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PubMed1996

"Doin' politics": linking policy and politics in nursing.

Policies affecting nursing are set within the larger environment of the health policy sector. That sector is characterized by increasing size, complexity, and goal displacement. All three characteristics have served to expand the resource base for this sector despite fiscal constraints on such growth. The environment of policy making shapes both the substance of policy change and the strategies for political adoption. Without understanding the dynamics of the policy environment, efforts by nursing leaders to enhance their growing political sophistication and to articulate nursing interests with maximum effectiveness will be compromised.

Decision Making, Organizational↗
PubMed2000

NHS reforms in the United Kingdom and learning from developing country experience.

The NHS has been the object of much international interest from its inception and through its periodic reforms. However, UK policy-makers have expressed only limited and selective concern for health sector reforms in other countries. This paper seeks to identify key elements of the present process and content of reforms to the UK NHS and examine the extent to which international learning would be important in developing these reforms. Particular emphasis is placed on learning from developing country experience. The paper therefore considers the policy process in the UK, the focus on primary care, the shift from competitive to collaborative strategies in addition to prioritising and planning. Each is considered in relation to developing country experience and the opportunities for learning. The paper concludes by setting out four areas leading to an international opening in NHS policy processes: developing political space in policy making, developing mechanisms for international exchanges, understanding policy context, and broadening international experience and changing values. The notion of a one-way process in international policy learning is rejected: while the South can learn from the North, so too can the North from the South.

Cooperative Behavior↗
PubMed2001

Randomised trials of socially complex interventions: promise or peril?

In the spirit of evidence-based decision making, research findings are increasingly being used to inform practice guidelines and policy making. Whether research informs the process accurately and appropriately depends on the quality of the design. This article examines the assumptions underpinning the randomised trial in relation to its application to evaluating socially complex interventions. Because the properties of the randomised trial are not independent of the characteristics of the interventions being studied, researchers need to be more attentive to selection bias, unmeasured contextual variables and uncontrolled interaction effects that arise because the environment interacts with the intervention. It is recommended that evaluations of socially complex interventions be modified by adding a complex contextual evaluation and using multiple sites.

Evidence-Based Medicine↗
PubMed1988

Technology assessment policy: top down or bottom up?

This paper briefly contrasts two approaches to formulating and implementing technology-related health policy. Policy changes are traditionally imposed from above, top down. However, policy changes related to adoption, diffusion, or rejection of new technologies for health care, can be very effective from the bottom up. The aggregated micro-decisions of thousands of health professionals and institutions can also become macro-policy, quite constructively. This paper argues for and documents the utility of bottom-up policy making.

Health Planning↗
PubMed1999

Health sector reform and the interpretation of policy context.

Health sector reform is on the policy agenda of national governments and international agencies. This paper focuses on the policy process of health sector reform and, more specifically, the policy context. The importance of understanding policy context is emphasised and the elements of policy context are discussed. These are: demographic and epidemiological change; processes of social and economic change; economic and financial policy; politics and the political regime; ideology, public policy and the public sector. The paper then discusses the means for, and methods of, interpretation of the policy context. Particular emphasis is placed on linking policy context with an overall understanding of the policy process, the 'messiness' of policy-making, the interrelationship between the contextual factors, the contextual factors interpreted by policy actors, the use of analytical categories in the policy analysis. The paper concludes on the importance of strengthening policy analysis for effective health sector reform.

Developing Countries↗
PubMed1997

Paradigms lost: the persisting search for community in U.S. health policy.

