NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
Advocacy represents the strategies devised, actions taken and solutions
proposed to influence decision-making on a particular cause/issue. The
purpose of advocacy is to create positive change for people and their
environments. Individuals, organizations, businesses and governments can all
engage in advocacy activities. As seen in Appendix 1, advocacy efforts range
from those on behalf of an individual to efforts directed at bringing about policy
change.
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Population health advocacy is directed at actions to improve the overall health
of a population. Generally, this is done through addressing the many social
conditions that impact the health of populations, such as early child
development, income, education, gender, etc. These conditions are often
referred to as the non-medical or social determinants of health (1).
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1 http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/overview_implications/01_overview_e.pdf
VCH Population Health Advocacy: Guidelines and Resources 2
Why is Advocacy important within Vancouver Coastal
Health?
Many Vancouver Coastal Health employees already integrate advocacy into
their day-to-day activities. Population health advocacy is mandated and
supported through the following VCH resources/initiatives:
• The VCH vision statement identifies a role for community level health
action: “We are committed to supporting healthy lives in healthy
communities with our partners through care, education and research”.
• A VCH Population Health Framework, endorsed by the Senior Executive
Team, outlines advocacy as one of four key population health strategies.
(See: www.vch.ca/professionals/docs/population_health_approach.pdf).
• The Ministry of Health directed Core Functions Framework Implementation
project highlights advoacy as a key component in several public health
core programs. (See: www.vch.ca/public/pip.htm). NURS 6050 – Policy and Advocacy for Improving Population Health Essay
• Advocacy is a key component of the newly released Core Competencies
for Public Health in Canada (See: www.phac-aspc.gc.ca/ccphcesp/pdfs/cc-manual-eng090407.pdf)
All of these resources and initiatives support VCH employees in providing a
credible voice in advocating for healthy public policies around issues related to
the social determinants of health. For example, this might be a public health
nurse describing the health impacts of poverty on children at a press release or
the Chief Medical Health Officer writing a letter to the Minster of Health calling
for a ban on Trans Fats.
What are the Principles of Advocacy?
Although VCH has a mandate to advocate on population health issues, we
must still work within our organizational and administrative policies. The following
principles can guide staff in choosing advocacy topics and activities.
Topics or activities should:
• Provide a non-partisan viewpoint.
• Adhere to the professional standards of your occupation.
• Focus on the health impacts of an issue. NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
VCH Population Health Advocacy: Guidelines and Resources 3
Individuals undertaking an advocacy topic or activity should:
• Be respectful of stakeholders/partners and ensure that they have been
consulted on the appropriate issues.
• Consider the expertise on an issue and ensure a response is based on
research/best practices whenever possible.
• Identify advocacy activities that are part of the VCH mandate,
sustainable and within the capacity of staff.
• Ensure approval of managers for advocacy activities and keep managers
informed throughout the advocacy process.
• Follow VCH communications guidelines (See Appendix 2).
Advocacy Resources
In addition to the descriptions of advocacy (Appendix 1) and communication
guidelines (Appendix 2), the VCH Population Health Advocacy Framework lists
key questions that can assist in advocacy decision-making (e.g., topic selection,
activity selection). The Advocacy Framework is found in Appendix 3A and 3B.
Appendix 4 provides additional resources for population health advocacy work.
The materials and resources listed in this document are provided as a starting
point for undertaking advocacy within VCH. If you have additional questions
regarding population health or advocacy, please direct inquiries to Vancouver
Coastal Health Population Health (PopulationHealth@vch.ca).
Advocacy resources and initiatives on the VCH Internet Site:
www.vch.ca/public/Advocacy.htm
VCH Population Health:
www.vch.ca/population/
VCH Population Health Advocacy: Guidelines and Resources 4
Appendix 1: Types of Advocacy
Self-Advocacy Speaking or acting on our own behalf and
standing up for our rights (e.g., asking to see
a store manager if not treated appropriately)
Natural Advocacy Speaking up in the moment, when one
notices that something is not right or unfair
and others are not able to speak up for
themselves (e.g., seeing someone being hurt
and intervening) NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
Peer Advocacy Encouraging and supporting other individuals
to speak or act for themselves (e.g., assisting
people to discuss their health issues with their
family physician)
Service Advocacy Working within systems to assist individuals
and families in ensuring their needs are met
(e.g., referral to a community agency for
postpartum depression support)
Program Advocacy Working to support a program or prevent its
demise (e.g., writing to stakeholders to keep
childcare programs from closing)
Cause/Issue Advocacy Working with other advocates to influence
politicians/senior bureaucrats at all levels of
government to change legislation or policies
that affect large numbers of people (e.g.,
engaging in joint initiatives with education
advocates to enact change re child poverty,
increasing childcare spaces in VCH).
