According to Sapru (2004), ‘Public Policy’ as an academic pursuit emerged in the beginning of 1950s and since then it has been acquiring new dimensions, and is struggling hard to acknowledge the status of a discipline in the comity of social sciences. As a study of products of government, policy forms a significant component in many a course and programme in numerous disciplines—political science, public administration, economics, management. So rapid is the growth that many researchers, teachers, public administrators now feel that it is becoming more and more unmanageable.
The disciplines need to comprehend public policy cut right across the old academic lines of demarcation. Indeed it is this interdisciplinary quality which makes the field of public policy interesting and thought provoking. ‘Public policy’ is a concept now much in vogue. It is frequently used term in our daily life and in our academic literature, where we often make references to the national health policy, the new education policy, wage policy, agricultural policy, American or French foreign policy and so on.
It is an area which had to do with those spheres which are so labelled as public. The concept of public policy presupposes that there is a domain of life which is not private or purely individual, but held in common. Thomas Dye, a leading scholar of policy analysis, says: “Traditional (political science) studies described the institutions in which public policy was formulated. BUT unfortunately the linkages between important institutional arrangements and the content of public policy were largely unexplored.
” He further believes that today the focus of political science is shifting to public policy—“to the description and explanation of the causes and consequences of government activity” (Sapru, 2004). Legislative and Public policy The distinction between legislation and public policy is important to bear in mind. The mare passage of legislation does not always produce public policy. In areas of intense group conflict congress frequently resorts to the passage of “skeleton” legislation in order to avoid directly confronting difficult political questions.
That is, it purposely passes vague legislation, with statutory language couched in very general terms, requiring interpretation by the president or the administrative agency to which the legislature delegates authority to carry out its intent. Ambiguous statutory provisions are not only the result of congressmen attempting to avoid taking political stands, but also of the complexity of the problems before the legislature. It is difficult for Congress to write comprehensive laws.
Legislative reliance upon the technical expertise of the bureaucracy is common. The technological problems that must be taken into account in most areas of public policy also change rapidly from year to year. Even if a legislative committee has the expertise to deal with such matters, it is cumbersome to pass new legislation as frequently as conditions change. Legislation must be kept flexible, delegating a large amount of discretionary authority to the administrative authority to the administrative agencies charged with implementation.
Legislative committees may oversee agencies on a fairly continuous basis (although these are rare) and in this way affect the nature of the policy that is being formulated and carried out by the administrative branch. However, this is not the same thing as legislating. The policy outputs of government, then, are often not to be found in the language of statutes, but in interpretations made by legislative committees, administrative agencies, and sometimes the presidency and the courts, after legislation has been passed.
Except where the president and the Supreme Court are exercising independent constitutional prerogatives, all public policy decisions have a statutory basis, however vague. Through legislation, Congress determines the general areas in which government agencies will have policy-making authority, the boundaries of their authority, and the amount of money needed for particular programmes. Complementing statutory law is administrative law, that is, the rules and regulations formulated by administrative agencies. These fill in the details of congressional legislation, and are supposed to follow the intent of congress.
Ambiguity of congressional intent often leads to challenges of administrative actions in courts, which may overrule agencies if they find that they are acting beyond the authority (ultra vires) granted to them by congress, as interpreted by judges. Adjudication is a very important ingredient in the policy process, both as carried out by courts and administrative agencies. It is often through the settlement of individual cases and controversies that policy is clarified and given concrete meaning for individuals.
Outside the areas of constitutional law-making by judges and the exercise of independent constitutional powers of presidency, the policy process goes through three fairly identifiable formal stages: • the passage of a statute; • the promulgation of regulation based upon that statute by administrative agencies; • the adjudication of disputes that arise under statutory and administrative law by administrative agencies, initially, and under certain circumstances by the courts where they exercise their authority to review the decisions of the agencies (Woll, 1982). Good leadership depends on systems thinking.
