Health Policy Lectures 1-5

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Health Sciences
Health Sciences 3400A/B
Sharon Regan

Health Policy Review Week One - policy triangle - actors, context, process, content - the public policy process diagram Definition: Health policy is assumed to embrace courses of action (or inaction) that affect the set of institutions, organizations, service, and funding arrangements of the health and health care system. It includes policy made by the public sector (government) as well as policies in the private sector. But because health is influenced by many determinants outside the health system, we are also interested in the actions and intended actions of organizations external to the health system that impact on health (p. 6-7) POLICY IS ABOUT….  Addressing an issue/problem  Action or inaction  Choices or decisions  Principles/values  Resource allocation The Health Policy Triangle ACTORS Individuals, groups and organizations that participate in the policy process (Government, Interest Groups, Individuals). 1 CONTEXT  Situational factors –Conditions or events that may influence policy  Structural factors –Relatively unchanging elements of the society such as the political system, type of economy, and employment base.  Cultural factors –Include values/beliefs, ethnic, language, religious influences  International or exogenous factors–global influences and collaborations The Policy Process - the process of shaping policy initiatives, from agenda setting to implementation and evaluation ANOTHER WAY TO THINK ABOUT POLICY….  Ideas –how issues/policies are framed and presented.  Institutions –Rules, authority and values of an organization and the ways in which it makes decisions or acts.  Interests –actors who decide on or influence policy Week Two - Dimensions of power and application to policy making 1) decision making 2) non decision making 3) thought control - Theories for accounting for distribution of power and implications for policy 1) Pluralism 2) Public Choice 3) Elitism - Political systems (Easton's Systems Model), types (liberal democratic), understand implications for participation in policy making 2 Theories of decision making based on role of power in the policy process 1) Rationalism 2) Bounded Rationalism 3) Incrementalism 4) Punctuated Equilibrium 5) Mixed Scanning Contexts that Shape Canadian Health Policy  geographic and socio-demographic contexts o Large land mass, majority of population in urban centers, aging population, First Nations population, rural and remote populations- difficult for resource allocation  economic contexts o one of the richest countries, relatively strong economy, some issues with income inequality, health care costs are growing!  political contexts o Canada is a federation, we have three levels of government, federal and provincial governments are constitutionally recognized, the Constitution Act, 1867 sets out powers for federal and provincial governments Division of Powers Federal Provincial Defence Property and civil rights Criminal Law Administration of Justice Employment Insurance Natural Resources and the Environment Postal Service Interprovincial Transportation Census Education Copyrights HEALTH Trade Regulation Welfare External Regulation Money and Banking Transportation Citizenship First Nations Joint Powers: Immigration, Agriculture, and Pensions What is Power "The ability to influence people and in particular to control resources" - the ability to achieve a desired result - the ability to get someone to do what they otherwise would not have done - Policy process involves the exercise of power by competing actors to control scarce resources such as financial or human resources. 3 Three Dimensions of Power  Power as Decision Making (Dahl) o actions of individuals and groups that influence policy decisions o use of "political resources" to influence decisions may include social standing, $$$, or official office or position i.e. authority  Power as Non- decision Making (Bochratz and Barotz) o influence of individuals or groups to limit action on a particular issue o reinforcing the "status quo"  Power as Thought Control (Lukes) o ability to influence others by shaping their initial preferences o influence through media or advertising Theories of Power Distribution Pluralism  dominant theory  power is distributed throughout society between multiple interests  no single group holds absolute power and the government arbitrate among competing interests  Features: o open electoral competition o individuals can organize into groups o freedom of speech o openness of the state to lobbying o the state is neutral- this is a contested idea, they are more likely to align actions with personal values o elite groups exist but no one group dominates- another contested idea, society has many elite that exert much power Public Choice  Agree with pluralism in that society is made of competing groups pursuing goals but disagree that the government is neutral o government is seen as an interest group wielding power over the policy process o those who run government- elected officials and civil servants- wield power to maintain their interests and positions  Policy making is heavily influenced by this interest group  Critics of Public Choice theorists argue that the power of civil servants is overstated Elitism  Policy is dominated by a privileged "elite" minority o power is vested in this small group rather than distributed throughout society (pluralism)  Characteristics: 4 o few with power and many without o elites typically come from higher socio-economic strata o interest groups exist but have unequal power and access o values are