures ○ Often Critical Combination of biological and social factors help society to describe what is health and health care and what are our values? Health and health policy are NOT just about agents that make us unwell… also, culture, society, economic, education and legislature and change Health has a definition, but... Health is also a SOCIAL construct! Traditional WHO definition leaves out a lot of people (or conversely, says they are not “healthy”) Social construction of illness: ○ Some illnesses are embedded with cultural meaning – not directly related to condition ○ Illness and disease, at the experiential level, are socially constructed (there’s a biological and an experiential piece) ○ Medical knowledge is created within the social norms and priorities (there is also a social construction of treatment) (Conrad and Barker, 2010) Whose health? Differences in how health presents itself depending on background (i.e. ethnicity, Indigenous status, etc.) Obesity rates in USA ○ Where are obesity rates higher in the US ○ Breakdown by subpopulations and realize that obesity is most prevalent in black populations Ableism Good example of ontology and epistemology See people with a disability and we make assumptions about their lives Science of Health Optimal health Disease states -- what is a disease state and what does that mean? Healthcare Policy exists in these areas of health Science of health is related to epistemology Why is Policy Challenging? There is no one-size-fits-all Everyone is different and has different experiences ○ There are lots of diff people with different status, races, values, etc. Health policy at a consensus and critical lens are also happening at the same time Worldviews People themselves make policies most challenging ○ Worldviews shape policy and how well you work within it ○ Cannot make everyone happy at the same time with a policy decision Worldviews are the most important consideration policy makers have to face Is a psychological evaluation about the beliefs you carry about how you govern yourself Comprehensive - collection of deeply held beliefs about how we interpret and experience the world Connection to individual experience of normative ethical theory (ergo, what is right or wrong) Aspirational and acted upon (Boylan, 2004, 2012) 3 States (Schiff, 1968): ○ Cognitive You learn things and think about Interpretation of a stimulus ○ Affective What you learn you think about, and what you think about that thing will produce a emotional response ○ Behavioural Creates a behavioural response Changes your behaviour Interpretation of stimulus brings change to response What you learn, process, think about affects you emotionally → there is an actual physiological emotional response → based on that your behaviour is such Ex: phobias ○ These states can be influenced by alcohol Identification of your worldview indirectly identifies your greatest weakness Decision Theory Plays into how we make choices ○ Say a person will often make the same choice in similar situations ○ E.g. will always choose Coke when given a choice between Coke vs Pepsi ○ Based on this, we make judgement on people (i.e. make assumptions about people who drink Tim's over Starbucks ○ Can start to profile people on any given occasion, a person is guided by beliefs and desires/values a theory of beliefs, desires and other relevant attitudes AND a theory of choice; what matters is how these various attitudes (call them “preference attitudes”) meld together. what criteria someone’s preference attitudes should satisfy in any generic circumstance. Could be suggested that this amounts to a minimal account of rationality All People are Inherently Biased “The concept of implicit bias, also termed unconscious bias, and the related Implicit Association Test (IAT) rests on the belief that people act on the basis of internalised schemas of which they are unaware and thus can, and often do, engage in discriminatory behaviours without conscious intent.” ○ Pritlove et. al, 2019 as published in The Lancet ○ https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32267-0/fulltext Challenge: Take the Implicit Bias Test HERE or use the link: ○ (https://implicit.harvard.edu/implicit/takeatest.html ) IAT - preference between Old people and Young people Ideology Political scientists - identify packages of positions, often seen as consolidated in a “single, preferred optimal state” ○ Strong correlation between political ideology and decision theory E.g. Samsung (decision theory) and political ideology “a set of beliefs or principles, especially one on which a political system, party, or organization is based” Can be used to denote the beliefs, attitudes and opinions of those with whom we disagree Political and social analysts tend to give extremely broad definitions, e.g. beliefs, attitudes and values. ○ This basically runs the gamut of all possible cognitive elements. (Martin, 2015) Issue of forcing values on others ○ Problems with political parties and that they are myopic ○ Policy functions om the political parties that may change every 4 years Worldviews vs. Ideology in summary Worldview: “A worldview is a set of assumptions about physical and social reality that may have powerful effects on cognition and behavior.” (Koltko-Rivera, 2004) Ideology: “Ideology is an admixture of political and socio-economic beliefs, values and symbolism that provides explanatory coherence: a focal lens through which people filter political narratives.” (Vezina et. al., 2021) ○ How people filter political narratives ○ Ex: flat earthers ○ Ideology is typically operationalized - used to wield power E.g. Roe vs Wade Alternative dispute resolution ○ When ppl can't agree, you dig into why so it's easier How we perceive the world influences how we frame problems, identify solutions, decide on appropriate levers/strategies, and how we evaluate policy and related outcomes! ○ BUT...Policy Makers must make policy for everyone! ○ How do you do this? Two Key Considerations Moral Decisions: Normative Ethics ○ What is right and what is wrong ○ What is a good decision and what is a bad decision ○ Ex: stealing is wrong ○ Regardless of ideology, we have a good idea of what is good/wrong Ethical Principles ○ Prescriptive recommendations for moral action ○ They are NOT values - "permanent, universal, and unchanging" ○ If someone breaks ethical principles, usually there is a big consequence -- ex: WAR ○ Health care professions operate on a set of ethical principles that are morally established Normative Ethics: Fundamental to Policy Fundamental to policy but hard to implement because there is no good one answer What makes a "good" action or decision? Justice ○ Fairness ○ Intrinsic value = moral standing ○ Procedural justice Ethical choices and actions ○ Deontology ○ Consequentialism ○ Virtue ethics Virtue Ethics - Aristotle The premise is: good people make good decisions ○ A virtuous person will make virtuous choices ○ Expectation that HC workers are virtuous people making virtuous choices Cultivation of virtuous habits: person-based rather than action- based Character is determining factor in deciding if someone is a good person Good people create good societies and good decisions In health care: ○ Compassion ○ Honesty ○ Morally correct actions Antithesis – German war-time experimentation & Nuremberg Trials (who decides what is virtuous?) Good decisions are made by good people Downside: give a lot of trust to physicians Consequentialism or Teleology e.g. Utilitarianism Moral (correct) decisions are identified based on extent to which they promote more happiness than unhappiness for the greatest number of people Ratio of happy: unhappy is not consistent Options initially accepted as moral may be rejected in specific circumstances Health care: professionals make decisions based on best interest of a particular collective of patients (e.g. quarantine) Often lead to further moral issues/conflict The rightness/wrongness of a decision by the consequence it produces Ex: PH, vaccines ○ Balance interest of collective with the autonomy of individuals Deontology or duty-based Every person has an inherent dignity and value What is right or wrong vs. the consequences of the action Do the right thing - universal and applicable in all circumstances – even if it produces a bad result (certainty) First step is to identify the 'morally correct' choice and proceed from there The Hippocratic Oath and the Universal Declaration of Human rights are examples of deontology (Kant) Opposite of consequentialism ○ You do the right thing even if it produces a bad result Ex: Hippocratic Oath, Universal Declaration of Human Rights Ethical Principles: Long-standing philosophies re: the “right” thing to do Identify Important/Relevant Considerations That Must Be Taken Into Account If You Are To Think About Moral Situations Involving Intrinsic Values In A Serious Way Principlism Arose as a response to the failings of the theories outlined above Core principles: 1. Autonomy 2. Justice -- for all regardless of race, gender, etc. 3. Beneficence -- make the most benefits for patient 4. Non-Maleficence -- do no harm E.g. Helsinki Declaration, Belmont Report E.g. development of different health systems (e.g. Bismarck, Beveridge, or NHIP) ○ Include these 4 principles Ethical principles help to guide normative ethics when making decisions Casuistry Essentially the case law of ethics ○ We did it this way before, so we are going to do it this way again ○ Ex: universal HC It was always this way, so don't even think about changing it Precedent-setting situations Need for similarly salient characteristics and moral issues Previous cases are a social construct in terms of being reflective of prevailing ideology, popular culture, or societal bias Path dependency ○ Doing things the way it's been Feminist Approaches Skeptical towards traditional ethical concepts like autonomy Social, political suppression of women Often care focused and power focused Compassion, freedom, equality Distributive justice In health care – Belmont Report, 1978 ○ USA doc that resulted from Nuremberg trials Personalism & Ethics of Care Emphasis on human dignity and subjectivity cannot be reduced to material objects and natural instincts (Phenomenology) Compassion, sympathy/empathy, and kindness Everyone should have access to wide possibilities of choice in treatment – therefore, need access to information to promote decision making ○ Historically, doctors would just state course of treatment patient will be receiving, now we have choices System should enable staff and patient participation Patients have a choice and have more say in treatment Dr. Charlotte Blease: Taking a Philosophical Approach to Improve Healthcare https://www.siliconrepublic.com/discovery/charlotte-blease-healthcare-research-inspirefest Focus on how we THINK about the practice of medicine and how this affects patient outcomes Not acknowledging how we think is equally problematic - this is a really critical idea What is Blease’s main argument (e.g. George Clooney vs. Gerald Barnes)? ○ Blease uses the comparison between George Clooney and Gerald Barnes to illustrate the difference between genuine medical expertise and superficial imitation. ○ Gerald Barnes, who lacked real medical knowledge but used acting skills to mimic a doctor, contrasts with actual doctors who might also rely on intuition and personal judgment without deeper reflective insight. ○ The main argument is that many doctors, despite their expertise, may not fully understand or reflect on their own practice. This lack of insight can lead to biases and ineffective patient care. Genetics loads the gun, environment pulls the trigger. Are there bullets we have not really considered? ○ Blease points out that there are additional factors, such as cognitive biases and unrecognized psychological influences, that can impact medical practice and patient outcomes How do psychological (or worldview) issues affect patient outcomes? ○ Doctors may unconsciously favor certain patients over others based on race, socioeconomic status, or other factors. ○ Biases and preconceived notions can influence diagnostic decisions and treatment recommendations, potentially leading to disparities in care ○ Socioeconomic Status: Patients of higher socioeconomic status receive more time, better communication, and more thorough explanations from doctors. ○ Racial Biases: There is a significant underrepresentation of Black doctors, leading to health disparities, such as Black patients being less likely to receive certain treatments. ○ Ageism: Older patients are often underrepresented in drug trials and may receive less aggressive treatment based on age alone. ○ Obesity Bias: Clinically obese patients are often unfairly labeled as lazy or non-compliant, leading to less aggressive screening and treatment. “Art is anything you can get away with” shows us influences on decision-making ○ Dr. Blease uses this phrase to critique the concept of "the art of medicine," which suggests that medical practice involves a personal, individualistic element that is not informed by science. This notion can lead to subjective, potentially biased decision-making that affects patient care. She argues that medicine should be more evidence-based and less reliant on personal style or unexamined practices. How can we improve this psychological problem? ○ Self-reflection ○ Leverage technology ○ Implement similar tactics as the military ○ Encourage patient advocacy Be empathetic Thinking & Thoughts are Key Concepts in Policy Development and Analysis! How MORALS, THOUGHTS and BIASES influence policy? ○ Deciding what is “health” and what is not (examples?) ○ Do we make a choice? Or is the choice to do nothing the best one? ○ Selection of goals – whose goals? Why? ○ Processes and Implementation – what will we choose? How will we choose? Why? ○ WHO are we choosing for? Can we make choices for everyone? Do we WANT to make choices for everyone? ○ What social theories of health are most likely applicable to the most #? ○ What is the ideological/epistemological/theoretical bases for these choices Week 2 Lecture 2 Policy Analysis Tools I: The Policy Analysis Triangle Briefing note Select 2 chapters from the textbook Tip: the first and last paragraph should be the best What is it? ○ Summarizes a topic to inform D/M ○ Includes key information about a topic or problem ○ May include options for change or recommendations Key sections ○ Purpose/overview ○ Background ○ Key considerations and discussion ○ Recommendations and next steps 2 types of briefing notes ○ Action vs information ○ Action: what you suggest and why you suggest it Last Day: Policy, like politics, is everywhere It's not always written down Can be purposefully chosen to 'do nothing' Involves intentions rather than results May not always be