This type of thinking focuses on ways to implement, in the short and long term, systems necessary for meeting identified needs. To ensure that system thinking is effective, public health agency leaders must support the system perspective and make certain staff understand what is involved in a systems approach to change. Communication must be frequent enough to allow the staff to help manage the implementation of strategic policies. The leader is responsible for guiding the implementation activities and presenting to the community the steps being taken by the agency in response to local public health issues.
Team building is a critical part of leading a public health agency. The leader creates team inside the agency and coalitions outside to address the programmatic needs of the agency. Once the members are appointed, the teams need to clarify the values that will guide their activities. Community coalitions and partnerships have basic similarities to teams, and their development resembles team development. Public health leaders must: • create a learning organization • coordinate knowledge management activities • think systematically and act strategically
• promote and support the change process • support the value of the agency and the community • understand the relationship between system inputs, programme interventions, and outputs • monitor and evaluate the effect of change • practice systems thinking at the five levels of leadership (Rowitz, 2009). In health reform debate in the early 1990s, the potential for the loss of choice of medical provider (and loss of power over other aspects of medical care) was a critical factor in the defeat of Clinton plan.
(To particularly fill out the list of American cultural values, Americans are preoccupied with the biggest and newest consumer products pursue dreams even when the chance of success is slight, are impatient, and tend to improvise in the making of changes. All these need to be taken into account in designing public health policies). Public health leaders, as protectors of the values of the agency and community, must emphasize the importance of maintaining high ethical standards inside the agency and in the community. One necessary task is to do an ethic check.
Are the procedures used in the agency and community legal? And even if legal, are they consistent with the values of the agency and the community? Leaders also need to examine the relationship between the science of public health, the facts that guide public health practice, and the explicit knowledge that comes from our formal learning. Leaders need to be oriented towards the future and help create the vision that guides the activities of the agency. They must also inspire their colleagues to share the vision and use it to guide their activities.
An agency’s mission and the vision must reflect each other. A vision is a picture of what, according to its leaders, the agency’s future should be like. The agency’s mission is the role it sees itself playing in the community. If the vision and mission truly reflect each other, then the agency, is fulfilling its mission, will help realize its vision (i. e. help bring out the kind of the future it desires). Leaders and managers have the critical role of translating tactic knowledge into explicit knowledge so that there is meaning in these events for internal and external stakeholders.
This translation help the organization address similar problems in the future. Public health leaders, besides identifying values, must consider how these values will affect the implementation of programs. They should be aware that the process of values clarification can simplify the solution of many local public health issues (Rowitz, 2009). The justice systems on public health policy Many of the social determinants of mental health cut across a range of sectors, such as labour and employment, commerce and economics, education, housing, other social welfare services, and the criminal justice system.
Mental health inputs are thus necessary in many departments to ensure that policies improve the mental health of the population and do not have the opposite effect. For example, mental health input in the criminal justice system can prevent the inappropriate imprisonment of people with mental disorders, make treatment for mental disorders available in prisons, and reduce the mental health sequel of imprisonment for prisoners and their families (WHO, 2001b), (e. g.
the AUDIT questionnaire) disorders are a more accurate way of monitoring community mental health because o low recognition rates for these disorders among health workers. The WHO is trying to bridge this information gap, at least in part, through the development of a set of indicators to monitor mental health systems and services at the country level (S. Saxena, personal communication). The implementation of these indicators could lead to substantial gains in the current status of mental health information.
Countries could be able to monitor progress in the implementation of their reform policies, provision of community services and activities, and the involvement of the communities, consumers’ and families’ associations, and other governmental sectors in mental health promotion, prevention, care, and rehabilitation. Countries would that reach a clearer and more comprehensive picture of the main mental health issues and be able to asses improvement over time.
Furthermore, at the country level, indicators may prompt governments and health systems managers to build a data infrastructure, implement information systems, and foster the use of surveys of mental disorders. Research is necessary to generate the necessary evidence for guiding an appropriate response by policy makers and practitioners to the large unmet needs of care for mental illnesses, particularly in developing countries. The need for psychiatric research to reflect the diverse realities of health systems and cultural factors is crucial if research is to inform local health policy and practice.