conservative and change is incremental- "status quo" Political Systems Politics- who gets what, when, when and how (p. 34) Political Systems- concerned with deciding which goods, services, freedoms, rights and privileges to grant (and to deny) and to whom they will be granted (p. 34) Canada's Political System is Liberal Democratic  relative stability  diverse participation of groups  elections, political parties, interest groups, and media However, differences exist between countries that are considered liberal democratic (e.g. US has a president, congress, and only two parties) EASTON’S SYSTEMS MODEL OF POLICY MAKING Inputs–demands & supports from individuals or groups for action on an issue Black box –decision-making process from input to output may be visible or invisible Outputs–decisions on the issue –e.g. laws, education campaigns, $$$. Individuals/groups react to outputs and new demands for action lead back to inputs individuals and groups what is we don't know are asking what is going being done the govn't to to deal with do something on inside the issue make further demands reactions to outputs 5 Decision Making Models Rationalism  Assumption that decisions are made in a rational way  Step-by-step rational-comprehensive process to identify options to achieve desired goals: o identify problem o clarify goals, values and objectives o list all strategies to achieve the goal o analyze the impact including cost-benefit analysis o compare options- alternatives and consequences o decision made- maximize values/preferences to achieve goals while minimizing costs  Critique: o who defines the problem?- may be too narrow or specific, could miss the cause of the problem altogether o whose values and goals? o challenge to gather all information o time consuming  Example: Romanow Commission - governments committed to sweeping reform of the health care system Bounded Rationalism  Decision making is rational but reflects the "real world" constraints of time, incomplete information, and inability to identify all possible options and consequences  Decision makers aim to find solutions or select strategies to address the problem that meet satisfactory standards  satisfy + suffice = satisficing, instead of perfection why not good enough (at least it's better than before) 6 Incrementalism  "Muddling Through"  Incremental changes from status quo  Testing out how potential changes will be received  Avoids significant changes which can be disruptive  Series of small changes can ead to significant change  Others argue that incrementalism doesn't foster reform or innovation Punctuated Equilibrium  is adopted from physics  Policy is marked by long periods of little change  A significant event or issue disrupts this stability leading to a marked change in policy  events can be external or internal  Example: SARS- outbreak in 2002-2003 lead to numerous commissions in 2004-2006 identifying big problems with our public health system and the capacity to respond to health crisis'- this lead to many changes in public health such as policy changes, more money, more healthcare workers, and new protocols for dealing with pandemic Mixed Scanning  Combination (or balance) of rationalism and incrementalism o tries to address the major problems in each approach- idealistic and conservative elements  More applicable to major decisions  Broad analysis of the problem(s) and focused reviews of selected options or strategies  Focus on long-term alternatives or specific aspects of the problem  Considered a more "realistic" approach to decision making SUMMARY  Theories help us understand who has power, how power is exercised in policy making, and how decisions are made.  The distribution of power in society among government, individuals/groups, and elites often depend on the policy issue.  In the real world, no one theory explains how decision making occurs but they do provide us with insights that help us to understand the "black box" of decision making.  While the rational view of decision making presents an ideal, incrementalism and mixed scanning more closely align with how governments make decisions on a day-to-day basis. Week Three - Events from the 60’s to 00’s shape and influence healthcare systems and health policy issues o Universal Healthcare- Tommy Douglas 60’s 7 o Royal Commission- Emmett Hall 64 and 80 o Canada Health Act 1984 o Economic “Crisis”- 90’s o Commissions and Health Accords- 2000’s - Healthcare financing- federal and provincial roles- role of taxation, federal transfer, other expenses (out-of-pocket and private insurance), provincial health budgets - Provisions of services- public health, primary care, hospital care, home care, emergency, pharmaceutical, mental health, and palliative care - **We are responsible for figures in lectures, NOT tables in readings** The Constitution Act  Sets out the relationship and responsibilities between provincial/territorial and federal governments  Federalism- basis of Canadian government  Federal government has jurisdiction over marine hospitals and quarantine; taxation and spending (are limited in distribution)  Provincial government is responsible for establishing, maintaining, and managing hospitals, asylums, charities, and charitable institutions Timeline Before 1962 - Before WWII healthcare was primarily privately delivered and funded - Charity Hospitals existed and were run by religious organizations, reliance was on family as caregivers - Tommy Douglas- the premier of Saskatchewan- introduced provincial health insurance in 1947 - “Humanity First”- common good supersedes private interest- access to healthcare regardless of ability to pay 1962 - Implementation of Medical