successful, nor will certain people or groups always be in agreement "There's no one-size-fits all solution" Health Policy Analysis A multi-disciplinary approach to public policy Aims to explain the interaction between institutions, interests and ideas in the policy process Helps us to understand past policy failures and successes and to plan for future policy implementation It's inherently challenging: e.g. how to measure levels of resources, values, beliefs and power of stakeholders? "The notion of ‘power’—fundamental to policy analysis—is a highly contested concept. Yet it is often used as if there were little difficulty in agreeing what power is, where it lies, and how it is exercised" Walt et. al, 2008 Everybody within HC works in policy Some people will advocate for new and some will advocate for chance Some work for ministry of health and write policy Sometimes those decisions will be handed down to the local gov through public health Good policy makers should be good evaluators Evaluate: Look at power structures, who it benefits, who is making the decisions Policy analysis aim is to look at the interactions between institutions, interests, and ideas Analysis is not easy because it involves people and we can't know what someone's true motivations are ○ Need to understand what makes people tick ○ i.e. worldviews Policy analysts look at power What do We Already Know about Making Policy? This is a basic example of policy analysis Problem ID Agenda Setting Policy Formulation Policy Legitimation Policy Implementation Canadian Public Health Ethics Framework The same 5 steps but an example of it applied Step 1: Identify the issue and gather the relevant facts in order to clearly understand the problem ○ Also related to framing ○ What is the problem, but also what is it about the problem that we can solve since there are so many different factors? ○ Don't want to throw 10 different policies at the same problem because we don't have enough money, resources, etc. -- it's hard to do Step 2: Identify and analyse ethical considerations, and prioritise the values and principles that will be upheld ○ All of these things happen at the same time ○ A good decision depends on the ethical principles that you follow as a decision maker Step 3: Identify and assess options in light of the values and principles Step 4: Select best course of action and implement Step 5: Evaluate ○ If successful it will expand to other health units Policy Goals (Stone, 2002) 1. Security 2. Liberty 3. Equity 4. Efficiency Policy analysis will also look at policy goals Easy to make policy that doesn't cost any money -- some don't use very many resources ○ No direct money ○ Some use more in-kind contributions rather than direct funds Normative Decision Making Considerations Always consider these 3 questions 1. Is this problem related to duty? (e.g. mandatory reporting) 1. Health providers must report to police if there is child abuse or a gunshot wound 2. Sometimes reports have bad consequences but it is a duty (deontological ethics) 2. Do we have faith in the decision makers as 'good people' (i.e. virtuous) to make good decisions? 1. Virtue ethics 2. Aristotle 3. Have we considered the consequences of our decisions and choices? 1. Utilitarianism Key Ethical Principles Justice Autonomy Beneficence Non-Maleficence Ethics of Care Personalism Feminism Policy Analysis Triangle (Walt and Gilson, 1994) A good way to study for midterm ○ A good way to apply content Involves 4 components ○ Content ○ Actors ○ Context ○ Process Content - policy objectives, operational policies, legislation, regulations, guidelines, etc. ○ Everything about the policy that goes into policy making, policy action Actors influential individuals, groups and organizations ○ Impacted by policy + people that enforce the policy Context includes systemic factors such as: social, economic, political, cultural, and other environmental conditions. ○ i.e. good policy in ON may not apply in AB Process: the way in which policies are initiated, developed or formulated, negotiated, communicated, implemented and evaluated ○ Think of the way policies are developed in Russia and in Canada -- very different set of circumstances Can be used both retrospectively and prospectively Canada's First SSBT – Newfoundland, 2022 Ex: Canada's sugar sweetened beverage tax ○ Passed in Newfoundland and Labrador Medscape, 2020 This video is on the American experience of sugar tax Used as a means to decrease obesity and diabetes 3 years after the tax was implemented consumption dropped by 50% Increased revenue for PH and community based organizations focused on equity --- 9 million raised Philly: In 1 year, the tax led to net 38% reduction in consumption of taxed beverages and funded free preschool seats for low-income families Reached the goal that they were aiming for Education and PH programs for disadvantaged communities Why? ○ It has looked at other jurisdictions and probably found that it is an effective means of targeting health ○ Want to make people make better choices ○ Will fund healthy living initiatives Stakeholders ○ People who are involved in the process of making policy choices, enforcement, and people who are impacted by it ○ E.g., the government, the companies that sell the products, low-income communities, WHO, Canada's Food Guide, etc. Context: ○ Problem: Increasing rate of obesity in Canada Public Policy Formation in Canada: ○ Evidence to build policy ○ Seek input from stakeholders ○ Talk to other jurisdictions where this has happened ○ Politicians will speak to constituents, lobbyists (affected by worldviews, companies who are affected) Content: ○ E.g., "ready to drink beverages" - this is what the policy is doing ○ What is impacted, the rules of the policy ○ What's in the policy and what isn't? ○ Exemptions and inclusions ○ Exemptions: Exports outside of Newfoundland and Labrador FN are exempt Beverages that include alcohol, etc. Other considerations related to the policy ○ What is the objective of the tax? Should we related to the expected outcome ○ Benefits and burdens Are they disproportionately spread? ○ Opportunity cost This is the cost you give up in favour of something else ○ Policy levers: how we implement the policy ○ Historical context: FN excluded bc of constitutional laws Week 3 Lecture 1 Danger at the Gates: Public Health Policy, Jurisdictions & Arrangements Related/Support readings in Chapter 1 2.2.1 Federalism in Canada: The Constitution Act, 1867 3.2 Role of the State 3.3.3 Equity 3.4 Framing 3.6 Ethical Frameworks 3.6.2 The Precautionary Principle 5.5 Globalization 5.8 Role of Media 5.9 Insurance, Elasticity and Moral Hazard 6.3.1 Public Health 7.2 Canada Health Act 8.1 Economic Analysis: Cost effectiveness 8.2 Screening 8.2.1 Criteria for Screening 8.2.2 Assessing Screening Tests (test/truth) 8.2.3 The role of Prevalence 8.3.2 Risk Perception **Concepts covered today that are in Ch 1 The Toronto TB Case “In the spring and summer of 1999, more than 200 people of Tibetan descent crossed the New York-Ontario border into Canada and asked for refugee status. Five of the Tibetans were found to have active pulmonary tuberculosis (TB), a contagious disease, with the infecting bacteria resistant to all of the front-line medications initially used to treat TB. Media coverage on radio, national newspapers, and television ensued, much portraying the Tibetan situation as an example of how the