As with most areas of health, the contribution of developing countries to mental health research is very low. Surveys of high-impact journals typically show that less show that less than 10% of published research originates from developing countries, and the vast majority of journals published in developing countries are non-indexed, limiting their impact (cited Patel & Sumathipala, 2001). A major factor that is impending the use of more appropriate interventions or a greater prominence to mental illness in policy is the lack of evidence about treatments and the tendency for research to be focused on psychiatrics and psychiatric contexts.
Arguably, if there was evidence that treatments were efficacious and cost-effective and that they were clearly linked to other community health problems, then they would be more widely adopted by health workers and health policy makers. It is clearly the time, then, to move from surveys demonstrating prevalence to research. Future psychiatric research in developing countries needs to be more action oriented, in the form of actual intervention trials or studies with the explicit goal of influencing the integration of mental health care in existing community health services and public health priorities.
The research must be sensitive to local needs and involve active participation from potential users of the findings. In selecting settings for intervention research, a variety of health systems should be considered to ensure that findings can be generalized to many regions of the world (Merson, Black & Mills, 2006). Bureaucracy on public health policy. The use of private intermediaries may also impede result development. Intermediaries may have negative feelings about the program and thus act inefficiently.
Outcome may be hampered because the coordination of various program elements is made more difficult if private middlemen enter the scene between government and clients. Implementation research must be credited for the discovery of the influence on program results of the third subcomponent of the larger administration factor: street-level bureaucracy. Michael Lipsky’s famous book Street-Level Bureaucracy has been particularly influential in this respect.
According to Lipsky (1980:3), street level bureaucrats are “public service workers who interact directly with citizens in the course of their jobs, and who have substantial discretion in the execution of their work. ” Typical street-level bureaucrats are teachers, police officers, social workers, judges, public lawyers, health workers, and many other public employees who grant access to government programs and provide services within them. According to Lipsky, street-level bureaucrats actually create policy through the multitude of decisions they make in interacting with the clients.
They posses discretion that cannot be completely controlled because there are never enough resources to provide close, frequent, and direct supervision of them, and also because they are physically separated from their superiors. There are no precise performance criteria in existence that specify exactly how an engineer, public health nurse, social worker, or teacher should do their job. In sum, argues Lipsky, policies are formed in implementation by program operators developing routines and shortcuts for coping with their everyday jobs
Obviously, the street-level bureaucracy’s comprehension of the program influences their work and thus program output and outcome. The capabilities of the street level bureaucrats will also impinge on program results. A seemingly universal problem is that front-end personnel feel that their resources are too scarce. A lack of educated personnel and technical equipment impedes the discovery of regulatory violations and their prosecution in court, and decreases the quality and quantity of the services provided.
For some inspections, the magnitude of the legislative charge makes it virtually impossible to have enough inspectors to keep an eye on violators. Occupational safety and health standards apply to more than 20,000 workplaces, yet the U. S. Board of Occupational Safety and Health (OSHA) can only inspect a tiny fraction of them every year. Time constraints generally limit the ability of inspectors to discover many of the infractions of norms and regulations. They are too hurried to a thorough job. Hemenway has pointed out that OSHA inspectors spend only about one-third of their available time in the field.
The rest is used to prepare for travelling and reporting the site visits. Regional inspectors for American Nuclear Regulatory Commission spend only about 25 percent of a typical working week at the power plant. In adjustment to the resource problem, program operators adopt various coping strategies. To avoid case load caseload, they limit information about their services, ask clients and inspectors to wait, make themselves unavailable to contacts or make ample use of referrals of client to other authorities (Vedung, 2000).
Interest groups on public health policy. The pace of politics and interest group competition had picked up by the early 1980s. A plethora of health related interest groups had opened offices in the capital, along K Street, N. W. More and more of the lunches consumed at the Rotunda, the Monocle, and other long-time power-lunch eateries huddled at the foot of Capital Hill were being bought by professional lobbyist whose clients wore white coats to work, or worked closely with those who did.