Advocacy targets may also be private
businesses or governance bodies.
VCH Population Health Advocacy: Guidelines and Resources 5
Appendix 2: Communications and Advocacy
The Public Affairs and Communications Department at Vancouver Coastal
Health can provide you with guidelines and resources for your advocacy
initiatives involving the media. If you wish to speak to the media on behalf of
VCH as an advocate (e.g., letter to the editor, media interview, etc.), please
contact VCH Communications to review the content. Prior to contacting
Communications, please ensure that:
1) Someone in your department has checked the content for accuracy.
2) All relevant personnel (i.e., managers) in your department are aware of
the initiative.
Communications will review the material through the political/media lens and
provide feedback. The material you have prepared does not necessarily need
to agree with VCH on a topic. However, if changes are suggested and you
choose not to accept them then you are asked to submit the material as a
private citizen, rather than as a VCH advocate.
Adhering to this process provides Communications with an opportunity to supply
additional information that may assist you in your initiative. Communications
can include the information in their daily communications summary in case the
media calls about a particular issue.
Public health is situated at the intersection of major social, political, economic and cultural forces in society. If the mission of public health is
to create environments in which people can be healthy, then the pursuit of this goal “…involves
the often contentious process of blending science, politics, and activism in the context of
social values and interests. This means that public health battles are often fought along
political fronts as well as behavioural fronts.”1
As such, improving public health requires an explicit commitment to advocating for policy changes that support the development of health promoting environments.
The purpose of this discussion paper is to delineate the boundaries of advocacy as it is currently understood and practiced within public health. This document draws on research and discussion papers addressing the role public health advocacy plays in the creation of conditions and environments that promote health
and prevent disease and injury. More specifically, the purpose is to outline the key attributes of public health advocacy, highlight
and explore the main challenges to practicing
public health advocacy, and identify key skills
required for public health advocacy. This paper
concludes with a brief overview of one type of
advocacy employed in public health – media
advocacy – to demonstrate the applied aspects
of this approach. NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
What is public health advocacy?
The focus of this discussion is on ‘policyfocussed’ public health advocacy, i.e., activities
that attempt to contribute to health promoting
systemic change by influencing policy
processes. While there are many available
definitions of public health advocacy,2-4 these
share key common elements, including: an
emphasis on collective action to effect desired
systemic change; a focus on changing
“upstream factors like laws, regulations, policies,
institutional practices, prices and product
standards;”5
and an explicit recognition of the
importance of engaging in political processes to
effect desired policy changes.
Public health advocacy is often defined as the
process of gaining political commitment for a
particular goal or program, and identified by
some as a critical population health strategy.2,6
Target audiences tend to be decision-makers,
policy-makers, program managers, and more
generally, those that are in a position to
influence actions that affect many people
simultaneously.4,7,8
Public health advocacy strategies espouse an
upstream approach, recognizing that ‘individual’
and ‘personal’ problems are often reflective of
social conditions. This approach involves
situating ‘individual’ health issues within the
broader context of social determinants external
to individuals. NURS 6050 – Policy and Advocacy for Improving Population Health Essay.It also recognizes the societal
breadth of many public health problems, and the
logistical and resource challenges inherent in
approaching these challenges at the individual
level. While downstream health promotion
activities (such as primary or secondary smoking
prevention, community-level interventions and
provider education) play an important public
health role and should be continued, “…to some
they resemble fixing with a pick and shovel what
is being destroyed with a bulldozer.”
Engaging in public health advocacy
acknowledges the explicitly political aspects of
public health, and the importance of addressing
social determinants of health as a key
component of a strategy for improving the health
of populations. Put another way, public health
advocacy is an important strategy for creating
environments supportive of health.10 If the goal
of public health is to reduce the societal burden
of health problems, then effective interventions
must “…alter the societal forces that foster these
problems.”11 Ignoring the social and political
dimensions of health has the effect of relegating
public health practice to the “…prevention and
promotion of individual risk factors.”12
Healthy Public Policy / Public health advocacy / November 2009 / Page 1
Advocacy strategies draw from a range of
tactics. These can involve “…creating and
maintaining effective coalitions, the strategic use
of news media to advance a public policy
initiative and the application of information and
resources to effect systemic changes that
change the way people in a community live. It
often involves bringing together disparate groups
to work together for a common goal.”13 It can
also involve gathering and presenting an
evidence-base for desired changes, although it
is worth noting that scientific evidence alone is
rarely enough to achieve desired political support for public health goals. Evidence is often
a necessary – but rarely sufficient – factor for influencing policy processes.
