试论个案研究方法在卫生政策分析中的应用

个案研究是社会科学中常见的研究复杂社会系统的方法之一,对于研究卫生政策过程有着很强的适用性。本文在回顾相关方法学与个案研究文献的基础上,从个案研究的特点、类别、设计与实施等方面初步介绍了个案研究方法的总体思路和手段,并结合卫生政策过程的特点,从研究设计、个案选择、研究推广等方面,初步探讨了个案研究方法在卫生政策研究中的应用。     

Alcohol industry influence on UK alcohol policy: A new research agenda for public health

The British government has been criticised for according industry interests too much weight in alcohol policy-making. Consequently, it has been argued that alcohol strategy in the UK is built around policies for which the evidence base is weak. This has clear implications for public health. The purpose of this commentary is to map recent developments in UK alcohol policy and related debates within the alcohol policy literature, thus laying the foundations for a systematic examination of the influence of the alcohol industry on alcohol policy. It highlights the changing structure of the industry and summarises what is known about the positions and strategies of industry actors towards alcohol policy. In so doing, it aims to contribute not just to debates about alcohol policy, but to a broader understanding of health policy processes and the relationships between government and other stakeholders. It advances a new research agenda focused on the role of corporate actors in the field of alcohol policy and public health more broadly.     

Local health policy development processes in the Netherlands: an expanded toolbox for health promotion

Although much research has been done on the existence and formation of risk and issue based health policies, there is only little insight in health policy development processes in a broader context. This hampers intervention in these policy processes to adequately develop integrated and effective health policies. Legislation in the Netherlands requires municipalities to develop and implement local health policies. These policies are supposed to aim at the promotion of health across sectors and with a strong community involvement. Health policy development processes have been studied in four Dutch municipalities. For each case, we identified a range of stakeholders and monitored the change or stability of their characteristics over 3 years. In addition, for each case, three overlaying maps of networks were made addressing communication and collaboration actions within the defined set of stakeholders. We point out a number of barriers which impede integrated policy development at the local level: the importance given to local health policy, the medical approach to health development, the organizational self-interest rather than public health concern, the absence of policy entrepreneurial activity. Furthermore, this article advocates the use of complementary theoretical frameworks and the expansion of the methodological toolbox for health promotion. The value of stakeholder and network analysis in the health promotion domain, at this stage, is two-fold. First, mapping relevant actors, their positions and connections in networks provides us with insight into their capacity to participate and contribute to health policy development. Second, these new tools contribute to a further understanding of policy entrepreneurial roles to be taken up by health promotion professionals and health authorities in favour of the socio-environmental approach to health. Notwithstanding the value of this first step, more research is required into both the practical application as well as in the theoretical connections with, for example, Multiple Streams theory.     

医疗服务价格改革政策快速终结的启示——基于政策行动者视角的案例研究

地方政策创新是我国公共行政领域的鲜明特征。国内既有研究多关注地方政策创新经验总结和政策出台,相对忽视地方政策创新终结。本文运用公共政策过程的理论和概念分析案例—重庆市医疗服务价格政策创新快速终结的原因。研究发现,政策制定过程中相对封闭的政策网络、政策执行过程中部分政策目标群体的抗争性策略、公众议程与媒体议程的互激等是政策创新迅速终结的主要原因。本研究有助于理解地方政策创新"昙花一现"这类非常态政策终结的逻辑机理,为提升我国卫生决策与改革的质量提供参考。     

Discursive gaps in the implementation of public health policy guidelines in India: the case of HIV testing

