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PubMed1990

Policy networks and the implementation of community care policy for people with mental handicaps.

Although community care has been the professed policy of successive governments over three decades, according to the Prime Minister's own adviser, Sir Roy Griffiths, 'in few areas can the gap between political rhetoric and policy on the one hand or between policy and reality in the field on the other hand have been so great'. This paper examines the extent and causes of this 'implementation gap' in respect of services for people with mental handicaps--a consistent priority group for national policymakers. We examine centre-periphery relations in the health and personal social services in the light of Rhodes' power-dependence framework and his concepts of policy networks and policy communities. The NHS has been described as the archetypal professionalised policy network but we conclude that it is possible to account for implementation failures in community care only partly in terms of the dominance of the medical professions' values and interests and the deficiencies of accountability and control due to clinical autonomy. Such failures are due also to the inherently limited power of the centre. Sub-central units are not merely its meek agents. Moreover, the centre must explicitly structure local environments by itself providing a coherent framework of service and resource policies compatible with the national objectives it is seeking to achieve.

Community Mental Health Services↗
PubMed1990

The labor impacts of policy change in health care: how federal policy transformed home health organizations and their labor practices.

Health care organizations are highly labor-intensive; policies designed to stimulate organizational change are likely to have labor impacts. This paper examines the labor effects of policy change in home health care. Major federal home care policy trends since 1980 have spurred the evolution of the typical home care provider toward greater organizational and market rationality. Greater managerial sophistication has introduced changes in management/labor relations. Survey data from the 1986 DRG Impact Study are used to show how the pressure of cost-containment policies has pushed agencies to cut labor costs by increasing workloads, managerial supervision, and control of the work process. Research on the effects of recent policy change in health care has to date focused primarily on potential client effects. Labor impacts are rarely examined and are poorly understood at the time that policy is made. Findings in this article suggest that these issues deserve greater, more systematic attention, because unanticipated labor impacts may prove to be significant impediments to the realization of intended policy goals.

Allied Health Personnel↗
PubMed1989

The power of policy: the relationship of smoking policy to adolescent smoking.

This study examined the effects of smoking policy on 4,807 adolescents in 23 schools over a two-county area in California. Amounts and prevalence rates of adolescent smoking were measured with a self-report survey and a biochemical measure; school smoking policy was measured with two independent surveys of school staff. Policy effects were evaluated with multiple and logistic regression analyses controlling for school-level socioeconomic status and environmental support for teaching and administration. Of the 23 schools, 100 percent had a formal written and regularly enforced policy component restricting student smoking on school grounds, 94 percent restricted students leaving school grounds, 65 percent restricted smoking near school grounds, and 57 percent had a smoking prevention education plan. Schools with policies having all four versus less than four components, high versus low emphasis on prevention, and a low versus high emphasis on cessation reported lower amounts of smoking in the last week and in the last 24 hours. Punitive consequences of policy violation had no effect. Results were compared to school staff observations of adolescent smoking, and school archival records of student smoking violations in the last year. Results suggest that school smoking policy is associated with decreased amounts of smoking in adolescents.

Adolescent↗
PubMed1996

The analysis of policy: understanding the process of policy development.

A key question in addiction studies is why do governments not readily adopt policies that research shows to be effective in reducing harm? In this paper, it is argued that policy development can best be understood as a political activity, which is not necessarily scientific. A descriptive model of policy analysis is illustrated by case examples from alcohol and tobacco policy arenas. By understanding policy development as a process, it is suggested that policy advocates can match their strategies to the stages of the process, and thus raise the probability that the advocated policy will be adopted.

Alcohol Drinking↗
PubMed1997

The conflict between least harm and no-use tobacco policy for youth: ethical and policy implications.

