Midterm - Health Policy Flashcards
What are the inputs of Policy Making?
Election results
Public opinion
Communication to decision makers
Media coverage (will cover next week)
Social Movements
Evidence
Values
What is the election system in Canada?
First past the post system
Elections held every 4 years on fixed cycle since 2007 (on the third Monday in October) unless:
PM resigns
Vote of non-confidence in House of Commons
What are Social Movements ?
Collective grouping whose purpose is to enact change
Organized/disorganized
What type of Political System in Canada?
Constitutional monarchy
Queen is the Head of State (GG)
PM is the Head of Government
What does Responsible government mean?
Government must be responsive to citizens
Cabinet ministers are individually responsible to Parliament and are also collectively accountable for all decisions of cabinet
What is the Executive branch (Federal)?
Decision-making branch
Includes
The King (Governor General)
Prime Minister and Cabinet
Public service
What is the Legislative branch (Federal)?
House of Commons - elected - 338 ridings (170 for majority)
Senate - Appointed by the Governor General (on advice of PM) - 105 Senators
Responsibility to make laws
How money is distributed
How programs will run
What projects will be funded
How does a bill become a law?
First Reading
Second Reading
Committee Stage (includes a report)
Third Reading
Repeat steps (1-4 in other Chamber)
Royal Assent
What is the Judiciary (Federal) branch?
Review laws made by legislature
Can strike them down if they are unconstitutional
How is the Provincial Government organized?
Executive branch: Lieutenant Governor (represents the King), Executive Council (Cabinet Ministers appointed by Premier)
Legislative branch: Legislative Assembly (Members of Legislative Assembly, Members of Provincial Parliament)
Judiciary
What is the Municipal Government?
No official powers under Constitution
Have delegated authority from province
Include: Mayor, City Council (Councillors that represent wards), Board of Health
What are the Important Sections of the Constitution for public health?
91 – the federal governments powers: Dominion of Canada responsible for international quarantine & marine hospitals, care of sick seamen, indigenous people and members of the armed services, as well as control of narcotic drugs
92 – the provincial governments powers: Provinces responsible for “establishment, maintenance & management of hospitals, asylums, charities & eleemosynary institutions
No huge mention of health and who is responsible for it
What is the Canada Health Act?
1984
Establishes the criteria for universal health care across Canada
Establishes monetary arrangement between federal government and provinces
Provinces must respect the Act in order to receive transfer payments
All PTs are responsible for funding the HC systems in their jurisdictions
How does the federal government influence health?
Direct and indirect taxing is the main sphere for influencing health
Feds have money to contribute towards health - distribution of payments to provinces
Can set standards that the provinces have to implement if they want to receive federal funding
Federal government responsible for a lot of things related to the determinants of health
What is the Federal Government Role in Health?
Financing healthcare
Provision of health care services to certain groups (First Nations living on reserves, Inuits, Members of the Canadian Forces and Prisoners in federal penitentiaries , Refugee claimants )
Health protection and regulations (Pharmaceutical products, foods, medical technologies )
Surveillance and disease prevention
Financing of health research
What is the PT Role in Health?
Manage, provide and pay for the majority of health care services (Services are financed partially by federal transfer payments)
Ensure that the principles of Health Care Act are respected
Plan, finance and evaluate health care in Hospitals, By doctors and other health care professionals
Plan and implement public health initiatives
Negotiate salaries with health professionals
Offer and finance supplementary medical services for certain groups (Ex. Prescriptions for seniors and children under 25)
Who is responsible for health of Indigenous populations?
Federal government’s role - Provision of public health services offered by First Nations and Inuit Health Branch - Health care to on-reserve and Inuit - Non-insured health benefits to registered indigenous and Inuit
Provincial government - Physician and hospital care
Many communities design and run own health related programs
What is the Oakes Test?
A legal test used in Canadian constitutional law to determine whether a law that infringes upon a right or freedom protected by the Canadian Charter of Rights and Freedoms can be justified under Section 1 of the Charter
* Burden is on government to prove that any limitation to Charter rights is justified
This section allows for reasonable limits on rights and freedoms as long as those limits can be justified in a free and democratic society.