The implementation of standardized policy guidelines for care of diseases of public health importance has emerged as a subject of concern in low and middle-income countries (LMIC) globally. We conducted an empirical research study using the interpretive policy analysis approach to diagnose reasons for gaps in the implementation of national guidelines for HIV testing in Indian hospitals. Forty-six in-depth interviews were conducted with actors involved in policy implementation processes in five states of India, including practitioners, health administrators, policy-planners and donors. We found that actors' divergences from their putative roles in implementation were underpinned by their inhabitation of discrete 'systems of meaning' - frameworks for perceiving policy problems, acting and making decisions. Key gaps in policy implementation included conflicts between different actors' ideals of performance of core tasks and conformance with policy, and problems in communicating policy ideas across systems of meaning. These 'discursive' gaps were compounded by the lack of avenues for intellectual intercourse and by unaccounted interrelationships of power between implementing actors. Our findings demonstrate the importance of thinking beyond short-sighted ideals of aligning frontline practices with global policymakers' intentions. Recognising the deliberative nature of implementation, and strengthening discourse and communications between involved actors may be critical to the success of public health policies in Indian and comparable LMIC settings. Effective policy implementation in the long term also necessitates enhancing practitioners' contributions to the policy process, and equipping country public health functionaries to actualize their policy leadership roles.     

Research utilization and the impact of health promotion policy

Summary Objectives:The conditions under which research utilization leads to policy impact are an important issue in health promotion. This analysis tests the assumption that utilization is positively associated with policy impact only if both political will (i.e., policy opportunities) and social strategies (in intervention and implementation) are present.Methods:A survey of 719 policymakers involved in four poli-cies was conducted in six European countries. Policy impact (output, i.e., program implementation, and outcome, i.e., effects on behavior) and its proposed determinants were analyzed.Results:Regression analyses reveal limited cross-national differences in research utilization, but show comparably high use in policies with a pathogenic focus. Utilization is associated with impact only if political will is lacking; for outcome, this tends to depend on social strategies. Political will is the strongest determinant of impact.Conclusions:Research utilization is not supporting health promotion policy impact if political will is favorable, but if it is poor; political will itself is the crucial determinant of impact. The study contributes to the research utilization-field by showing that research utilization may partially compensate for lack of, rather than depend on, political will.     

From public health research to health promotion policy: on the 10 major contradictions

Summary The rise of evidence-based medicine has given impetus to calls for more research evidence to be incorporated into health policy. The difficulty in effecting this research transfer has often been attributed to the different worlds of researchers and policy-makers. There are other contradictions, however, that must be addressed in attempting to bridge public health research and health promotion policy. These include such issues as: what forms of evidence are required, what types of research are usually funded, the limited scope and duration of health promotion programs, how health policies are formulated, contemporary public sector management reforms, and so on. These contradictions need to be recognized and managed if closer links are to be formed between public health research and health promotion policy.     

Determinants of evidence use in public health policy making: Results from a study across six EU countries

The knowledge-practice gap in public health is widely known. The importance of using different types of evidence for the development of effective health promotion has also been emphasized.Nevertheless, in practice, intervention decisions are often based on perceived short-term opportunities, lacking the most effective approaches, thus limiting the impact of health promotion strategies. This article focuses on facilitators and barriers in the use of evidence in developing health enhancing physical activity policies.Data was collected in 2012 by interviewing 86 key stakeholders from six EU countries (FI, DK, UK, NL, IT, RO) using a common topic guide. Content analysis and concept mapping was used to construct a map of facilitators and barriers.Barriers and facilitators experienced by most stakeholders and policy context in each country are analysed. A lack of locally useful and concrete evidence, evidence on costs, and a lack of joint understanding were specific hindrances. Also users’ characteristics and the role media play were identified as factors of influence.Attention for individual and social factors within the policy context might provide the key to enhance more sustainable evidence use. Developing and evaluating tailored approaches impacting on networking, personal relationships, collaboration and evidence coproduction is recommended.     

政策反馈理论视域：中国医疗卫生政策钟摆式变迁及其逻辑

新中国成立以来,党和国家不断强化医疗卫生建设,70余年来医疗卫生政策演进呈钟摆式变迁的特征,即从公益导向的福利性医疗卫生政策摆向效率导向的市场化政策,再摆向公益为主兼顾效率的民生导向政策,在公益与效率间发生三次摆动。本文借助政策反馈理论分析医疗卫生政策钟摆式变迁的内在逻辑,发现政策变迁过程中原有政策通过资源效应、解释效应、演化效应和学习效应影响新政策的制定,使得新政策留有原政策的烙印,呈现出摆动式变迁而非剧烈或范式变迁。政策反馈理论为医疗卫生政策制定提供新视角,制定医疗卫生政策需注重原政策的历史影响力,以公共价值引领医疗医保医药政策,从多重政策反馈效应视角出发优化卫生政策的制定。     

Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme

The public social policy and programme decisions that are madein low-income countries have critical effects on human socialand development outcomes. Unfortunately, it would appear thatinadequate attention is paid to analysing, understanding andfactoring into attempts to reshape or change policy, the complexhistorical, social, cultural, economic, political, organizationaland institutional context; actor interests, experiences, positionsand agendas; and policy development processes that influencepolicy and programme choices. Yet these can be just as criticalas the availability of research or other evidence in influencingdecision making on policies and their accompanying programmesand the resulting degree of success or failure in achievingthe original objectives. Ghana, a low-income developing countryin sub-Saharan Africa, embarked on a national policy processof replacing out-of-pocket fees at point of service use withnational health insurance in 2001. This paper uses a case studyapproach to describe and reflect on the complex interactionsof context with actors and processes including political powerplay; and the effects on agenda setting, decision making andpolicy and programme content. This case study supports observationsfrom the literature that although availability of evidence iscritical, major public social policy and programme content canbe heavily influenced by factors other than the availabilityor non-availability of evidence to inform content decision making.In the low-income developing country context there can be imbalancesof policy decision-making power related to strong and dominantpolitical actors combined with weak civil society engagement,accountability systems and technical analyst power and position.Efforts at major reform need to consider and address these issuesalongside efforts to provide evidence for content decision-making.Without an analysis and understanding of the politics of reformand how to work within it, researchers and other technical actorsmay find their information to support reform is not appliedeffectively. Similarly, without an appreciation of the needfor critical technical analysis to support decision making ratherthan an indiscriminate use of political approaches, politicalactors may find that even with the best of intentions, desiredpolicy objectives may not be attained.     

The future of public health nutrition: a critical policy analysis of Eat Well Australia

Objective: To better understand how public health nutrition has been represented during the past decade in Australia this paper critically analyses Eat Well Australia: An Agenda for Action for Public Health Nutrition 2000 – 2010 and its accompanying National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan. Method: The paper uses an interpretive approach, drawing on Bacchi's method of problem representation, to examine the strategies being offered within the policy. It uses this framework to uncover how public health nutrition has been represented and examines if the representation provided considers all aspects of the issue. The paper also considers how contextual factors affected policy development through examination of publicly available documents. Results: The problem is represented as being both an individual one and one due to social, structural and economic circumstances. There is a large focus on collaboration, research and capacity building. The context of the policy's development has affected the solutions contained within. Conclusion: The policy's proposed actions reflect the policy‐making environment in which it was conceived. A manifestation of this was unclear division of roles and responsibilities, lack of dedicated resources and inadequate focus on the social determinants of health. Implications: As the policy's timeframe is drawing to its end, critical reflection on how the problem of nutrition has been represented over the previous decade provides greater insight and awareness to direct future public health nutrition work.     

Course and predictors of mental health of unaccompanied refugee minors in the Netherlands: one year follow-up

This epidemiological investigation addresses the prevalence, course, and predictors of the psychological distress and behavioral problems of unaccompanied refugee minors living in the Netherlands. The legal guardians, teachers and minors themselves all reported on the mental health of the refugee minors (n=582) at baseline and follow-up approximately 12 months later. The self-reported psychological distress of refugee minors was found to be severe (50%) and of a chronic nature (stable for one year) which was confirmed by reports from the guardians (33%) and teachers (36%). The number of self-reported experienced adverse life events were strongly related to the severity of psychological distress. Baseline psychopathology was the largest predictor of psychological distress at follow-up reported by all informants accounting for 22-51% of the variance. The present study, which used a population-based sample, further enlarges the knowledge of mental health among refugee adolescents. The investigation is unique because of the large sample size, the longitudinal nature of the study, the use of multiple informants, and the culturally diverse sample.     