Local communities have long played an important role in health and social policy in the United States. But the concept of community was strangely absent from the federal debate on health care reform in 1993 and 1994. I attribute this absence to the paradoxical nature of community as a frame for guiding policy making. The concept of community has broad appeal across the ideological spectrum, but this breadth masks a set of long-standing and powerful tensions that determine when communities are seen as appropriately given responsibility for addressing societal problems. This article reviews the historical evolution of the role of community in health policy, highlighting the ways in which various tensions emerged. It applies these perspectives to an analysis of the attitudes of the U.S. public and congressional staff in 1995. Data from two surveys demonstrate that support for community-based reforms is much lower for medical care than for other social needs, including some health-related concerns such as long-term care and the treatment of substance abuse. Statistical analyses suggest several possible explanations for the lower support for community-based medical care. The article concludes with a discussion of the implications for future communitarian strategies designed to improve U.S. medicine or social policy.

Attitude to Health↗
PubMedDate not supplied

Healthy Communities and public policy: four success stories.

As Healthy Communities initiatives mature, many of them are discovering that their work in building community consensus for improved health care and other quality-of-life issues can be transformed into public policy. This article shows how Healthy Communities initiatives have had important effects on policy making at both the county and state level in several cities and states.

California↗
PubMed2002

Commentary on Skene and Parker: the role of a church (or other ideologically based interest group) in developing the law--a plea for ethereal intervention.

This paper discusses the provocative views of Skene and Parker as to the role of religious or other ideologically based interest groups in law and policy making. We draw distinctions between doctrine and prejudice and between argument and ideology which we trust take the debate further. Finally we recommend an ethereal, democratic, and populist partial solution.

Abortion, Legal↗
PubMed2005

Challenges in translating scientific evidence into mandatory food fortification policy: an antipodean case study of the folate-neural tube defect relationship.

OBJECTIVE: To identify challenges in translating scientific evidence of a nutrient and health relationship into mandatory food fortification policy. DESIGN: A case study approach was used in which available evidence associated with the folate-neural tube defect relationship was reviewed against the Australia New Zealand Food Regulation Ministerial Council's Policy Guideline for mandatory food fortification. RESULTS: Three particular challenges were identified. The first is knowing when and how to act in the face of scientific uncertainty. The second is knowing how to address the special needs of at-risk individuals without compromising the health and safety of the population as a whole. The third is to ensure that a policy is sufficiently monitored and evaluated. CONCLUSIONS: Despite the availability of compelling evidence of a relationship between a particular nutrient and a health outcome, a definitive policy response may not be apparent. Judgement and interpretation inevitably play significant roles in influencing whether and how authorities translate scientific evidence into mandatory food fortification policy. In relation to the case study, it would be prudent to undertake a risk-benefit analysis of policy alternatives and to implement nutrition education activities to promote folic acid supplement use among the target group. Should mandatory folate fortification be implemented, comprehensive monitoring and evaluation of this policy will be essential to know that it is implemented as planned and does more good than harm. In relation to mandatory food fortification policy-making around the world, ongoing national nutrition surveys are required to complement national policy guidelines.

Australia↗
PubMed1995

German politics of genetic engineering and its deconstruction.

Policy-making, as exemplified by biotechnology policy, can be understood as an attempt to manage a field of discursivity, to construct regularity in a dispersed multitude of combinable elements. Following this perspective of politics as a textual process, the paper interprets the politicization of genetic engineering in Germany as a defence of the political as a regime of heterogeneity, as a field of 'dissensus' rather than 'consensus', and a rejection of the idea that the framing of technological transformation is an autonomous process. From its beginning in the early 1970s, genetic engineering was symbolically entrenched as a key technology of the future, and as an integral element of the German politics of modernization. Attempts by new social movements and the Green Party to displace the egalitarian imaginary of democratic discourse into the politics of genetic engineering were construed by the political élites as an attack on the political order of post-World War II Germany. The 1990 Genetic Engineering Law attempted a closure of this controversy. But it is precisely the homogenizing idiom of this 'settlement' which continues to nourish the social movements and their radical challenge to the definitions and codings of the politics of genetic engineering.

Genetic Engineering↗
PubMed1997

[Required manpower for health care and nursing services for the aged at home public health nurses, visiting nurses, dental hygienists, dietitians, physical therapists, and occupational therapists].