Canadian immigration system was flawed, and was potentially putting Canadians at risk of contracting a deadly disease. This case addresses several policy issues, including: ○ screening for communicable diseases ○ immigration policy ○ risk perception, and ○ federal-provincial relations.” (Deber and Mah, 2014) Agenda Overview of Tuberculosis ○ Characteristics of TB vs. other infectious diseases (e.g., AIDS, flu) ○ How infectious? How deadly (and how to define deadly)? Types of screening/justification Who is at risk? Risk assessment Institutional Arrangements ○ Jurisdiction (fed/prov/local) Moral decision-making & Civil rights issues- Are these criteria appropriate? What values are assumed? Role of media. When is something newsworthy? Did the public even notice this issue Policy Options – Strengths/weaknesses Public health is like a where's Waldo book ○ Kind of know what you're looking for but don't know form it will take ○ About who does it affect, who is in contact with it ○ Keeping population healthy but balance individual liberties ○ What are you going to do once you find it? Unethical to look for something and not do anything about it ○ About keeping societies well Learning Objectives To summarize the Toronto TB case and review the different policy problems/decisions that are related to this case Define institutional arrangements and detail the relevant legislation in Canada that guides public health practice and provision of health care services; inter-governmental relationships To identify the different types of screening that are available and identify circumstances in which they would be used To describe the role of the media in policy practice and framing To differentiate between Incidence and Prevalence and to understand their role in risk perception; to describe other aspects of risk that cause people to act To understand and apply the list of policy theory terms provided Public Health No common definition Health of populations ○ Focus on health of populations rather than the individual ○ Individual health is obviously important but more broad application Prevention & promotion ○ Prevention -- Trying to control issues before they become problematic ○ Promotion -- the tools to live healthy active lifestyles, educating people Not addressed by Canada Health Act PH has been around for longer than formalized HC (i.e. basic sanitation) Population health: “an approach to health that aims to improve the health of the entire population and to reduce health inequities among population groups” (PHAC, 2012) ○ Became important in hospitals because now we are looking more at population rather than individual which has been the general practice in the past ○ Pop health looks at the entire community ○ Don't have to memorize -- understand what PH practice is like 10 Essential Public Health Services PH has legal actions built into it -- has the power to quarantine ppl??? Check this later What happened in Toronto? Spring 1999, 200 Tibetan refugees crossed from Buffalo Sent to shelter in Toronto awaiting processing 5 were found to have active, contagious MDR TB strain Media hyped up the story to emphasize public health risk to Canadians; worked up previous anxieties related to Kosovar and Chinese refugees ○ Timing when it comes to the unfortunate role of media ○ This became an issue because of TIMING Important Disease and Surveillance Concepts Ideally, policy should always be evidence-based! When you approach a case --> what is the problem (ID problem from the steps) Best way to frame a problem is to understand the problem before considering a solution Best PH policy is evidence based Communicable disease transmission How is it transmitted in the first place? ○ The policy response is going to correlate to how it is transmitted Direct ○ Person-person ○ Ex: Ebola ○ Need to be in close proximity to contract disease Indirect (vehicle) ○ You get it, but don't get it from person-person, you get it from a vehicle (i.e. water or food) Indirect (vector) ○ Instead of a vehicle, you get it from a vector (pathogen), from source to next person ○ Some vectors stop at a person and stops ○ Others like COVID will continue and spread throughout population Airborne ○ Don't need to be proximate to contract the disease, droplets are suspended in the air long enough that you inhale it and become ill ○ This is the problem with TB -- it is airborne Hinman, 2003 TB is airborne and direct But it is highly treatable What is Tuberculosis? TB air droplets remain in the air after a person coughs and someone else can inhale it in Collect in alveolar sacs and bacteria begin to multiply In 8-10 weeks, positive for latent TB infection Progression from latent and active occur when granule opens and TB multiplies -- pulmonary TB Extra TB when it leaves lung and goes to other parts of body Can occur immediately years or never Tuberculosis: Important Considerations Latent TB ○ Not infectious ○ Prophylaxis for at risk people (e.g. HIV, dialysis, incarcerated, homeless, First Nation, transplant) Active TB ○ Infectious, deadly if not treated ○ Adherence is important; prompt treatment necessary ○ If you don't treat properly, you get drug resistance ○ 5-10% only actually develop ACTIVE TB, the rest are just latent ○ Proper adherence is important because otherwise leads to MDR TB MDR-TB ○ Multi-drug resistant TB (expensive, public health threat) ~$250,00 annual to treat ○ Frontline (cheap) antibiotics do not work ○ Refugees had MDR TB ○ Not simple treatment ○ Very contagious and very expensive to treat Lower risk illness ○ It is airborne, but it is highly treatable ○ In 80% have latent TB and never get ○ Likely to get sick if stressors on the body that lead to the granule to open ○ Certain groups are more susceptible than others ○ In low SES, more likely to get sick from TB ○ Highly treatable ○ Doesn't seem too complicated What is the big deal? ○ The population affected by TB is burdened by jurisdictional boundaries that complicate the treatment ○ When you work in health policy you can't ignore the jurisdictional boundaries Framing Framing helps us categorize and perceive a potential threat Mental structures that people use to provide categories and a structure to their thoughts ○ Consider the mental biases, worldviews, etc. How a potential hazard is processed? How a policy is perceived? How a policy is evaluated? Demonstrates how the same set of facts can be used to present different messages ○ Meaning you can solve a problem in many ways, but you pick one How to best influence an outcome Helps determine what stakeholders can participate ○ Important in a democratic system -- how you frame it may lead to public involvement or lack of public involvement Sometimes best response is NO RESPONSE ○ Doing nothing is a policy choice ○ Not always about creating something new Ex: Virtue ethics -- how would you approach this problem? ○ Virtue ethics --> good people make good decisions ○ You trust PH authorities that they make good decisions Ex: Deontological perspective ○ Morally correct choice is duty based HC practitioners have a duty to address it Ex: Utilitarianism ○ Based on consequences ○ If we do nothing what happens, if we do something what happens? ○ Choice + consequences What are the Different Ways we Could Frame this issue? Illegal immigration ○ This is not a health issue, this is an immigration issue ○ Policy response has to do with immigration, cracking down on border