For their part, public health officials may themselves resist the premise that their mandate extends beyond core public health functions to include transportation, housing, and school reform. Or should the field remain focused on the more proximal causes of poor health, such as risky behaviors and infectious diseases, and refrain from attempts to influence and intervene in distal policy spheres?
Thoughtful reflection on the statutory and professional responsibilities of governmental public health requires these organizations to communicate about data and evidence, and convene other sectors and stakeholders toward health-supporting policy action that extends beyond the historical arenas in which these institutions have worked. Apart from politics and philosophical questions, the fragmented structure of government is itself an obstacle to the HIAP approach.
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Federal, state, and local governments are often balkanized in silos—agencies with discrete policy interests and regulatory concerns that lack the culture, tools, and language to cross boundaries and coordinate with counterparts in other agencies. An infrastructure that supports such collaboration, such as an interagency task force, cannot be formed or operate effectively without hard work to build relationships and solve interagency barriers that impede communication, collaboration, and the sharing of resources.
The committee believes these philosophical and structural obstacles—both external and. These actions will allow this nation to make good on the promise of the level of health that a wealthy nation should furnish its population. In its purest form, the HIAP approach entails collaboration among multiple sectors, reaching beyond the government, to foster the conditions for good health. Nor can the private sector do this alone. Effective strategies require collaboration as well as coordination, with the latter being important to marshal and leverage limited resources, avoid duplication, and use the talents and assets that each partner offers.
Few would dispute the merits of coordination and collaboration, but the infrastructure for forming such partnerships is lacking in most communities. What is the role of the public health department in facilitating action? Policy, in both the public and private sectors, can facilitate and guide these partnerships. In its first report, the committee discussed the topic of accountability for population health and presented a measurement framework for accountability in two contexts. The second is compact or mutual accountability, which characterizes the relationships among public health agencies and the many.
This approach, called health in all policies, brings health issues from the traditional health sectors into other government entities, thereby positively influencing transportation, housing, environment, education, and fiscal policies. The framework for accountability in any context can be outlined in three steps: 1 agreement among implementers and those holding them accountable on specific plans of action targeting health priorities; 2 holding implementers accountable for execution of agreed-on plans; and 3 measurement of execution and outcomes of those plans, and further agreement on revisions to the action plan.
In the present report, the committee endeavors to give structure to the process described in the first report. For example, given the notion of non-public health implementers e. The question the committee seeks to answer in this section is how do legal, or more broadly, policy frameworks, inform the structures needed for effective multi-sector engagement on population health, where there are and where there are not statutory or funding relationships that serve as the natural bases for holding participants accountable?
Despite the fact that an estimated half the overall public health expenditures are incurred by nongovernmental actors see Mays et al. Accordingly, the committee looked for models that could create accountability that span public and private action and investments. Several models are available to inform efforts to develop advisory mechanisms that involve the private sector.
Other examples of governance mechanisms, including some oriented toward public oversight of government expenditures, are found in the context of international urban governance arrangements Burris et al.
The Social Determinants of Health: Coming of Age | Annual Review of Public Health
Fawcett and colleagues , have also described community partnership models. The committee believes that state and local versions of the National Prevention Council can create opportunities for private and civil society engagement, similar to what federal legislation has envisioned for the National Prevention Council.
In that context, a framework was provided to demonstrate the changes needed in the US medical care delivery system, and four levels were described: Level A, the experience of patients and communities; Level B, the microsystem of care for example, provider practices ; Level C, organizations for example, managed-care organizations ; and Level D, the environment shaped by policy, payment, regulation, and accreditation. The present committee believes that that framework holds relevance for its own examination of measurement in the context of accountability and has adapted it for its own purposes.
The cycle begins after a needs assessment has been done, priorities set, and a plan agreed on.
Level B refers to microsystems, which in the context of population health 6 are programs, policies, and interventions that may be thought to refer to the points of contact or interactions between community groups, local businesses, others in the neighborhood, and their local public health agencies and allied entities. An example of microsystems is an interaction among a health department, a local medical care provider, community coalition, or local business concerning a particular health outcome.
Specifically, a health department could assist a food retailer in facilitating healthful customer choices or could support a local business in developing. Often in public health, such microsystems need to align and integrate across organizations; for example, the local cancer-control program should feed into the statewide cancer-control program, which feeds into the national program. The organizations include the local public health agency, hospitals and other clinical-care entities, community organizations, schools, businesses, religious congregations, and many others that perform roles that influence health outcomes.