Insurance plan for physician services in SK - Prior to implementation there was a 23 day doctors strike - Physicians were then paid by fee for service - Tommy Douglas is the “Father of Medicare” 1964 and - Emmet Hall- Chair, Royal Commission on Health Services- one of the founding 1968 fathers of medicare - 1968 Medical Care Act- federal legislation for 50/50 cost sharing for provincial/territorial medical insurance plans 68-84 - Provinces and Territories developed individual medical insurance plans (FFS) - Block funding- 50/50 not working - 1984 Emmett Hall report- end user fees and extra-billing, set national standards - See Table 2.1 on page 27 1894 Canada Health Act - Sets out the primary objective of Canadian health care policy “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 barrier” - Includes all medically necessary hospital, physician, and surgical dental services 8 - Conditions five principles in order for provinces to receive full federal cash contribution through the Canada Health Transfer - The CHA fails to define what reasonable access is and what other barriers there may be - More below 90’s - Economic downturn - Reduction in federal transfer payments - Adoption of business models in healthcare o Restructuring and regionalization o Layoffs of healthcare workers, hospital closures (waiting times increased and 10,000 nurses went to the states) - Concerns about sustainability with funding - Numerous provincial commissions o Attempt to address economic impact on healthcare o “Innovation” to address “crisis” 2000’s - Romanow Commission (2002) o To examine the long-term sustainability of a universally accessible and publicly funded healthcare system o Canadians value Medicare; aligns with values - Kirby Commission (2002) o To examine the federal role in healthcare o Opens the door for some private delivery of services - First Minister’s Accord on Health Care Renewal (recommit to Medicare) - First Minister’s A 10 Year Plan to Strengthen Health Care - More below - Development of the Health Council of Canada, Canadian Patient Safety Institute, Public Health Agency of Canada, Patient Wait Times Guarantees Initiative Today - Federal government commits to continued funding for Accord through 2016- 2017 - Then, funding will be tied to growth in GDP- less than 6% annually - Federal role will likely be limited Canada Health Act Services NOT included under the CHA: - Home Care - Residential Care - Dental care outside hospital - Pharmaceutical outside hospital - Extended health services- physiotherapy, massage therapy, etc Groups of people NOT covered by the CHA: - First Nations people living on reserves - Inuit people - Canadian Forces - RCMP 9 - Veterans - Inmates - Refugee Claimants - All of these groups are covered under federal programs or combined programs between federal and provincial; just not CHA Comprehensive: - Provinces insure all medically necessary services provided by hospitals, by physicians, by dentists in hospital Universal: - Entitles insured persons to health insurance coverage on uniform terms and conditions Portability: - You can go anywhere in Canada and be covered - When you move to a different province, your first three months are covered by your home province and then you will be covered by the new province Accessibility: - Reasonable access to medically necessary hospital and physician services without financial or other barriers Public Administration: - Is not-for-profit by a public health authority Key Features of the 2003 Accord and 10-Year Plan  Commitment to Medicare and Canada Health Act Wait times reduction Health human resources planning –address shortage of healthcare providers  Home care –compassionate care benefit (fed); expanded home care (prov)  Primary health care –multidisciplinary teams; 24/7 access; eHealth/telehealth  Pharmaceutical policy –catastrophic drug coverage, national strategy  Aboriginal health –consultation; clarify roles and responsibilities; funding  Other –public health, rural health,  Funding -Annual increase of 6% Federal- Provincial Health Care Financing - Primarily generated through tax revenue - Federal- Canada Health Transfer- $40 billion disbursed- ~$10 billion to Ontario - Health care accounts for ~46% of provincial spending - Ontario- 2013-2014- $48 billion Ministry of Health and Long-term Care (federal is ~20-25%) 10 - Federal portion of funding may decrease after 2016 - OHIP entitles Ontario residents to provincially funded health coverage Private Health Insurance and Out-of-Pocket  Prescription drugs, dental care, vision care, rehabilitative services, complementary and alternative services  Private health insurance- majority is employer based  Out-of-pocket- additional expenses not covered by provincial health plans and private insurance  We are now spending less on hospital care and more on drugs Week Four - Canadian Health Services Research Foundation Provincial and Territorial Health System Priorities o Values, principles, goals, key policy issues - Getting on the agenda o Number of explanations for how they get on it 11  Two most common- Hall et al. and Kingdon  Hall et al.- legitimacy, feasibility, and public support  Kingdon- problem, politics, and policy streams meet to form policy windows - Actors- who sets the agenda? - Agenda to action? Main Stuff from Week Three - 5 principles of the CHA o Accessibility, public administration, comprehensibility, universality, and portability - The Kirby and Romanow Commissions - Taxation as the main source of funding What is agenda setting? - Policy Agenda o The list of issues which an organization, usually the government, i
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