The purpose of this study was to estimate the manpower required for the health care and nursing services for the aged at home. For prefectural health care and welfare planning for the aged, data such as the proportion of the aged who need help, service demand, and required frequency of services were obtained. The means and "mean +/- 2 x standard deviations" were calculated to obtain various parameters. Calculated figures were those which can be obtained with some effort. The results are as follows (middle level estimation (low level estimation-high level estimation)): requirements are 1.9 (0.61-5.7) public health nurses, 2.6 (0.63-14) visiting nurses, 0.20 (0.084-0.42) dental hygienists, 0.35 (0.17-0.66) dietitians, and 0.25 (0.014-1.27) physical and occupational therapists per population 10,000. For the national total, requirements are 23 (7.3-67) thousand public health nurses, 31 (7.5-160) thousand visiting nurses, 2.4 (1.0-5.0) thousand dental hygienists, 3.9 (2.0-7.8) thousand dietitians, and 3.0 (0.17-15) thousand physical and occupational therapists. By population sizes, for example in the municipalities which has 10-30 thousand people, required are 4.2 (1.7-11) public health nurses, 5.3 (1.3-27) visiting nurses, 0.4 (0.2-0.8) dental hygienists, 0.5 (0.3-0.9) dietitians, and 0.5 (0.0-2.5) physical and occupational therapists. Comparison of the present numbers with estimated manpower needs show that, the present number of public health personnel is almost the same as the low level estimation. But the present numbers of other manpower is lower than the low level estimation. Considering other services such as maternal and child health, it seems that the municipalities which has 10+ thousand population should employ full-time dietitians and dental hygienists. For policy making in a municipality, the policies of other municipalities should be considered. Because it is based on means for municipalities, the results of this study should be useful for application by other municipalities.

Community Health Nursing↗
PubMed1998

Are tobacco industry campaign contributions influencing state legislative behavior?

OBJECTIVES: This study tested the hypothesis that tobacco industry campaign contributions influence state legislators' behavior. METHODS: Multivariate simultaneous equations regression was used to analyze data on tobacco industry campaign contributions to state legislators and legislators' tobacco control policy scores in 6 states. Campaign contributions were obtained from disclosure statements available in the specific state agency that gathers such information in each state. Tobacco policy scores were derived from a survey of key informants working on tobacco issues in each state. RESULTS: As tobacco industry contributions increase, a legislator's tobacco policy score tends to decrease (i.e., become more pro-tobacco industry). A more pro-tobacco position was associated with larger contributions from the industry. These results were significant even after controls for partisanship, majority party status, and leadership effects. In California, campaign contributions were still significantly related to tobacco policy scores after controls for constituent attitudes and legislators' personal characteristics. CONCLUSIONS: Tobacco industry campaign contributions influence state legislators in terms of tobacco control policy-making.

Financial Support↗
PubMed1992

Cost-utility in practice: a policy maker's guide to the state of the art.

In recent years QALYs (quality adjusted life years) have achieved considerable fame or perhaps even notoriety in health services policy making. Yet little has been done to date to assess the potential benefit in policy terms of studies that have used cost-utility analysis (CUA). It was in recognition of this fact that this particular investigation was undertaken. An evaluation of 51 cost-utility studies is reported in the paper. Several criteria were applied to each study including aspects of technical and policy relevance. The main findings were: few studies had been undertaken; they were limited to few areas of health care; their technical execution was often of poor quality; the majority of studies used the empirical findings of health state valuations obtained from original developers of different quality of life techniques; and many claimed their results to be 'favourable' (i.e. efficient interventions). This claim, however, is misguided because individual results get fed into generalised QALY league tables which ignore the context of specific studies and use results not performed on a common basis. Consequently, the state of the applied art of CUA is currently open to considerable question.

Cost-Benefit Analysis↗
PubMed2004

Developments in National Physical Activity Policy: an international review and recommendations towards better practice.