- law must have pressing and substantive objective
- must have rational connection between law and objective
- law must minimally impair right or freedom
- law must be proportionality between the benefits of the law and its deleterious effects
What are the Fundamental Freedoms - Charter of Rights and Freedoms?
Section 2. Everyone has the following fundamental freedoms:
(a) freedom of conscience and religion;
(b) freedom of thought, belief, opinion and expression, including freedom of the press and other media of communication;
(c) freedom of peaceful assembly; and
(d) freedom of association.
What is the Mobility of Citizens - Charter of Rights and Freedoms?
Section 6. (1) Every citizen of Canada has the right to enter, remain in and leave Canada.
What is Life, liberty and security of person - Charter of Rights and Freedoms?
Section 7. Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.
What is the Equality before and under law and equal protection and benefit of law - Charter of Rights and Freedoms?
Section 15. (1) Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.
What is the Detention or imprisonment - Charter of Rights and Freedoms?
Section 9. Everyone has the right not to be arbitrarily detained or imprisoned.
What sections of the Charter of Rights and Freedoms are important for Public Health?
Fundamental Freedoms
Mobility of Citizens
Life, liberty and security of person
Equality before and under law and equal protection and benefit of law
Detention or imprisonment
What is the Notwithstanding Clause?
Parliament can declare that any piece of legislature is still going to apply regardless of charter of rights and freedom – only apply to section 2 and 7-15 of charter
What types of International agreements that are common in health?
Treaties - binding
Declarations - non- binding
Frameworks and Action Plans - strategic documents
How are international agreements enforced?
Self-enforcement: relying on countries to enforce their agreements domestically
Countries may shame other countries for not following it
What are challenges in enforcing international agreements?
Sovereignty
Variability in Commitment (States may not prioritize international obligations).
Funding and resources vary
Lack of Centralized Enforcement: (no centralized authority to enforce international treaties).
What is the Policy Domain?
substantive area of policy over which participants in policy making compete and compromise
What is a Policy Community?
the group of people that are involved in the policy making in a specific domain (open or closed)
Who are Official actors in policy?
Have power to make/enforce policies
Activities sanctioned by Constitution, Legislature, Executive, Judiciary
Who are Unofficial actors in policy?
Play role in policy process but NO official legal authority
Remain important to process
The Federal Health Portfolio consists of:
Canadian Food Inspection Agency (food safety)
Canadian Institutes of Health Research (CIHR) – fund research
Health Canada
Patented Medicine Prices Review Board (Ensures that manufacturers’ prices of patented medicines are not excessive)
Public Health Agency of Canada
Health Canada: Core Roles
Leader/Partner through the administration of CHA (Canadian Health Act)
Funder through Canada Health Transfer
Guardian/Regulator regulates and approves the use of thousands of products (e.g., medical devices, pharmaceuticals)
Service Provider - provides supplementary health benefits to First Nations and Inuit (e.g., pharmaceuticals, vision care, transportation)
Information Provider - performs high quality science and research
PHAC: Core Roles
Role:
Preventing chronic disease and injuries
Preventing infectious disease
Responding to public health threats/emergency preparedness
Strengthening intergovernmental collaboration on public health
What they do:
Provide information
Surveillance
Grants and contributions
Ontario- Ministry of Health: Core Roles
Provides overall direction and leadership for the health system
Responsible for:
Overall strategic direction and provincial priorities for the health system
Developing legislation, regulations, policies, and directives to support those strategic directions
Monitoring overall performance of Ontario’s health system
Establishing levels of funding for the health care system
What is the Media’s role in policy making?
Set the agenda
Highlight some issues/ignore some issues so shape what we think about
Media outcry can have great impact
Significantly shape the discourse (i.e. how an issue is talked about) - Who do journalists quote?
Usually associated with a specific ideology - Globe & Mail vs. National Post - CNN vs. Fox News
Government officials/Interest groups use the media - To bring visibility to their policy - Government uses strategic leaks to gage public opinion
What are think tanks? How different from academia?
Independent organizations that conduct research
Many associated with a specific ideology
Academia - Research organizations - Perceived as more neutral ideologically
What are front groups?
Groups that claim to represent public interests but in fact are funded by industry
Also called Astroturf groups (as they appear to formed by grass roots group)
Industry form front groups to do dirty work and keep corporate brand image clean
What is lobbying?