The Ontario Health Promotion Resource System categorizes advocacy activities as low, medium,
and high profile. Low profile activities could
include quiet negotiation, meetings with civil servants, sharing information, and the
development of non-public briefs. Medium profile
activities include on-going negotiation, development of public briefs, ‘feeding’ the
opposition, giving deputations at committees,
participating in meetings with elected officials,
forming strategic alliances with other groups, and writing letters to elected officials or
newspapers. High profile activities include public
criticism, public relations activities, advertising campaigns, information distribution, letter writing,
and participation in demonstrations and rallies.14
Within this categorization system, many activities(e.g., meeting civil servants, sharing information)
may fall within any of these categories, depending on the nature of the activity and its
intended result.
There are many examples of successful public
health advocacy efforts, and “…every branch of public health can point to the critical role of
advocacy in translating research into policy,
practice and sea changes in public opinion.”15 To date, public health advocacy has been used to
advance policies in several public health areas,
including gun control, injury prevention, and tobacco control.13 In spite of the importance of
this work, Chapman argues that “…advocacy remains a Cinderella branch of public health
practice. Advocacy is often incandescent during
its limited time on stage, only to resume pumpkin
status after midnight. Routinely acknowledged as critical to public health, it is seldom taken
seriously by the public health community,
compared to the attention given to other disciplines.”16 The lack of attention paid to public
health advocacy is reflected in the limited body of research literature on public health advocacy research or practice.
Advocacy skills
Engaging in policy advocacy requires a diverse
set of skills. Gomm et al. identify three core skills required for successful public health advocacy:
1) the ability to work collaboratively with
multiple stakeholders,
2) strategic use of media, and
3) ability to conduct strategic analysis.17
This latter skill requires a focus on three central
questions (what is the problem? what is the
desired solution? who is the target for change?)
Although sometimes overlooked as a skill, being
able to identify a policy solution is as important
as being able to identify the problem in public
health advocacy.18
The ability to frame issues effectively is identified
as a key component of public health advocacy.
Chapman argues that “…the currency of
advocacy is metaphor, analogy, symbol” and as such, it is imperative to present data and issues in ways that are both compelling and resonant
for audiences without public health expertise.19
According to Chapman, successful advocacy
framing involves drawing on “…subtexts or
value bases which have widespread support
(‘this issue is like that issue’) so that the
solutions proposed to the problems are seen as
consonant with solutions demanded for problems with parallel values underlying them.”19
Once frames are established around an issue,
elements inside the frame are perceived as credible or legitimate, while elements outside the
Healthy Public Policy / Public health advocacy / November 2009 / Page 2
frame are considered marginal and have limited
currency in public debate.NURS 6050 – Policy and Advocacy for Improving Population Health Essay.20
Framing is critical with respect to both identifying the problem and the solution. For example, in
the fight against tobacco, over time the focus of
advocacy efforts shifted from tobacco users (i.e., smokers) to tobacco producers. Strategic effects
of this shift include the opening of new areas for advocacy efforts, and allowing advocacy efforts to shift from an emphasis on changing individual behaviours (i.e., getting smokers to quit) towards
changing polices that govern both the production
and usage of tobacco.21 It also resulted inincreased scrutiny of tobacco marketing
practices.
Freudenberg argues that public health
advocates could benefit from increased
theoretical competency, particularly increased
content knowledge in three key areas:
organizational and behavioural change,communications, and social movement theory22
– all areas typically not included in public health
education curricula. Hoover notes the strategic
importance of working collaboratively in multistakeholder coalitions, which allows
stakeholders to take on relevant and institutionally appropriate roles as required.8
For
example, it might be that non-governmental
organizations would serve as the ‘public’ face of the coalition while other organizations contribute
more fully ‘behind-the-scenes.’
Challenges of public health
advocacy
There are many challenges inherent in the practice of public health advocacy. Perhaps the
most obvious challenge is related to the explicitly political nature of fostering systemic change, and the tensions this creates for public health professionals given that the vast majority of this
work is funded by public sector resources. Given
that “…most fields of public health have objectives that are highly contested by
opponents,”16 public health advocates may find themselves engaged in public conflict with
sometimes powerful interest groups or governments determined to resist change. This
creates a significant tension, as public health
advocacy often requires its practitioners to be “unpopular vanguards,”5
a challenging role in
institutional contexts that are often resistant to
politically contentious change initiatives.