Physical activity (PA) is increasingly considered an important public health issue and as such requires the development of good public health policy. This paper provides a summary of the literature on policy development and defines what a policy on PA may usefully comprise. The results of an international review of national level PA policies, using a defined set of criteria, are reported. Considerable similarities were found in the methods and approaches to policy development on PA across countries, with most adopting an intersectoral approach, with consultation and partnership between sectors occurring at a high level of government. The need for action across the lifespan is recognised, as is the need for multiple strategies across a variety of settings. A review of Australian PA policy found that, after promising strategic developments through Active Australia in the late 1990s, PA policy and the role of the federal health sector has become less clear, with PA policy existing now only as a component part integrated into other chronic disease prevention policy initiatives. Recommendations towards better practice in policy making are made with particular reference to developing a clearly defined integrated national PA policy in the Australian context.

Australia↗
PubMed2002

National Institute for Clinical Excellence (NICE). HTA rhyme and reason?

The technology appraisal program of the National Institute for Clinical Excellence (NICE) was established on April 1, 1999. Its role is to advise the NHS in England and Wales on the clinical effectiveness, cost-effectiveness, and service impact of new and emerging as well as established healthcare technologies. This paper describes the role of HTA in the NICE technology appraisal process, discusses some of the challenges of the use of HTA in national policy making, and considers some of the potential ways forward.

Academies and Institutes↗
PubMed2002

Risk, response, and mental health policy: learning from the experience of the United Kingdom.

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.

Attitude to Health↗
PubMed1999

The influence of health needs assessment on health care decision-making in London health authorities.

OBJECTIVES: Health needs assessment gained prominence under the model of health care purchasing developed to support the 1991 reforms of the UK National Health Service (NHS). The objectives of this paper are to determine how needs assessment has been used in the NHS, to assess the influence it has had on decision-making, and to relate the observed uses of needs assessment to competing theoretical models of health care policy-making. METHODS: A survey of needs assessment activity in 14 London health authorities identified 217 needs assessments conducted between 1993 and 1996. Semi-structured interviews were conducted with public health and commissioning staff in each authority. RESULTS: The survey indicated that needs assessment directly supported decision-making and action in two-thirds of the studies identified, but up to 20% of needs assessments had no impact on service provision. Four key functions of health needs assessment were observed: identifying a problem; planning detailed changes to services; providing post hoc justification for earlier decisions; and using participation in needs assessment to build 'ownership' of subsequent decisions. CONCLUSIONS: The survey suggests that needs assessment is, in practice, consistent with a 'mixed scanning' model of decision-making. Needs assessment is used to help select issues for detailed investigation and to direct analytical and decision-making resources. However, certain key areas are not amenable to technical analysis and solution, and are resolved through bargaining.

Data Collection↗
PubMed2006

Can human rights discourse improve the health of Indigenous Australians?

OBJECTIVE: Recognition of the poor health outcomes of Indigenous Australians has led to an interest in using human rights discourse as a framework for arguing that the Australian Government has an international obligation to improve Indigenous health. METHOD: This paper explores two potential directions for human rights discourse in this context. The first is the development and elaboration of an asserted 'human right to health'. The second focuses on developing an understanding of the interactions between health and human rights, particularly the underlying social determinants of health, and thereby creating an advocacy framework that could be used to promote the inclusion of human rights considerations into the policy-making agenda. RESULTS: This paper argues that despite the symbolic force of human rights discourse, its capacity to improve the health of Indigenous Australians through international law is limited. This is so irrespective of whether recourse is made to a legal or moral imperative. CONCLUSION AND IMPLICATIONS: The 'human right to health' is limited primarily by several barriers to its implementation, some of which are perpetuated by the current Australian Government itself. Although the potential advocacy capacity of human rights discourse is similarly limited by the hostility of the Government towards the notion of incorporating human rights considerations into its public policy decision making, it does provide a sustainable intellectual framework in which to consider the social and structural determinants of health and maintain these issues on the political agenda.

Australia↗