Level D refers to the environment, which includes a variety of social, physical both naturally occurring and constructed , and economic factors and is shaped in part by social realities, large-scale policies and political will , and economic arrangements Syme and Ritterman, Figure also depicts accountability pathways for all levels but focuses on Level C—the organizations that perform functions that affect health outcomes.
In the context of this report, developing a structure to operationalize intersectoral action on health is useful for several reasons. First, it establishes a forum for stakeholders to come together and creates mechanisms for interested parties to provide input, and it also creates an entity that is appropriately placed and configured to adopt a HIAP approach.
Finally, a multi-sectoral group that brings together the thinking, experience, and financial resources of many community actors will facilitate more nuanced planning, implementation and evaluation of policies that are intended to simultaneously serve both health and other key objectives of a local community. The following recommendation intends to describe the role of the public and private sectors in jointly implementing health in all policies approaches.
When a policy is considered worth enacting, the key government sector or organization will work to bring together the relevant stakeholders and find ways to align their interests and compel them to engage in action. Stakeholders will examine a policy idea through multiple lenses, including feasibility, effectiveness, acceptability, affordability, and legality. This is particularly true when policies are seen as posing a risk to public health.
The social determinants of health: coming of age.
The effectiveness of public policies in general, and of legal interventions in particular, historically has been poorly studied, although the body of evidence is growing see Burris et al. Some of the strongest examples are found in the work of the Task Force on Community Preventive Services and of the Cochrane Collaboration, both of which use the approach of systematic assessment of the effectiveness of certain laws and their enforcement on behaviors with health consequences. The Task Force has identified and recommended effective legislative or regulatory interventions in several areas of interest to public health.
These include the prevention of motor vehicle injuries and deaths, where the evidence supports recommending laws and enforcement of child safety seat use Evans and Graham, ; Guerin and MacKinnon, ; Margolis et al. Another example is state and municipal clean indoor air laws to reduce exposure to secondhand tobacco smoke a risk factor for cancer, heart disease, and child health problems, including Sudden Infant Death Syndrome. Bans on indoor smoking have led, within months, to decreases in hospital admissions for acute coronary heart disease events such as heart attacks Juster et al.
Other examples include the effect of Corporate Average Fuel Economy standards on lowering energy consumption and carbon dioxide emissions; the effect of state immunization requirements for school and child care entry on increasing immunization rates; the effect of primary education requirements on educational achievement; and the effects of ignition interlock policies, retail outlet density, and taxation on high-risk alcohol consumption.
Post-enactment evaluations are sometimes done, though. Examples include gun control ordinances, ignition interlocks for drivers with alcohol-related driving convictions, alcohol outlet density restrictions, and tobacco laws. Burris and colleagues , p. Health impact assessments HIAs have emerged as an important tool to assist policymakers with weighing the merits of a proposed policy.
Although HIAP and HIAs are closely related concepts, the former refers to a broad approach to public policy and the latter to a decision-support tool that may be used in evaluating that approach. It has been asserted that the health consequences of policies can be predicted, and tools such as the health impact assessments and simulation modeling can be used to enable policymakers to foresee the outcomes of choosing different options Burris et al.
However, HIAs can be difficult, time-consuming, and costly to complete. As noted below, meaningful evidence and data are not always available to arrive at definitive conclusions. It is therefore important for the law to impose some parsimony in dictating requirements for conducting HIAs. Apart from the administrative burden, it is neither necessary nor useful for policymakers to commission HIAs for every policy proposal. For example, enacting a modest retail redevelopment policy where the health impact is foreseen i.
In other cases, assessing the evidence is critical, as in the cases of federal laws with the potential for broad health impact that require periodic authorization. Although the administrative and methodological tasks of such research are challenging, the committee adopts as a general principle the obligation of policymakers to study, to whatever degree possible, the potential ramifications of policies in any sector that could substantially affect the health of the public.
Recommendation 9: The committee recommends that state and federal governments evaluate the health effects and costs of major legislation, regulations, and policies that could have a meaningful impact on health. This evaluation should occur before and after enactment. This recommendation applies to both public health and non-public health agencies working in concert. Before and after enactment, a scientific assessment would be conducted whenever possible.
Before enactment of such policies, the vested authority e. After enactment, the. Such evaluation and assessment could be conducted by the responsible agency, such as through National Environmental Policy Act NEPA requirements, or by the public health agency.
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