security, etc. ○ Politics can turn this health issue into a migration issue Infectious disease transmission and natural progression of disease ○ We have to treat it because it’s a disease and these are people (duty based, deontological)Public Health and Risk to public Cost, cost-benefit, opportunity costs ○ Opportunity cost: what do we give up to get something else "Old Disease": many physicians have not been trained to recognize it or have little experience ○ Not taught to look out for it because it's not as common anymore ○ So there is a bit of a ignorance factor in that medical schools don't teach it very well Risk Identification/Perception Knowing what the risk of a problem is will help you decide what to do Decisions involve risk Not doing anything involves risk Uncertainty How well risk is understood Extent to which it evokes dread ○ Some irrelevant things also lead to dread ○ E.g. cancellation of NBA season leading to chaos but how important is that How many people exposed Less acceptable if classified as involuntary, dread, or catastrophic (vs. common) Media attention alters perceived risk ○ Can take something and make it a bigger deal than it is, make it seem like an emergency Risks with identifiable victims are more severe than statistical People perceive risk differently!!! ○ Subjective aspect 5-10% of outpatients get disease ○ Most likely in marginalized populations Risk Identification / Perception Winning Lottery 0.0003/100,000 Being hit by lightning in one year 0.15/100,000 Pedestrian killed by a car in one year: 2.11/100,000 Dying from a venomous snake bite in one year 0.001/100,000 Getting TB in Canada 4.7/ 100,000 Getting TB in Toronto 9.2/100,000 ○ Higher than London because: Densely population More immigration to Toronto Higher clusters of marginalized and homeless people in big cities Getting TB in London 2.77 /100,000 ○ Relatively a low risk activity ○ Almost as likely to get hit by a car ○ Know that the likelihood of getting TB in London is similar to the likelihood of getting hit by a car Risk vs. Hazard Hazard: something that can potentially cause harm ○ Ex: shark Don't ban sharks just because they exist Risk: hazard + exposure ○ Ex: shark + swimming make it a risk Only people who are swimming are at risk If you leave the water, then the shark just becomes a hazard, no longer a risk Prevalence/Incidence Prevalence ○ is an epidemiological measure of how often a disease or condition occurs in a population. ○ It measures how much of a particular disease or condition exists in a population at a particular point in time ○ Ex: # of people in London currently experiencing coronary artery disease Incidence ○ measures the rate of occurrence of new cases of a disease or condition. ○ Incidence is a relative measure which considers the number of new cases in a specific time period (e.g. annually) in relationship to the population which is initially disease-free. ○ NEWLY diagnosed cases ○ Ex: The number of healthy Canadians who developed coronary artery disease ○ High incidence of a condition will lead to a different action than if its low incidence ○ TB is 2.77 incidence rate Tuberculosis in Canada: 2017 M LaFreniere, H Hussain, N He, M McGuire Results: There were 1,796 cases of active TB reported in Canada in 2017 compared with 1,750 cases in 2016, representing a 2.6% increase. There was a corresponding increase in the incidence rate from 4.8 to 4.9 per 100,000 population. Foreign born individuals continued to make up the majority of cases (71.8%) and the incidence rate remained highest among Canadian born Indigenous people (21.5 per 100,000 population), in particular, among the Inuit population (205.8 per 100,000 population). Consistent with the previous decade, TB incidence rates in 2017 continued to be higher among males (5.5 per 100,000) compared with females (4.3 per 100,000), and the majority of cases (45.6%) were between the ages of 15 and 44 years. The incidence rate was highest among adults over 75 years of age (13.8 cases per 100,000 for males and 7.2 for females). Of the TB cases diagnosed in 2016 where outcomes were reported, 80.4% were treated successfully Population health matters when we look at specific subgroups of populations For policies, knowing which populations are at specifically higher risk is important and helpful, especially for allocation of resources Don't memorize numbers, know who is at higher risk Incidence and prevalence are low in the general Canadian population, but some subgroups have higher risk 2021 TB Updates (Health Canada) Numbers of Cases in Canada ○ 1,829 cases of active tuberculosis reported in Canada (+50 over 2020) ○ foreign-born individuals and Indigenous Peoples = majority of cases ○ 1,055 were foreign-born individuals 321 were Canadian-born, of whom 232 were Indigenous Peoples (>incr. over 2020) ○ MUST REPORT TB cases when detected = this is a deontological policy Rate of tuberculosis in Canada ○ one of the lowest in the world ○ steady decrease between the 1940s and 1980s; rates have been steady since that time ○ In 2020, the rate of active tuberculosis in Canada was 4.8 per 100,000 population. The rate was highest among Canadian-born Inuit Peoples (135.1 per 100,000 population; First Nations 16.1 per 100.000). Significantly higher than the average Canadian Housing, water, etc. -- so many problems that we are not addressing well https://www.canada.ca/en/publichealth/services/diseases/tuberculosis/surveillance.html Whenever we make a PH decision, we always study the data Inuit more at risk People born outside of Canada more at risk Triangles: Canada rate Data just supports what we already talked about Endemic area -- somewhere that had TB circulating already Not widespread bc its clustered in specific marginalized populations Males are more at risk Why do we want multiple sets of data? ○ Want to make sure that the data that you're looking at is not biased, ensure that you are targeting the most affected population, not just the first thing that you see ○ Confirm what you see with different sources to ensure that resources are allocated properly What do we think about RISK? What should we do about it? Ex: 1. Do nothing 2. Immigration policy 3. Screening 4. Testing 2.5% of the Tibetan decent refugees have active TB (5/200) If we could identify a specific group it would be awesome but not policy Going forward what do we do? (if we don't have one) Screening Mass screening ○ Screen everybody ○ Bureaucracy nightmare, chaos, impossible ○ Done with newborns ○ Sometimes mass screening costs are less than the long term benefits Selective screening ○ Screening high risk populations Multiphasic screening ○ Do it multiple times, at different times ○ The use of several or a whole battery of screening tests to search for early evidence of a wide variety of preventable diseases and precursors of disease. Surveillance ○ Look at data in the environment to figure out if it is an issue or not Case finding ○ If you find 1, you would case find all 300 ○ Actively looking for people who could be exposed ○ Where case X was, and test everyone there ○ A targeted approach to assessing patients suspected of having a condition or who are at risk Population surveys ○ Stats Screening differs on resources, the case, etc. ○ What is the most cost effective? ○ For TB most likely to do selective because the data shows clearly that there is a specific population that is more at risk, so