The policy context for community development practice in public health: a Canadian case study

The Community Action in Public Health Study explored how public health managers, frontline staff, and community participants interpret, implement and receive policy guidelines urging collaboration with community groups in public health work. In-depth case studies of 6 public health units in Ontario, Canada focussed on 19 community development projects in 3 program areas (107 interviews). In the absence of formal policy guidelines on community development at provincial or local levels, informal policy predominated. Local senior management frequently set the tone, distinguishing health units in which community development was a basic philosophy underlying a broad spectrum of public health practice from those in which it was seen as only one among many possible strategies. Uncertainty and risk associated with informal policy lead many frontline staff to adopt strategies intended to preserve autonomy in community work, including "seeking forgiveness rather than permission" and maintaining relative "invisibility."     

Cost-containment in the Netherlands: government policy versus public opinion.

This article deals with the lack of information on the side of policy makers, especially the national government, on the opinions of the population with regard to cost-containment. Often important policy matters are developed before the preferences of the public have been adequately sounded. An insight into the view of the public can be obtained by representative surveys among the population. In the article the results are given of a survey conducted in 1984. One of the conclusions is that there are well-balanced opinions on cost-containment in health care among the public. It appears that the public is willing to accept financial cuts, even up to 10%. The public would also agree on less use of hospital beds. However, a majority of the public rejects a reduction of beds. Another conclusion reached by the authors is, that the government should give more information to the public about the consequences of less use of beds, in relation to the total amount of beds, in financial as well as in medical respect.     

政策工具视角下我国基本公共卫生服务均等化政策研究

目的：通过对基本公共卫生服务均等化政策的量化分析,全面了解其总体特征、政策工具组合运用情况,为促进我国基本公共卫生服务均等化政策完善提供建议。方法：以2009—2022年中央政府发布的促进基本公共卫生服务均等化的政策为研究对象,构建“政策工具(X维度)—利益相关方(Y维度)—政策过程(Z维度)”三维政策分析框架,开展政策内容分析。结果：供给型政策工具比例合理、政策重点立足于政府部门和政策执行阶段;主要运用公共卫生项目推进,重视基层医疗机构能力提升,并给予资金、人才支持。但存在总体结构失调、利益主体政策格局失衡和政策阶段关注不均等问题。建议：优化政策工具内部结构、对利益相关方投入多元化政策关注及合理布局政策阶段。     

Global health in public policy: finding the right frame?

One of health promotion's major contributions has been its discursive challenge to biomedical and even behavioural models of health and illness. The concept of social determinants of health is now widely accepted by health authorities in many parts of the world. When health promoters focus on these determinants, however, it is often at local or national scales. Contemporary globalisation demands a more critical appraisal of how many health problems have become inherently global in cause and consequence. In making such an appraisal, it is helpful to consider how global health is presently being framed to determine which arguments are most likely to be health-promoting for the greatest number. This article reviews five such frames: health as security, as development, as global public good, as commodity, and as human right. Most offer some useful argumentation to health promotion, although the rights-based frame, when supported by ethical reasoning (a moral voice), is the most consistent with health promotion's more empowering roots.     

The delivery and organization of public health in England: setting the research agenda

The publication of Best Research for Best Health highlighted the need for the NHS Service and Delivery Organisation (SDO) Programme to develop a programme of research on public health service delivery and organization. This paper reviews the need for this research by reviewing recent policy documents and public health research activity. The paper outlines the role of the SDO Programme in relation to other current developments and discusses how these respond to the need to develop research on public health and what the research priorities are.     

Q fever in The Netherlands: the role of local environmental conditions

The Netherlands is facing a Q fever epidemic in which dairy goats are implicated. People living close to an affected farm have an increased risk. However, no human cases were reported around a number of farms with serious Q fever problems. To assess the role of local environmental conditions which may add to the transmission or risk of Q fever, we gathered datasets on vegetation, land use, soil characteristics, and weather conditions in 5 km areas around infected farms. Areas without transmission had a higher vegetation density and relatively shallow groundwater conditions. Vegetation and soil moisture are relevant factors in the transmission of Coxiella burnetii from infected farms to humans, by reducing the amount of dust available for dispersion of the bacteria. The findings suggest that intensive goat and sheep husbandry should be avoided in areas that are characterized by a combination of arable land with deep groundwater and little vegetation.