President Jimmy carter’s demand for spending controls on hospitals had aroused the powerful Chicago-based AHA, which stepped up its lobbying and built up its campaign contribution base. Business lobbyist, too, had health care on their menus. Cost had caught the eye of business executives as the fringe benefit line in their annual reports began to show a higher rate of growth that wages, sales, or profits. Though the AMA and a few other organizations had PACs in the 1970s, PACs became a noticeable feature of the political landscape only in the 1980s, thanks in part to reforms of the 1970s.
In an attempt to shrink the influence of a few well-heeled givers, those who wanted more citizen financed campaign had pressured congress to cab contributions from individuals and interest groups and to set up a public financing mechanism for major party candidates for president The authorization of PACs in the 1974 law led to an extraordinary increase in their number and influence. Health care associations took notice.
Clearly there are many whose interests were not being represented by the AMA, the AHA, or the insurance companies. With their own PACs, optometrists, chiropractors, dentist, nurses, nursing homes, group practice associations, family doctors, pharmacist, drug companies, occupational therapists, and others could mount lobbying efforts or make campaign contributions to ensure that when the body politic wrote national health insurance legislation, it did not neglect the part of the human body in which they had a particular interest.
The body of theory that describes interest groups and their actions reflect the changes the groups have undergone. Key element of this theory includes how and why interest groups form and why they persist. Interest groups have evolved rapidly from close-knit alliances into diverse, large, and powerful players in federal (and state) policy making. Many groups occupy somewhat narrow “niches” in policy, but they also participate in coalitions that allow them to pull their efforts to effect or deflect broad policy change.
Interest groups provide information and campaign support to elected officials and use several strategies to influence policy, including direct lobbying, grassroots organizing, campaign contributions through PACs, and participation in coalitions. Though interest groups spend most of their time attempting to influence congress, they also recognize the importance of lobbying the executive branch. Interest groups also use the court, often as the final avenue for action when other means fall short.
Interest groups play an important role in both electing members of Congress favourable to their cause and working with these members to enact the policies that the members desire (and stop the policies they oppose). In sum, the role of interest groups in defining and shaping health care policy is pivotal. Next to congress, interest groups may well be the most important actors in healthy policy. Interest groups consist of individuals who have organized themselves around a shared interest and seek to influence public policy.
Interest groups include organizations as diverse as the Federation of Behavioural, Psychological, and Cognitive Science and the Association of State and Territorial Health Officials, as broad as the American Public Health Association and as narrow as the American Society of Gastrointestinal Endoscopy. They also include corporations and institutional interests such as hospitals, medical schools, HMOs, and schools of public health (Weissert, & Weissert, 2006) Political parties on public health policy. The election of the labour government by May 1997 appeared to herald a change in emphasis for health-care policy.
Within weeks of the election, the government had appointed the UK’s Minister for Public Health and announced the end of the internal market with a shift towards more collaborative arrangements for health care commissioning and provision. Livings centre to be funded from the lottery and are also evident in the proposals for HAZs. The development of HAZs represents one element of the government’s intention to provide ‘joined up solutions’ to complex problems, a desire to move away from compartmentalize which characterises health a social care issues.
Collaboration between health and local authorities is also highlighted as essential to the broader promotion of public health and proposals for HIPs (cited DoH, 1997) emphasize the important role of local authorities. Direct involvement in the development of HIPs is seen as a key task for local authorities and will be underpinned by a new statutory duty to ‘improve the economic, social and environmental well being of their areas’ (cited DoH, 1998b) and the Green Paper envisages an important role for local authorities in tackling public health issues through housing, transport, education and social policies.
Therefore the proposals contained in the Green Paper support a wider public health approach and implicitly acknowledge the primary care function of other front line agencies and their importance in improving health. However responsibility for the coordination of the public health strategy will remain with the directors of public health at regional and health authority level. Health authorities are still dominated by the medical model, raising concerns that the ever-present need to increase the provision of medical services may override the longer term strategic need to develop collaborative strategies.