there is no need to test everyone Screening: looking for possible symptoms ○ E.g. annual mammogram ○ E.g. COVID screening checklist Testing: confirming your suspicions ○ E.g. testing mass shown on mammogram ○ E.g. COVID rapid test ○ E.g. TB skin test if someone shows symptoms ○ Testing sometimes takes longer Consideration of Ethics and Moral Decision Making Ethical D/M & the Precautionary Principle Normative ethics: what is the right thing to do? ○ What do you want to follow in your policy? -- decisions are made in that context ○ What are the consequences, what is the duty, etc. What is the right thing to do? Consequentialism? Utilitarian? Deontological perspectives Moral decision-making: autonomy, justice, beneficence, nonmaleficence in public health: ○ Risk ○ Intervention effectiveness ○ Economic costs (direct/indirect) ○ Individual burden ○ Fairness of policy Obligation to protect/act even if there is not sufficient evidence ○ Precautionary principle -- the need to actr weven if the evidence doesn't say it’s a problem ○ The future law suits will likely be climate change lawsuits because we aren't doing anything now and it will probably lead to problems later, which means that the younger generation now will do a precautionary principle lawsuit Role of Government (which is complicated in Canada...) Can make people quarantine Policy makes the policy making hard Institutional Arrangements “Institutional arrangements are the policies, systems, and processes that organizations use to legislate, plan and manage their activities efficiently and to effectively coordinate with others in order to fulfill their mandate.” (UNDP, 2016) ○ Different ministries of health, different levels of government, different systems that we use to manage ourselves ○ Why is it complicated? Constitution Act Jurisdictional Issues British North America (BNA) Act; Constitution Act ○ Said in Canada this is who is responsible for what Federal: Laws for the Peace, Order, and good Government of Canada ○ Things related to military, criminal code, law and order Federal level responsible for quarantine and the establishment/maintenance of Marine Hospitals ○ Federal level had a limited role in HC BNA Act specifies that the Provinces (NB, NS, Ontario and Quebec) had jurisdiction over health care: ○ “The Establishment, Maintenance, and Management of Hospitals, Asylums, Charities, and Eleemosynary Institutions in and for the Province, other than Marine Hospitals” ○ Health care was designed to be run by provinces Over time, the levels of government arrived at a compromise where the provinces, supported by federal cash, would provide a national standard for health care Since 1867 diff roles for diff levels of government Constitution Act, 1982 Charter of Rights and Freedoms Repatriation of the Constitution ○ Has 7 parts ○ Parts 1-4 is the Charter of Rights and Freedoms, includes the “Notwithstanding Clause”, recognizes the rights of Aboriginal peoples; recognizes the equalization payments process ○ Parts 6 & 7 amended the BNA Act to include provincial jurisdiction over natural resources – the health part is pretty much the same as in 1867 Nowhere in the constitution does it say we have a right to healthcare Agriculture was responsible for health in the early days Canada was never set up jurisdictionally to manage health which is why it is difficult Canada Health Act, 1984 Legislation: publicly funded health insurance Canada Health Act ○ the primary objective is to "protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers" (CHA, RSC 1985) sets out criteria and conditions that provincial and territorial health insurance plans have to meet in order to receive the full cash contribution for which they are eligible under the Canada Health Transfer. Key principles: UPPAC Doesn’t say we have a right to free health care but says we have a right to access healthcare Role of the Federal Government In 1982, The Supreme Court of Canada stated: ○ “…’health’ is not a matter which is subject to specific constitutional assignment but instead is an amorphous topic which can be addressed by valid federal and provincial legislation, depending on the circumstances of each case on the nature or scope of the health problem in question.” The federal government is most involved in health in ways directly related from 3 constitutional powers, the spending power, the power to pass laws for peace, order and good government and criminal law power. ○ The federal government is responsible for immigration First Nations and Inuit, Veterans and active military, prisoners in federal penitentiaries Under Peace, Order, and Good government so it is Federal Healthcare program developed since this TB issue where there is a provision that HC shall be provided to refugees because if they come into the country and they're ill they pose a risk, and if they stay, it's better to keep them healthy Cancelled when Harper was Pm Portability clause of CDN Health Act -- refugees had to wait 3 months before access to provincial HC if they moved Role of the Provincial Government Public Hospitals and Clinics Drug benefit plans (and deciding what is in/out) ○ Most of us don't have drug coverage in Ontario Training and regulation of physicians and other health professionals Long term care The province also determines the C in UCCP formula ○ Determines what are the necessary medical services in the Canada Health Act that should be covered Role of the Municipality (Public Health) Public health unit operates at the municipal level ○ Half funded by prov and half by municipal ○ PH board runs the PH office The Health Protection and Promotion Act (HPPA) 1983 1998 – amalgamation of Metropolitan Toronto into one administrative unit, reducing number of PHUs from 5 to 1 (Toronto Public Health) ○ To save money ○ Chaos because all of the PH boards merged from 5 to 1 Typical responsibilities included vaccinations, communicable disease tracking/tracing/treatment, vector borne disease surveillance, sexual health, etc. ○ PH unit is responsible for screening, tracking, treating, etc. City of Toronto, City Council Legislative Documents Making Policy Decisions: How do we Decide? Considerations beyond those already discussed … Screening, tracking, treating is the responsibility of provincial level Can't quarantine the refugees bc that is responsibility of the federal government Resource sharing responsibility problem ○ When multiple levels are responsible, then nothing really gets done because they are waiting for the other party to do something One of the first time Canada's healthcare was stalemated bc of competing levels of government Federal government beefed up HC program for refugees Additional Stakeholders TB Specialists ○ Drug resistance If we don't treat properly, more MDR TB Harming the population by not treating properly ○ Symptoms vs. screening ○ Medical school curriculum ○ Quality of care: uneven and potentially dangerous At the time, people didn't care about refugees at first ○ Social, psychological and pharmacological The Media ○ Timing ○ Relevance ○ Fame ○ Human interest ○ PH emergency was minor, but the media made it major The Media What was the 'focusing event' ○ Was probably a slow news week ○ Immigration was already a hot topic How did the media frame this issue? ○ What we see in the media is not always representative of what is actually going on When is something newsworthy? Did the public even notice? Policy