While advocating for systemic change to
address determinants of health affecting populations may make intuitive sense to public
health professionals overwhelmed by the
logistical and resource demands of individual level change, institutional restrictions on
advocacy practices are common. The practice of public health advocacy can be limited by
boundaries of professional roles, employer
policy, or limited access to resources for
advocacy activities.23 When the object of advocacy is to influence public policy,
“…government funded public health workers
mostly see advocacy as strictly off-limits.”24
Another challenge to those wanting to employ
public health advocacy strategies stems from the
epistemological underpinnings of public health
education, much of which is grounded in the concept of scientific neutrality, and the belief in
the possibility of ‘value-free’ research. NURS 6050 – Policy and Advocacy for Improving Population Health Essay.For adherents of a logical positivist perspective, there is a belief among many that “…public health ought to remain a value-free, mainly
scientific activity, devoid of any partisan reference.”25 This challenge is compounded as public health professionals typically receive little or no training in “how to advance or advocate the policy implications of research,”15 and thus are poorly equipped to promote advocacy as a viable and important public health strategy. It is argued, however, that the success of future public health practices require a “…willingness
for the field of public health to rethink its posture
of ‘value neutrality’ and ‘objectivity’ so as to
encompass the types of social action necessary to effectively modify the social determinants of
health. Planned socio-political action must be an
appropriate adjunct to a scientifically-based public health, and no longer threateningly antithetical to it.”26
Healthy Public Policy / Public health advocacy / November 2009 / Page 3
A further challenge noted for the practice of public health advocacy is that of language, and
in particular, the linguistic divide between the social approach required for public health and the individual approach typically employed in issues of health care. As Wallack and Lawrence
state bluntly, the language of individualism “is
not a sufficient language for advancing public health.”27 If the goal of public health is to assure
conditions in which people can be healthy, the
creation of these conditions typically requires
systemic change, the type of change brought
about by collective, public, political action. This
type of change is rarely attained by using the language and focus of individual behavioral change, given that “…barriers to health cannot always be dismantled by individuals or on a
case-by-case basis.”23 Freudenberg22 draws attention to the way language frames public
health problems and solutions with his use of the
phrase ‘corporate disease promotion’ to highlight the role major American corporations play in six
industries identified as major causes of U.S. NURS 6050 – Policy and Advocacy for Improving Population Health Essay.
mortality and morbidity.*
All of the challenges noted above reflect and
contribute to the inherent difficulty of evaluating ‘successful’ public health advocacy. Advocacy
activities are often developmental in nature,
emerging and progressing in response to
contextual factors and policy opportunities, making it difficult to anticipate expected
outcomes in advance.4,28 In addition, policy
development – particularly public policy – is a complex process, with multiple and often
competing stakeholders. Again, this provides
challenges for assessing possible outcomes of
advocacy activities. Finally, the long-term nature of systemic change also requires a long-term
evaluation strategy, and indicators reflective of
the long time frame involved in systemic change.
Media advocacy
Although it has been observed that little research
attention has been paid to public health
advocacy overall,6
the area of ‘media advocacy’
has been the focus of a body of research,
primarily by Lawrence Wallack and various
colleagues. This discussion paper now turns to a brief synopsis of media advocacy to provide a practical example of a public health advocacy approach.
Media advocacy is a policy-oriented approach to
using mass media for public health promotion.
Although mass media are used in many health
promotion activities, the end result of media use
varies according to the approach driving the
intervention. Wallack and Dorfman highlight the
difference between using the media to address
an ‘information gap’ and using the media to
challenge a ‘power gap.’ A traditional view “…results in mass media being used as an
educational strategy primarily to provide
individuals with more information to make better
health choices”. In media advocacy, however, mass media is “…used as a political tool to
target and pressure policymakers for social
change and to mobilize widespread support to
apply the pressure.”29 This represents a
fundamental change away from a social marketing approach to promoting health and towards “…approaches that change the rules
defining the environment in which health behaviors take place.”29
Media advocacy interventions require
community development model or focus on
broad-based grassroots mobilization as the
means of achieving desired change.