Ongoing process of trying to persuading legislative/executive branches to enact policies that promote specific interests
Organized
Want elected officials/bureaucrats to see the problem and its policy solution from their vantage point
In public health usually about influencing regulation and legislation
Paid lobbyists need to be registered - Registry of lobbyists
What is Elite Theory? What are criticisms of it?
Policy making dominated by a small number of elites
Government, business, media
Policy is dominated by the elites – closed system
Difficult for other groups to get in and change any of the rules
Criticisms: Assumes elites have same goals, behaviours and interests
Assumes other less powerful groups don’t compete with elites
What is pluralism?
Political theory
Political system is relatively open
Many groups compete for power
Power is broadly distributed
Policy is a result of group competition
What are policy monopolies?
Central part of elite theory
Concentrated and closed policy system dominated by certain actors
Have agreed-upon vision of problems, causation and solutions which are represented by symbols
It’s difficult for other groups to influence agenda unless society questions this
What is a coalition?
Compete against elite groups
Groups join coalitions to
- Advance their goals
- Promote common interests
Coalitions can
- Attract more attention for an issue
- Have a unified message
- Gain greater access to policy makers
- Pool their resources (financial, skillful leadership, supporters, information)
Issue specific vs. broad coalitions
What is the Agenda in policy?
The items currently being discussed by policy makers, media, the public
A list of problems, their causes and potential solutions
What problems are important?
Exist at all government levels
What is Agenda setting?
The process by which problems and alternative solutions gain or lose public and elite attention
The activities of various actors and groups that cause issues to gain greater attention or prevent them from gaining attention
What are the different agenda levels?
Systemic agenda: any idea that could be considered as long as it does not contradict values/legal/ideological norms of society
Institutional agenda: ideas that are seriously being considered by the institution
Decision agenda: ideas that are being acted upon; few ideas reach this level
What are the 5 principals of Medicare? that the Canada Health Act is based on?
Universality of coverage - everyone is entitled to health services
Portability of coverage - can still access services when moving between provinces
Reasonable accessibility to services - everyone must have reasonable access to health services
Comprehensiveness of service - must have access to all health services provided by hospitals, physicians or dentists (current system not comprehensive)
Public administration - must be administered and operated on a non-profit basis by a public authority
What is Canada’s healthcare model?
Beveridge system
Single payer system (government is the single payer)
Health care financed through taxes
All individuals contribute
Contributions determined by salary
All individuals are covered
What is the USA healthcare model?
Mandatory Private Insurance
Some public healthcare:
Medicare - 65 and older and disabled
Medicaid - low income
Children’s Health Insurance Program - children not admissible to Medicaid
Veteran’s Health Administration - military service and veterans
What is Obamacare?
Patient Protection and Affordable Care Act (2010)
Mandatory private insurance health care
All adults must purchase health insurance for themselves and their families
Fines for non-compliance
Later abolished at federal level but some states have maintained
Children are covered on parents’ plans until age 25
Insurance companies must follow regulations
Large employers must provide insurance coverage
Expansion of Medicaid
Advantages: More Americans are now insured, Can keep insurance regardless of employment status
What is the history of universal healthcare in Canada?
1947 - Saskatchewan’s Premier Tommy Douglas first introduces a bill on 1st hospital insurance program in Canada (first universal hospital health care plan)
1966 - Federal government introduces national Medicare program (feds pay 50%)
1977 – Feds retreat from 50:50 cost-sharing and replace it with block funding
1984 – Canada Health Act introduced
What is the Canada Health Act?
Establishes the criteria for universal health care across Canada
Establishes monetary arrangement between federal government and provinces
Called Canadian Health Transfer now
25% of the public funds
Provinces must respect the Act in order to receive transfer payments
All PTs are responsible for funding the HC systems in their jurisdictions
How is health care delivered in Canada?
Mix of public (70%) & private (30%)
Public: Hospitals, acute care facilities, long-term care, doctor’s salaries
Private: Diagnostic laboratories, occupational and physical therapy centers, and other allied professionals
Private health care insurance - available on a group basis (employee benefit) or individual
What services are covered by the Canada Health Act?