Another concern is that there appear to be few links between the White Paper on NHS and the Green Paper on public health. So, while the rhetoric of collaboration and partnership may be present in both NHS and public health policy, the mechanisms for implementation of policy do not appear to be through and through. The new NHS also represents a further extension of managerialism within the UK health service with the incorporation of primary care more firmly within the NHS.
The development of PCGs sets out an agenda for incorporating primary care within the NHS hierarchy and presents a real challenge to the independent nature of general practice. The organization of commissioning is likely to lead to greater managerial scrutiny of and accountability for primary care. Yet at the same time, the White Paper promote the development of clinical governance and support the increased involvement of clinician and others, such as nurses, in service planning and commissioning.
This support for clinical involvement is a key theme of the White Paper and appears to encourage professional involvement in decision making which may be at odds with increasing managerial control. At one level, this emphasis on professional involvement is to be welcomed as there is a shift away from a specific focus on doctors to an increased nursing role in decision making, particularly in PCGs. However, there is a clear preference for doctors to be lead clinicians in both commissioning and clinical governance as nurses have less presentation on PCG boards.
However, it is not clear that clinical skills are necessarily the most appropriate skills for commissioning and there is a tension between whether nurses in managerial roles would be more suitable nursing representatives than those with only clinical experience (Craig & Lindsay, 2000). Media on public health policy. Developing and managing successful public health activities require the ability to communicate effectively with the varieties of stakeholders involved in these efforts. Increasingly, public health organizations rely on explicit communication strategies to manage relationship with the media, policy makers, and the public.
Key channels of communication include press releases, news conferences, radio, cable and satellite television, pamphlets, posters, videotaped messages and town meetings. Media relationships can be especially helpful in mounting population wide health promotion and disease prevention interventions. External communication strategies should be coordinated with internal communication processes to ensure organization performance. Robert Frost once wryly noted that “good fences make good neighbours.
” Nothing could be further from the truth in the effective practice of public health. Effective communication is in fact vital to the ability to improve the quality and quantity of life locally, nationally, and globally. And though the science of public health has continued to advance, the concomitant ability to communicate result and accomplishments has lagged behind. This one reason why public health practice—for all its success in improving life expectancy over the past 100 years—continues to toil in relative obscurity compared with organized medical practice.
As result, population based approaches to health improvement continue to suffer from poor funding and limited advocacy. It has been estimated that health promotion and disease prevention expenditures constitute 3 percent of health care expenditures. An added difficulty is the fact that public health activities such as the prevention of epidemics, assurance of safe water and food, and maintenance of health statistics are largely transparent to the general public and, consequently, undervalued. Thus, although former Surgeon General C.
Everett Koop’s well known comment, “health care is vital to all of us some of the time, but public health is vital to all of us all of the time,” resonates with public health professionals, it often fall on deaf ears when aimed at the public, the media, the policy makers. Fortunately, the realization that “good communication equals good public health” is growing. Three decades ago, public health communication was generally limited to sterile brochures, pamphlets, and early morning public service announcements (PSAs).
Modern public health organizations use social marketing and entertainment education techniques to encourage lifestyle changes, media advocacy to transform health policy making, and risk communication to better characterize health risks. Public health administrators are also becoming increasingly aware that organizational efficiency and employee morale are dependent on effective organizational communication. Nonetheless, the effective use of communication to improve public health practices is still the exception rather than the rule.
Public health administrators continue to on the job about communication strategies and do admirably well under many circumstances. However given the importance of communication in public health, these strategies should not be left to chance. Academic institutions and continuing education programs need to offer pragmatic training in effective communication strategies to improve public health practice (Novick, 2005).
References Craig, P. M. , & Lindsay, G. M. (2000). Nursing for public health: population-based care. London: Elsevier Health Sciences. Great Britain. Dept. of Health. (1998). Our healthier nation. London: Stationery Office. Novick, L. F. (2005). Public health administration: principles for population-based management. Mississauga: Jones & Bartlett Learning. Rowitz, L. (2009). Public health leadership: putting principles into practice. London: Jones & Bartlett Learning.