Analysis Triangle Effects & Implementation Framework Effects and implementation Consider always in policy choices, the effects component and how you implement Effects -- How well does it work, are there unintended consequences? Is it equitable? Implementation -- Is it costly, feasible, acceptable? Policy Options Board of Health Perspective ○ Who is at risk? ○ Who must we work with? How? ○ Who covers the cost? ○ Surveillance – who and how? ○ Quarantine – is it necessary? Is it ethical Social justice/equity Common good Autonomy ○ Going forward, what is our standard screening protocol? A public health emergency is always dealt with front-line board of health with the support of provincial groups Do the work and worry about the financial costs later Possibilities? Test ALL Test only High Risk Do not screen or test – use contact tracing Screening is NOT testing ○ Screening: looking for disease in the wider population that does not have risk factors ○ Testing: confirm diagnosis or aid in monitoring or treatment What are the most important issues? Canada Health Act ○ Issues are compounded by Canada Health Act Immigration Constitution Act - Funding – who is responsible ○ 3 levels of government for health Screening, then follow-up problematic Lack of education in medicine for TB awareness, etc. because it was a disease on the decline Wrong treatment furthers symptoms and infectiousness; Lack of adherence to treatment Active TB – they quarantine you Media and fear mongering Policy Changes that Resulted: Toronto Public Health: ○ instead of waiting 60 days for immigrants to present, they were identified at the Border and sent to immigration officials ○ TB x-ray supplemented with TB skin test Ontario Ministry of Health: ○ TB Diagnosis and Treatment Services for Uninsured Persons (TB-UP) Federal Government (2012) ○ Cancelled health insurance services for refugees – but TB care would have been exempt as it is a risk to public health ○ November 2014 – the Federal Court of Canada determined this was unconstitutional ○ December 2015 – IFHP ○ April 2016 – program fully reinstated 5/200 immigrants Most cases via immigration When should immigration screen ? Prior or surveillance Canadian Charter of Rights and Freedoms which is now the supreme law in the land which guarantees fundamental freedoms for all individuals residing in Canada, including citizens, landed immigrants and even refugees Poor federal screening = burden Typhoid Mary – 30 years in isolation – asymptomatic but infected others “media do more than reflect the interests of their readers; they often shape public opinion and in turn help to shift political agendas Policy Theory & Epistemology Considerations Consensus or Conflict? Utilitarian? Ratio of happy: unhappy Deontological? Actions relative to duty or obligation Ethics of care Principilism (big 4 from the Belmont Report) Week 3 Lecture 2 Policy Analysis Tools I: The Effects and Implementation Framework Reminder: NO CLASS NEXT WEEK! Note: we are doing a top down approach to policy today Last Day: Policy alternatives and selections should be evidence-based ○ Best policy solutions should always be evidence based ○ Doesn't always happen in practice ○ Depending on worldviews, how you frame your ideology, etc. you are actually going to discount certain evidence Framing is an important consideration in solving any policy problem and once you have 'done that', there are multiple ways to work towards a solution ○ Taking a health problem and figuring out what the problem is and the nature of it ○ Everybody interprets differently depending on ideology, worldview ○ Framing will allow people to tackle a problem a certain way and discount/count certain evidence ○ Not doing anything is also a policy decision Sometimes, it's relatively simple to arrive at a good, science- based solution; however, there are contextual factors or system factors that prevent you from implementing: ○ Institutional arrangements ○ Resources People, Money & tools Resource scarcity ○ Resistance from political leaders (ideology – e.g. COVID waste water) Public Policy Public Policy: “a strategic action led by a public authority in order to limit or increase the presence of certain phenomena within the population” (National Collaborating Centre for Healthy Public Policy [NCCHPP], 2012 We are talking about public policy today because the Effects & Implementation framework was designed by researchers to be a good way to analyze public policy ○ It may not apply to private policy (e.g. policies in a corporation, or families, or in a community organization) ○ This is public body policy No policy worker works in isolation, always a team environment Public policy is any policy choice that is used to limit or increase the presence of a phenomena within the population Healthy Public Policy "Healthy public policy improves the conditions under which people live: secure, safe, adequate and sustainable livelihoods, lifestyles, and environments, including, housing, education, nutrition, information exchange, child care, transportation, and necessary community and personal social and health services" Healthy public policy is also a focus of the Effects and Implementation framework, where we are looking at public policy but through a health care lens in any number of health care environments Ideally, want to start at Problem ID/framing ○ But sometimes policy can start at any point in the timeline Once you implement a policy, one of the key features is making sure that it works Mostly going to focus on the stage between Policy Implementation and Problem ID today ○ Want to look at existing policies, and we can use it to understand policy making, but today we are going to look at it as a evaluative framework Evaluate policy ○ Take a policy and see if it is doing what it is supposed to do ○ Was it implemented in a way that is equitable, efficient, and normative? ○ If it's good we might recommend it to be used elsewhere, if it's not you identify problem and come up with solution Before a Policy Decision is Made...(or alternative chosen) what should we do? How to make the best recommendations? ○ Sitting, writing a briefing note and you need to make a recommendation -- how do you make the best recommendation in public policy inform a decision maker/stakeholder about the relevance of adopting a particular public policy; bias-free, aim is to provide information ○ Talk to stakeholders -- talk to the people who are impacted by the policy ○ Find out how important things are to them ○ What is a culturally appropriate way to implement this policy? ○ Make sure it is bias free ○ Any policy is going to gain better traction if you engage the people ○ Why are we talking about pre policy? If you don't do this part (pre policy) right, your policy will not work Sometimes people look at the actual policy and how it functions in society and wonder why the policy is not working They spend a lot of time looking at the backend but forget about the frontend Ex: few weeks ago administration of Western passed a policy to prevent protesting without a permit That decision was not done in such a way that was frontend motive to seek the influence of stakeholders on what they thought As a result this decision received a lot of push back So need to consider frontend and also backend (but today we are focusing on backend) promote the adoption of a public policy; you are an advocate ○ If you want to promote a