Medically necessary diagnostic, treatment & preventive services
Extended HC services - Long-term residential care (partial)
Variation across the provinces on what is considered “medically necessary”
Uninsured health services include:
Prescriptions
Physiotherapy
Psychologists, counsellors
Foot care
Vision correction
Dental care
What is policy?
Policy is what we agree to do to get things done
Public or private realm
What is public policy?
Not confined to the private/personal sphere
It’s a matter of public interest
Course of action (or inaction) taken (or not taken) by public authorities
Government is at the centre
Public policy is “whatever governments choose to do or not do.
Public policy is the outcome of the struggle in government over who gets what.”
What are public policy outputs?
Laws - Statutes/Legislation/Acts: made by legislature - Case law: made a result of judicial decisions
Regulations - rules developed by government to administer gov’t activities
Services/Programs
Money
What is self-regulation?
Someone other than government is doing the regulation
Industry regulate themselves
Save resources
What is included in health policy?
Includes Health care policy (focus on individual outcomes)
- Organization of health care
- Health care access – if people have family physician
- Health care delivery – hospitals, dental
- Resource allocation
- Pharmaceutical policy – who’s paying for it, what regulations
Public health policy
- Policies aimed at improving the health of the population
- Focus on addressing the determinants of health (e.g. income, education, housing)
- Government has a direct role to play
What is health policy?
Policy that aims to impact positively on population health
example - Health Canada’s Healthy Eating Strategy
What are the levels of policy implementation?
Micro-system – individual
Meso-system – social environment (social networks, peers, family, provider) - change social setting
Exo-system – physical environment (worksite, school, practice, organizational setting) - change the physical environment
Macro-system – community environment (state, local community secctors) - change that is country or province wide (i.e. new sugar tax on soft drinks)
What is the health impact pyramid?
Describes the impact of different types of public health interventions and provides a framework to improve health
Socioeconomic factors (base): interventions with the greatest potential impact, are efforts to address socio-economic determinants of health
4th tier: interventions that change the context to make individuals’ default decisions healthy (e.g. clean water, safe roads)
Long-lasting protection interventions (3rd tier): clinical interventions that require limited contact but confer long-term protection (e.g. immunizations)
Clinical interventions (2nd tier): ongoing direct clinical care
Counseling and education (1st tier): health education and counseling
What are upstream vs downstream policies?
Upstream - reach broader segments of society (increased population impact) and require less individual effort (but can be more controversial since actions address social and economic structures of society)
Downstream - more focused on individuals rather than entire populations, increased individual effort needed but require less political commitment
How are public health policies cost effective?
Legislation, national and health protection interventions have the highest return on investment
Public Health policies are very effective in returning on investment
What is the Stages Model?
This model an help situate the context and the channels of influence and help to determine what type of information is required by decision makers
5 stages of the model:
- Agenda setting: When a policy and the problem it’s intended to address are acknowledged to be of public interest
- Policy formulation - Public administration examines the various policy options it considers to be possible solutions
- Adoption (or decision making) - Stage where decisions are made at the governmental level,
- Implementation - Policy’s implementation parameters are established (can effect the outcome of the policy)
- Evaluation - Policy is evaluated, to verify whether its implementation and its effects are aligned with the objectives that were explicitly or implicitly set out
What is the discussion agenda vs the decision agenda?
Discussion agenda - includes issues that have become highly visible and become subject of discussion
Decision agenda - list of issues the government has decided to address
What are advantages and disadvantages of the Stages Model?
Advantages simplifies complex process of public policy
- Identify moments in life of public policy and adapt info sharing, persuasion and action strategies as appropriate
- Maps out legislative and administrative processes involved
Limitations - oversimplifies
- shows policy making as rational
- considers the actors but not their power differential
- doesn’t reflect reality
- stages of policy process often run parallel
What is the policy environment?
Includes
Structural environment (e.g. constitution, federalism)
Social environment (e.g. ethnic makeup of population, aging population, labour force participation)
Economic environment (e.g. GDP, unemployment rate, inflation rate, Gini coefficient)
Political environment (e.g. party in power)
What is the Multiple Streams Framework?