As in other types of public health advocacy, the
framing of issues is a critical component of
media advocacy.8,18,27,30 For example, Hoover
distinguishes between two key types of framing
in media advocacy: access and content.8
Framing for access involves shaping the story to
get media attention. Framing for content involves
shaping the story from a policy advocacy
perspective. This often requires reframing the
story to highlight the social and environmental
conditions contributing to the public health
‘problem’, and the presentation of a policy
solution that will contribute to changing the
problematic conditions.NURS 6050 – Policy and Advocacy for Improving Population Health Essay.31 Framing for content
involves four key steps:
1) emphasizing the social dimensions of the
problem;
2) shifting primary responsibility away from
the affected individuals to those whose
decisions affect these conditions;
3) presenting policy alternatives as
solutions; and
4) ensuring that policy options have
practical appeal.
The evaluation of media advocacy initiatives is also
noted as a challenge. Stead et al. argue that while
media advocacy is a promising area, it requires
“…systematic research if it is to move from plausibility
to proven effectiveness.”32 To address this research
gap, the authors propose a comprehensive evaluation
framework for media advocacy, and stress the
importance of having a clear understanding of both
the intervention being proposed, as well as how this
intervention is expected to contribute to the desired
policy changes.
Conclusion
It is paradoxical that while public health
advocacy is considered by many to be a critical
strategy for improving the health of populations,
it is also largely ignored by the public health community.6
In part, this paradox speaks to the complexity of practising public health advocacy.
Developing an upstream approach requires recognizing that ‘individual’ and ‘personal’
problems are often reflective of social conditions, and thus developing a ‘social’ response – one
that goes far beyond an individual-level approach to public health. Public health
advocacy is also a highly skilled activity, requiring practitioners to be conversant with theories of social change, critical analysis,
strategic framing and the ability to collaborate with a diverse set of stakeholders on complex problems.
Advocating for health promoting social change is also an inherently political activity. Due to the
potential for conflict with powerful stakeholders, and the public-sector nature of most public
health practice, public health professionals attempting to advocate for health promoting
social change may find this work limited by institutional restrictions and a lack of organizational support for advocacy activities.
Yet public health advocacy also has the potential
to result in significant public health benefits, given its upstream focus and potential for
addressing the impact of non-medical determinants of health rather than merely dealing with the symptoms.
Healthy Public Policy / Public health advocacy / November 2009 / Page 5
In today’s rapidly changing healthcare delivery system, decisions made within the political arena impact the future of healthcare systems and the populations that healthcare professionals serve. In this course, students examine healthcare reform and its impact on healthcare delivery, population health, and nursing practice. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.They evaluate policies that influence the structure, financing, and quality in healthcare and examine healthcare delivery from a global perspective. Through discussions, case studies, and other activities, students examine the effects of legal and regulatory processes on nursing practice, healthcare delivery, and population health outcomes. Students also examine ways to advocate for promotion and preservation of population health and gain the necessary skills to influence policy and support changes effected by the passing of new healthcare reform legislation.
Advocacy plays a key role in building strong health systems. It gives people a voice in the decisions that affect their lives and health and helps hold governments accountable for meeting the health needs of all people, including marginalized groups. Health policies developed with broad participation help governments and institutions provide better healthcare. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
In the fields of HIV, family planning and reproductive health (FP/RH), and maternal health, advocacy occurs throughout the policy process. Advocates detect problems and raise awareness of those problems. They participate in policy dialogue and contribute to designing policy solutions, then marshal support to adopt those solutions. Their work doesn’t end with the passage of policy measures. Instead, they help ensure equitable and effective implementation of health policies, monitor the impact of those policies, and identify gaps and challenges. To do all this successfully requires a specialized set of skills and knowledge.
What We Do
HPP is a catalyst. We help ensure that those most affected by policy decisions have a voice throughout the policy process. We help bring disadvantaged groups to the table and work from the bottom up to bring in new groups and actors. We bring people together and promote policy dialogue. Most of all, we work to ensure that local government, civil society, and other partners in host countries have the capacity to do all this themselves as they advocate for supportive policy environments. Focused on sustainability, we are also preparing local partners to take on this capacity development role in the future.
We strengthen advocacy partners around the world, from India to Jamaica. Our partners include government officials, religious leaders, local NGOs and faith-based organizations, parliamentarians, universities, networks of people living with HIV, key populations, indigenous women, and other marginalized populations. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.We help organizations develop advocacy strategies and provide them with the tools and skills they need to put those plans into practice, placing particular emphasis on the use of data in advocacy. We provide financial and technical support, strengthen country-level and international advocacy networks, and generate information that supports advocacy efforts, including translating the latest research for use in policies and programs.