This paper examines policy and ethical implementation issues associated with local drug policies that are aimed at producing a "least harm" approach toward youth, with particular application to tobacco policy as an example of a legal, but addictive drug. Research is reviewed which shows the inconsistencies between federally mandated enforcement of zero tobacco use, the Synar Amendment and local community and school policies which appear to relax enforcement of no-use policies for the purpose of retaining youth in school. The inconsistencies are described from the perspective of a "least harm" approach, in that tobacco use may be considered less harmful than absence from school, or use of other substances. The conflict between law and intent to reduce harm is examined with implications for long-term enforcement of federal policy, and for effectiveness of tobacco and other drug abuse prevention programs and other drug policies. Several strategies for reducing the conflict are recommended. These include provision of support-orientated smoking cessation programs for youth on school campuses and in community organizations, and promoting consistent no-use norms across all drugs and across multiple channels that affect youth-mass media, school, point-of-purchase settings and public settings and events.

Adolescent↗
PubMedDate not supplied

Reforming the health sector in Thailand: the role of policy actors on the policy stage.

This paper reports on exploratory research carried out into the processes of policy-making, and in particular health sector reform, in the health sector of Thailand. It is one of a set of studies examining health sector reform processes in a number of countries. Though in the period under study (1970-1996) there had been no single health sector reform package in Thailand, there was interest in a number of quarters in the development of such an initiative. It is clear, however, that despite recognition of the need for reform such a policy was far from being formulated, let alone implemented. The research, based on both documentary analysis and interviews, explores the reasons underpinning the failure of the policy process to respond to such a perceived need. The research findings suggest that the policy formation process in Thailand successfully occurs when there is a critical mass of support from strategic interest groups. The relative power of these interest groups is constantly changing. In particular the last two decades has seen a decline in the power of the bureaucratic élites (military and civilian) and a related rise in the power of the economic élites either directly or through their influence on political parties and government. Other critical groups include the media, NGOs and the professions. Informal policy groups are also significant. A number of implications for policy makers operating under such circumstances are drawn.

Delivery of Health Care↗
PubMed2003

Determinants of health policy impact: a theoretical framework for policy analysis.

This paper addresses the role of policy and evidence in health promotion. The concept of von Wright's "logic of events" is introduced and applied to health policy impact analysis. According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.

Evidence-Based Medicine↗
PubMed2003

Food and nutrition policies of Nordic countries: how have they been developed and what evidence substantiates the development of these policies?

The present paper addresses the emergence and development of Nordic food and nutrition policies, with some reference to the types of nutrition policies characteristic of other North European countries. Nutrition programmes aimed at dietary change have a long history of public responsibility in several Nordic and North European countries. The extent of involvement, the orientation and (indication of) success have, however, varied considerably between countries. First, different types of policies are characterised by their choice of programmes and measures, e.g. information campaigns v. market regulation or catering and public services. Second, the distinctions are associated not only with programmes, but also with the status and validity of nutritional advice and dietary guidelines in public policy making. Third, when focusing on how and on what grounds the governments have developed nutrition policies, it is evident that while more or less the same participants and issues are involved, their roles and relationships may be different. In this case the role and involvement of nutritional expertise and scientific arguments in various countries will be discussed. Finally, nutrition policies may entail conflicts of interest, particularly when health concerns are confronted with food industry and agricultural interests. This situation is quite evident in the question of animal fat. The present paper addresses how these issues have been dealt with quite differently in various countries.

Europe↗
PubMed1999

Drug treatment systems and policy frameworks: a comparative social policy perspective.

The article offers a discussion of drug treatment systems from a social policy perspective. Comparative studies of social policy have utilised typologies to aid analysis. These are briefly characterised in this article. Current analysis of social policy points to changes in the shape of policy regimes. How are these changes impacting on drug treatment systems? Key principles around which policy forms are organised are the desire to effect social control, the desire to meet human need, and the need to minimise harm from risks present in the environment. In practice, these principles operate in tension and different outcomes are observable in different societies. The article argues that, in spite of these historical and cultural differences, some convergence is observable in systems as they adapt to global influences. There remains however an urgent need for more detailed empirical research on policy responses in different countries, utilising the case-study approach adopted by the ISDRUTS collaborators.

Attitude to Health↗
PubMed1989

Policy process framework: a systems approach to policy development.