Explains when policy change occurs
-Three streams that come together in “windows of opportunity” to cause policy change
- problem stream: the issues that policymakers and the public perceive as problems. It involves the identification and recognition of issues that require government action, often influenced by events, statistics, or reports.
- politics stream: political context, such as the current administration’s priorities, public opinion, interest group activities, and the overall political climate.
- policy stream: potential solutions and proposals developed by policy experts, researchers, and interest groups. These solutions often undergo a process of discussion, refinement, and evaluation to determine their feasibility and effectiveness.
What is a policy window?
an opportunity to make a change to a policy (i.e. new evidence or controversy so more people are paying attention and calling for the change)
Right people in power, right policy and focus on issue align to create policy window
What is the punctuated equilibrium model?
Long periods of stability (little policy change) punctuated by short periods of change
Explains why sometimes policy is incremental others times there are big policy shifts
Interaction of policy image and policy venues
Punctuated equilibrium model is the interaction between policy image and policy venue and impacts political subsystems (subsystems thrive when images are positive, attention is limited and policy venues are favourable)
They mutually reinforce each other (negative or positive feedback) - If policy venue remains unchallenged and retains monopoly then image change is unlikely (positive policy images that protect subsystems don’t encourage involvement of new policy venues)
Punctuation can occur by Mechanism for discontented = change policy image, expand conflict to include actors previously uninvolved and shop for new policy venues
What is a policy image?
The way in which a public policy is discussed in public and in the media
It encompasses the values, beliefs, and narratives associated with a particular policy issue.
Positive image often leads to incremental changes and negative leads to punctuation (positive image protects a subsystem)
What is a policy venue?
The institutional locations where authoritative decisions are made concerning a given issue
Each policy venue can have different decision-making bias due to varying participants, values, concerns and decision-making processes
The choice of venue can influence the types of policies that are proposed and the likelihood of their adoption. Certain venues may be more conducive to change
What is Wilson’s Cost Benefit Policy Typology?
Benefits of a policy can be concentrated to a certain group or distributed across large number of people
Costs of policy can be concentrated on certain group or distributed across large group of people
What are the end results of the policy process?
Policies can
Accomplish their intended goals
Misfire - Unintended consequences, Worsen a problem it was intending to improve
Fail to accomplish their intended goals
What is the role of evidence in policy making?
Objective vs. subjective evidence
Evidence can be useful and can play an important role
It is one input in the decision-making process
Not always necessary
what is a policy domain?
substantive area of policy over which participants in policy making compete and compromise”
what is a policy community?
the group of people that are involved in the policy making in a specific domain
-some communities are open (anyone can participate), others are closed
What factors influence the public policy change process?
Situational factors - can be sudden or violent events
Structural factors - a radical change in political leadership can trigger health policy change - Demographic and social factors are also structural determinants
Cultural factors - political and cultural environment can influence levels of participation and trust in government and the possibility of political change
Environmental factors - external or international factors
What is the 3-I Framework?
This framework holds that policy developments and choices are influenced by actors’ interests and ideas, and institutions
Interests (e.g. economic, professional, political) - the agendas of groups of people
Ideas - Knowledge or beliefs about what is (e.g. research knowledge), views about what ought to be (e.g. values), or combinations of the two
- Values can influence how different societal actors define a problem and how perceive different policy options to be effective, feasible and acceptable
Institutions - government structures (political arrangement of a country), Policy networks (unite the government with actors outside of the formal process of government) and policy legacies (constitution and past policies)
- can shape and constrain policy developments
What are common tactics of front groups?
Astroturfing - pretending group represents the little guy (make public feel like group is on their side and interests under attack by government and elite)
Shooting the messenger - discrediting critics by mocking them (marginalizing them)
Buying science - paying for research, hiring scientific experts as spokespeople, placing science stories in media without disclosing conflict of interest
Fearmongering - preying on people’s fears (especially related to economy) - lose tons of jobs
What is the 4 P’s model of agenda setting?
For understanding how issues gain attention in public policy
Power - Refers to the power to persuade and to elicit action
Perception - Refers to the representation or impressions of an issue (how issues are framed and understood by public and policymakers)
Potency - Refers to the severity or seriousness of consequences of an issue
Proximity - Refers to the closeness or imminence of impacts