Our advocacy efforts include:
- helping women leaders enhance the role of women in FP/RH policymaking
- helping advocates address maternal mortality and promote respectful labor and delivery services
- working with indigenous women’s networks to address inequities, and
- supporting advocacy efforts to reduce stigma and discrimination and address harmful gender norms within HIV programs.
Publications and Resources
The Health Policy Project (HPP) HIV policy analysis and advocacy decision models are systematic structures and methodologies designed to help stakeholders create an inventory of country policies, analyze these policies against international best practices and human rights frameworks, assess policy implementation, and create a strategic advocacy plan.
Developed with support from the USAID-funded Health Policy Project, A Guide for Advocating for Respectful Maternity Care is a comprehensive resource centered on the Respectful Maternity Care charter, a groundbreaking consensus document that demonstrates the legitimate place of maternal health rights within the broader context of human rights.
Road Map for Implementing and Monitoring Policy and Advocacy Interventions
This suite of tools, developed by the USAID-funded Health Policy Project, the University of Washington, USAID, and the U.S. Centers for Disease Control and Prevention, was designed to strengthen the capacity of key stakeholders to engage in and monitor health policy development and advocacy interventions.
Networking and Coalition Building for Health Advocacy: Advancing Country Ownership
The Health Policy Project prepared this brief to provide leaders of civil society organizations with guidance on working within networks and coalitions to advocate for improved family planning, HIV care and treatment, and maternal health policies and programs.
Accountability and Transparency for Public Health Policy: Advancing Country Ownership
The Health Policy Project prepared this brief to provide leaders of CSOs working in family planning, HIV care and treatment, and maternal health with guidance on ensuring good governance, social accountability, and transparency.
At the request of the Ghana AIDS Commission and other in-country stakeholders, the Health Policy Project (HPP) updated an analysis of the effects of various funding scenarios on program impact and HIV incidence and coverage. The project used the Goals Model to develop these scenarios, NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
Health Policy Project Advocacy Activities and Accomplishments – 2012
News
Case Study: Parliamentarians in Malawi Examine Impacts of Rapid Population Growth
The Family Planning Association of Malawi presented the social and economic effects of high fertility to Malawi’s Parliamentary Committee on Health and Population, illustrating how the Government of Malawi could save U.S. $751 million in education and U.S. $1.5 billion in health over a 30-year period.
Mixing Technology and Tradition to Improve Women’s Health
Traditional communicator adopts RAPIDWomen model as persuasive advocacy tool to improve health, well-being of women and girls in Mali.
Advocating for Life-Saving Changes
African women leaders define priorities in family planning and reproductive health at advocacy workshop organized by HPP.
Indigenous Women Urge Political Commitment for FP/RH in Guatemala
The National Alliance of Organizations for Reproductive Health of Indigenous Women of Guatemala organized a public forum with candidates for the national congress to demand greater commitment for improving the reproductive health of indigenous women. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
As the model shows, policies and programs play an important role in health improvement through their influence on health factors as well as health outcomes.
The finite and generally scarce nature of available resources for population health improvement creates an imperative for focusing on those policies and programs that have been shown to be most effective. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.However, because tight resources also limit the quantity and quality of evidence on any given policy or program, it can be very challenging for those working to improve health to determine the best course of action. Fortunately, a growing number of online resources help point to recommended policies and programs.
Policies can be implemented at many different levels, from an individual school or worksite to municipalities, regions, states, and even the national level. Examples of effective health policies include smoking bans, excise taxes on cigarettes and alcohol, seat belt laws, water fluoridation, and restaurant menu labeling. There is an increasing call for a “health in all policies” approach among population health academic and practice leaders. Emerging in response to a growing understanding and recognition of the many different factors that influence health, “” underscores the need for policymakers in various sectors such as education, housing, transportation, agriculture, development, environment, and others to carefully examine the health implications of the policies they put into place.
Programs aimed at population health improvement are extremely diverse and address the full range of health determinants/factors. They not only encompass efforts to improve access to health care and individual behavior but also work to create healthy options and opportunities in the environments where people live, learn, work, and play.
social marginalization, and psychosocial stressors get “under the skin” in many ways that provide a biological basis for health vulnerability. As argued by Alice Furumoto-Dawson and colleagues, negative conditions in early life are especially critical, for these exposures can interact with developmental gene expression and, in turn, can influence adult health through multiple mechanisms and pathways, including hormonal, neurological, and immune system dysfunction. Their paper calls for community-based policy responses that will improve neighborhood social environments for children and that will reduce marginalization, discrimination, and other forms of psychosocial stress over the life course.