This paper discusses a framework for understanding policy analysis and development. The framework presented can be used in the policy development process or post facto in policy analysis. The usefulness of the framework is that it provides a means to think about a policy and its development. It is not prescriptive, nor is it predictive about any particular policy. Policy analysis has tended to rely too heavily on technical analysis, with insufficient attention to other dimensions. This framework offers a basis for people to talk across organizations and cultures.

Decision Making↗
PubMed1998

The impact of health economics on health policy in England, and the impact of health policy on health economics, 1972-1997.

This paper contains a review of the impact of health economics on health policy in England during the past 25 years. Some health economists have expressed disappointment with the scale of the impact that health economics has had on policy but the record set out below suggests that there is modest cause for celebration. That is not to say that there is cause for complacency. There is still a long way to go before all important health policies are based on sound economics reasoning and evidence. The paper begins with some definitions and background; it covers nine areas of health policy, and health policy making, where past impacts of health economics have been postulated; it covers briefly the reciprocal impact of health policy on health economics; and it concludes with a discussion about the findings.

Economics, Medical↗
PubMed2002

Quasi-experimental longitudinal designs to evaluate drug benefit policy changes with low policy compliance.

A causal relation between drug benefit policy change and the increase in adverse outcomes can be tested by comparing the experience of a group of patients affected by the policy vs. the (counterfactual) experience of the same patients if the policy had not been implemented. Because counterfactual experiences cannot be observed, it must be assumed that the counterfactual is correctly described by extrapolating from the same population's previous experience. The null hypothesis of no policy effect can be empirically tested using quasi-experimental longitudinal designs with repeated measures. If compliance to a policy is low, results may be biased towards the null, but a subgroup analysis of compliers may be biased by nonignorable treatment selection. Using the example of reference drug pricing in British Columbia we discuss assumptions for causal interpretations of such analyses, and provide supplementary analyses to assess and improve the validity of findings. Results from nonrandomized comparisons of subgroups defined by their compliance to a policy change should generally be interpreted cautiously, and several biases should be explored.

Attitude of Health Personnel↗
PubMed1994

How nutrition policy affects food and agricultural policy.

The impact of the improved understanding of nutrition and the importance of the diet in nutrition status has had subtle but far-reaching consequences for food and agricultural policy. Many of the changes in the food supply are in response to increased consciousness of diet, nutrition and health status. The simple connection between nutrition policy and food and agricultural policy follows from the sovereignty of the consumer. Nutrition policy influences consumers' attitudes and choices. These impact the behavior of agents in the food and production system. And, if properly designed, food and agricultural policies can accelerate the process of adapting the production and distribution systems for agriculture and food to better meet the demands of the more informed consumer. Policies that reflect the behavior of consumers and supply better information to the agents in the food and agricultural system will be the most effective.

Agriculture↗
PubMed2006

Learning from the best: the benefits of a structured health policy fellowship in developing nursing health policy leaders.

This article describes the experience of a nurse leader engaged in a state Health Policy Fellowship instituted in North Carolina by the North Carolina Center for Nursing (NCCN). This Health Policy Fellowship is designed to provide a focused practicum in major aspects of state-level health policy with emphasis on the role of the nurse leader. The program design includes exposure to experienced mentors with diverse areas of focus to learn from observation and interaction. This article describes the experience of a state Health Policy Fellow and includes discussion of understandings derived from interacting with key state stakeholders in the health policy arena and pearls of wisdom from the policy fellowship experience.

Attitude of Health Personnel↗
PubMed1981

Values and policy conceptions of health policy elites in the United States, the United Kingdom, and the Federal Republic of Germany.

This essay presents data on the thinking of health policy elites in the United States, the United Kingdom and the Federal Republic of Germany. These three national groups are compared in terms of the values they perceive health policy should serve and their conceptions of appropriate policies for realizing these values. The different values and policy conceptions are then related to various propositions as to why social policies differ across nations, particularly to the hypothesis that social policies differ as a consequence of elite values and attitudes.