certain policy, then effectively you become an advocate ○ Advocacy is a really important part of policy -- it helps with frontend building compare public policies to inform the DM process ○ Another part you that might consider as important to post evaluation that has to be considered beforehand is alternatives ○ Sometimes there are more than one way to do something ○ You can look around and share ideas with other policy makers in other settings ○ The broader your opportunities for choice, then advocate, and speak to stakeholders, the better outcome you have Note: we are thinking more backend but don't lose sight of the fact that some evaluation outcomes say that a policy is terrible, but might not be terrible but might be how you implement To analyze an existing policy... what should we do? Evaluate! ○ How well does it work? ○ Ppl often fall into the trap of just doing a program that exists bc people don't plan ○ A good policy should have evaluation built into it ○ Not having evaluation built in to a policy leads to bias ○ Can evaluate everything but evaluation is a purposeful thing Determine whether or not the policy/program should be prolonged or identify weaknesses so they can be corrected Evaluation could focus on many components/aspects Effects/Implementation is an analytical framework that presents a range of possible evaluation questions ○ most relevant to the context at hand should be chosen Dimensions for Analyzing Public Policies NCCHPP Effects & Implementation Framework Straightforward Effects and evaluation -- there are subsets within Durability refers to the sustainability of a policy ○ Ex: Seatbelt legislation is very durable There is education, implemented, people follow, etc. ○ Ex: making ppl wear masks everyday is not a durable policy Effects: Effectiveness: @achieving its objective (-ve or +ve); can be difficult due to time ○ Did it achieve its objectives? ○ Ex: nutrition labels If people are using them to make healthier choices -- that's a positive outcome If it causes further equity issues and didn't benefit poorer ppl with less education -- negative outcome Distal effects: long term ○ Can't really measure them ○ But know that certain characteristics of lifestyles will create effects Immediate effects: deconstruct chain of events to identify relationship to problem (link to logic model – coming up in future weeks) ○ Small changes that are made immediately you know will have to make long term effect??? Unintended Effects (-ve or +ve) ○ Other things can create positive or negative effects Equity: different effects on different groups ○ Different policies effect different populations ○ Ex: smoking cessation policy Equity balance in terms of who is efffected in a positive way and not Lower income community, people stop smoking due to financial reasons But higher income community, find ways around it Implementation: Costs: actual, relative, hidden, opportunity; incurred by policy makers (e.g. government) or other agencies ○ What does it actually cost to implement your policy ○ Per $ you put in, how many ___ did you get out? ○ Blood tests, etc. end up saving millions in the long run ○ Costs are not necessarily dollars, can be resources, hidden costs, etc. Feasibility: congruency, resource availability, pilot programs, other contextual conditions (e.g. administrative programs to facilitate), cooperation or interference ○ How easy is it to implement? ○ Ex: tuberculosis The way they identify ppl w it wasn't feasible in that situation ○ Pilot programs are a good way to test out your idea in a smaller group Acceptability: do stakeholders think it will work as intended, how does it compare to alternatives, coercion, changing interpretations ○ How well do you think it's gonna work? ○ Is coercion necessary? ○ Changing interpretations -- changing contexts ○ Contextual variables change, and so policies may not be suitable anymore This is just one organization's implementation model Public Health Communicable Disease Management Today: looking at policy analysis tools ○ #2: Effects and implementation framework Mpox outbreak ○ First hit in 2022, coming back again ○ Not called monkey pox anymore Unintended change of the policy ○ Policy affected the name of it ○ Not monkey pox anymore bc it had racial connotations Prevalence of MPox graph ○ Not incidence bc there is no rate ○ But usually graphs like this are incidence but this one is not ○ New = incidence ○ Looking back at # of cases = prevalence ○ Prevalence -- How many of something in the population; a count Natural History of Disease (MPox) Understanding the disease helps us make policy decisions 1. Transmits from a vector Zoonosis -- reservoir uncertain 1970s first case; endemic to West/Central Africa Early 2022 global outbreak linked to travel Contagious from symptom onset to full hearing of pox Three stages: 1. Incubation (13 days) Takes 13 days to develop symptoms 2. Prodrome (1-4 days) Feel really bad for 1-4 days 3. Eruptive phase (14-28 days) Have pox Symptom severity and duration depends on density of lesions 6-15% mortality rate; worse outcomes in immunocompromised UK outbreak IMPORTANT CONSIDERATION: ○ If you don't define what you are trying to manage in healthy public policy, there is a problem right away, people don't understand what it is Airborne Policy response ○ What it is, what it's not ○ Fill in ○ Risk strat Risk stratification ○ Rather than identifying everyone who might have MPox, you stratify by risk ○ This saves more resource ○ Really important policy response!! ○ There are not enough Public health advice ○ Ranges from nothing, monitoring, limiting travel, no school, avoiding contact form immunocompromised people, etc. ○ This is how the UK is responding Lets look at the effects of MPox policy Effects Effective ○ It's effective bc we want to deal with MPox ○ How do we measure? Compare incidence rates at timepoints Epicurve -- number of cases over time; as the numbers go down, the cases go down Progress means less cases in the community ○ Immediate effects Will start to see effects in about 28 days that the policy is working Unintended effects ○ What are the unintended effects of this policy? ○ Further inequity May have a disproportionate impact on lower income populations -- they are told they have to stay away from work but they might not be able to afford to do that ○ Mental health effects Negative effect on mental health related to isolation ○ Positive effects People are isolating and other diseases are not spreading (ex: flu) Equity ○ Changing the nae from monkey pox to MPox is an equity consideration ○ When you do public health policy and healthy public policy, in Ontario, part of the pre work involves a health equity assessment Built into public policy work Assess it before implementing which can avoid these types of issues Implementation Cost ○ Why are they not vaccinating everyone? Cost to administer it is really expensive That is why they implemented risk stratification -- helps to reduce the cost and target ○ Opportunity cost Allocation of health care resources can result in a backlog of surgery for example ○ People are giving up their autonomy for a period of time ○ Hidden cost Feasibility ○ Do we have enough resources to do this policy? ○ Risk stratification strategy makes it possible ○ This strategy can be modified easily making it feasible in a lot of circumstances because

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