Such arguments reinforce a critical yet often neglected lesson for health policymakers: For policy responses to health vulnerability and population health disparities to be effective, they must extend beyond the provision of medical care. In this essay we offer the perspective that U.S. health policy has become too focused on medical care as the primary policy lever. Along with an increasingly medicalized view of population health and health vulnerability has come a policy focus on the narrow issue of improving access to personal health services. The overarching goal of improving health status has become displaced by the more immediate goal of increasing access to health care services. As a result, we have a fragmented and beleaguered health care safety net, and insufficient policy attention is being paid to socioeconomic conditions that give rise to health vulnerability in the first place. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
MEDICALIZATION AND HEALTH POLICY
A century ago, policy interventions addressing health vulnerability often reflected a broad view of the causes of vulnerability and the conditions that needed to be addressed through public action. The specific etiology of most illnesses and diseases was poorly understood. However, given the large and obvious statistical association between poverty and illness, health status vulnerability was readily seen as a consequence of socioeconomic vulnerability. As a result, public health activities in the late nineteenth and early twentieth centuries focused on “upstream” causes of poor health, including poor sanitation, overcrowded and squalid housing conditions, work-related hazards, food security, and nutrition. Interventions in these realms are believed responsible for sharp mortality declines across age groups in the United States.
Concurrent with these public health improvements, a sea change was under way in biomedical science, with an increasing focus on individual causes and manifestations of illness and disease. This increasingly individualized perspective fostered a tendency to medicalize health and illness. Irving Zola defines medicalization as the expansion of medicine as an institution and the use of a medical lens to view human processes and behavior. A medicalized perspective tends to define health problems as the result of individual failures of biology, hygiene, and behavior, with the implicit or explicit belief that the primary strategy for addressing these problems is through biomedical treatments delivered to individuals by physicians and other providers. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
Multiple economic, social, and political factors fueled the growth and dominance of individualistic, medicalized perspectives regarding public health, although a detailed analysis of this topic is outside of the scope of this essay. Michael Katz argues that individualized accounts of illness and vulnerability strongly resonated with Americans’ historic ambivalence toward disadvantaged individuals and groups, with accompanying moral and ideological distinctions between citizens deemed worthy and unworthy of assistance
As health status and health vulnerability became more medicalized throughout the twentieth century, discourse and decisions regarding policy priorities changed as well. Given an increasingly medicalized view of health vulnerability, public policy became focused on expanding access to individualized medical care. The federal government was providing personal health services to certain populations (such as merchant seamen and Native Americans) before 1900. However, as the problems of vulnerable populations became more medicalized, policies and initiatives focusing on health care access proliferated across populations and across a range of pertinent medical services.
Given this policy emphasis on medical care, a piecemeal, categorical, and separatist approach to providing health care services to vulnerable populations emerged. Throughout the twentieth century, the making and buying of health care services through government policy created facilities, systems, providers, financing arrangements, and bureaucracies that exist outside the mainstream health care delivery system and operate specifically for vulnerable populations. Examples abound, including community and migrant health centers, Title X family planning clinics, local public health clinics, Medicaid managed care, Medicaid expansions for pregnant women, the National Breast and Cervical Cancer Early Detection Program, and the State Children’s Health Insurance Program (SCHIP).
THE LIMITS OF MEDICALIZED POLICY RESPONSES
Current public policy responses to health vulnerability focus primarily (although not exclusively) on the procurement of medical care services, with a reduction in access barriers proffered as the central benchmark for success. Although policies that address financial and geographic barriers to health care bring important services to populations in need, many such policies establish and reinforce a two-tier “safety-net” system in which vulnerable populations primarily go to separate institutions or providers for their health care.
These separate programs are viewed as necessary as a result of the dominant system’s failure to provide adequate access for those who are marginalized and vulnerable. These programs, however, are not well funded, and the services provided are neither adequately paid for nor completely covered. This leaves safety-net providers and programs plagued by financial pressures and often unable to deliver high-quality medical care to the populations they serve. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
A second, less noticed consequence of medicalized perspectives is a conflation between health status disparities and health care disparities. Medicalization encourages the view that one can solve socioeconomic and racial/ethnic health status disparities through initiatives and policies that reduce disparities in health care access, use, and quality. This conflation, for example, can be seen in some aspects of the Health Disparities Research Plan of the National Institutes of Health (NIH) and also in the National Action Agenda of the Department of Health and Human Services (HHS) Office of Minority Health.