Attitude to Health↗
PubMedDate not supplied

National immigration health policy: existing policy, changing needs, and future directions.

Canada has a long history of welcoming immigrants and a longstanding immigration policy framework. The historic principles that govern immigration selection and processing also include regulatory policies in the area of health. Based on historical principles that pre-date Confederation, Canadian immigration health policy has remained relatively constant. Policies are based on the identification of specific individuals and the exclusion, if appropriate, of the affected individuals - an approach that continues today. During the past three decades, however, evolutionary changes in the patterns, volume and demography of immigration have created situations that may necessitate changes to existing policy frameworks. This paper reviews current immigration health policies and practices in Canada, describes the nature and impact of existing challenges, and proposes some alternatives for future consideration.

Canada↗
PubMed2006

Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies.

BACKGROUND: Pharmaceuticals can be important for people's health. At the same time drugs are major components of health care costs. Pharmaceutical pricing and purchasing policies are used to determine or affect the prices that are paid for drugs. Examples are price controls, maximum prices, price negotiations, reference pricing, index pricing and volume-based pricing policies. The essence of reference pricing is to establish a maximum level of reimbursement for a group of drugs assumed to be therapeutically equivalent. OBJECTIVES: To determine the effects of pharmaceutical pricing and purchasing policies on drug use, healthcare utilisation, health outcomes and costs (expenditures). SEARCH STRATEGY: We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (date of last search: 22/08/03), Cochrane Central Register of Controlled Trials (15/10/03), MEDLINE (07/09/05), EMBASE (07/09/05), ISI Web of Science (08/09/05), CSA Worldwide Political Science Abstracts (21/10/03), EconLit (23/10/03), SIGLE (12/11/03), INRUD (21/11/03), PAIS International (23/03/04), International Political Science Abstracts (09/01/04), NHS EED (20/02/04), PubMed (25/02/04), NTIS (03/03/04), IPA (22/04/04), OECD Publications & Documents (30/08/05), SourceOECD (30/08/05), World Bank Documents & Reports (30/08/05), World Bank e-Library (04/05/05), JOLIS (22/08/05), Global Jolis (22/08/05 and 23/08/05), WHOLIS (29/08/05). SELECTION CRITERIA: Policies in this review were defined as laws, rules, financial and administrative orders made by governments, non-government organisations or private insurers. To be included a study had to include an objective measure of at least one of the following outcomes: drug use, healthcare utilisation, health outcomes, and costs (expenditures); the study must be a randomised controlled trial, non-randomised controlled trial, interrupted time series analysis, repeated measures study or controlled before-after study of a pharmaceutical pricing or purchasing policy for a large jurisdiction or system of care. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study limitations. Quantitative analysis of time series data, for studies with sufficient data, and qualitative analyses were undertaken. MAIN RESULTS: We included 10 studies of reference pricing and one study of index pricing. Most of the reference pricing studies were for senior citizens in British Columbia, Canada. The use (dispensing) of reference drugs increased in five studies, between 60% and 196% immediately after introduction of reference drug pricing, whereas the use of cost sharing drugs decreased by between 19% and 42% in four studies. In three studies the reference drug group expenditures decreased (range 19% - 50%), whereas in the fourth study the expenditures increased by 5% in the short term. The results after six months of reference pricing do not show any clear pattern in relationship to the immediate effects. We found no evidence of adverse effects on health and no clear evidence of increased health care utilisation. For index pricing the evidence was much more limited than for reference drug pricing. A small reduction in drug prices was found. AUTHORS' CONCLUSIONS: We found relatively few studies of pricing policies. The majority of the studies dealt with reference pricing. They had few methodological limitations. Based on the evidence in this review, mostly from senior citizens in British Columbia, Canada, reference drug pricing can reduce third party drug expenditures by inducing a shift in drug use towards less expensive drugs. We found no evidence of adverse effects on health and no clear evidence of increased health care utilisation. The analysis and reporting of the effects on patient drug expenditures were limited in the included studies and administration costs were not reported.

Cost Control↗