In turn, when health vulnerability and disparities are medicalized, health care access becomes overvalued and overemphasized as the most promising policy path. It is also an easier path, politically, than are fundamental social and economic reforms. The result is our current situation, in which an estimated 95 percent of U.S. health services spending goes toward direct medical services, and only 5 percent is invested in population or community approaches for prevention and health status improvement.
Medicalized framing of health vulnerability can be an effective strategy to defend policy benefits/transfers to the disadvantaged by sidestepping social and political debates over the deservingness or worthiness of vulnerable populations. The Supplemental Security Income and Social Security Disability Insurance programs are examples of how a medicalized approach to complex social problems can bring valuable income support and other benefits to people living with disabilities. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.Similarly, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides housing and social services that extend beyond the domain of medical care to people living with HIV and AIDS. In addition, Medicaid provides a funding umbrella under which many states finance expanded services and social supports that extend beyond medical treatment and care. Nonetheless, these types of social services and interventions tend to become available only after a person is diagnosed as sick or disabled, and they focus on individuals and families rather than on the social and economic conditions of communities that are the fundamental drivers of poor health over the life course.
CONCLUDING COMMENTS
Increasing recognition is being given to the social and nonmedical determinants of health, with an emphasis on the need to address upstream causes of health vulnerability and social disparities in health. The Acheson Report regarding health inequalities in the United Kingdom concluded that policy action must “address all of the layers of influence on health (e.g., social, environmental, economic, etc.), as well as ensuring that access to and use of health care services improves among those who have previously been underserved.” The report advanced thirty-nine specific recommendations that promote policy in five general areas: (1) breaking the cycle of health inequalities by addressing poverty (especially among families with children) and investing in early childhood development programs and in education interventions to close attainment gaps; (2) addressing social gradients in modifiable health risk behavior (such as smoking, obesity, and physical risk taking); (3) improving access to and use of public services and facilities, including social services, primary health services, and transportation; (4) strengthening disadvantaged and marginalized communities by investing in neighborhood renewal, housing, safety, the physical environment, and educational and employment opportunities; and (5) focusing attention on extremely vulnerable groups, such as the homeless, the mentally ill, and their families. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
Building on the Acheson Report, Al Tarlov promotes an “intervention framework” to improve population health that includes five broad objectives: (1) improve child development; (2) strengthen community cohesion; (3) increase opportunities for self-fulfillment; (4) increase socioeconomic well-being; and (5) modulate hierarchical structuring. Interventions in these areas require participation on the part of multiple sectors, including public policy, private-sector investment and action, and community programs.
David Kindig has repeatedly warned against falling “into the medical model trap of thinking that all health improvement comes from individual medical care interventions.” The genuine benefits of improved medical technology and personal health services heighten the temptation to place too many policy eggs in the health care access basket. This temptation is further increased by a host of political, social, and economic factors that favor increased medical investments. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
Given these pressures, participants in health policy must remind citizens and policymakers that lack of access to health care is not the fundamental cause of health vulnerability or social disparities in health. Medical care rarely addresses the early-life conditions that are fundamental causes of health vulnerability later in life. Medicalization prioritizes health care vulnerability over health status vulnerability, and it encourages us to believe that expanding access to personal health services is the best policy response. Ironically, social and economic inequalities in access to health care are often smaller than corresponding inequalities in access to housing, education, nutrition, and other resources. Although these resources lie outside the traditional domain of medical care, they are often more important than personal health services in generating or ameliorating health inequalities.
I f public investments were channeled to ensure that more citizens have economic security, receive a high-quality education, and grow up and live in thriving communities, medical care would be one resource among many to improve the health of vulnerable populations. This would enable us to provide medical services for “fine tuning” the health of vulnerable populations, instead of using health care as the primary way to address vulnerabilities that derive from complex social environments and extend far beyond the scope of the health care safety net. NURS 6050 – Policy and Advocacy for Improving Population Health Paper.
Paula Lantz ( plantz@umich.edu ) is a professor, Health Management and Policy, at the University of Michigan in Ann Arbor; Richard Lichtenstein is an associate professor there. Harold Pollack is an associate professor in the School of Social Service Administration at the University of Chicago (Illinois).
The authors thank Nonie Hamiilton and Helen Reid for research assistance.
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