What influences the transfer of research into health policy and practice? Observations from England and Australia

OBJECTIVES: To explore the role of evidence in the public health policy-making process, and show how the way in which public health problems are defined and measured influences policy outcomes. METHODS: The policy responses of the Blair Labour Government in the UK and the Howard Coalition Government in Australia to persistent health inequalities over the last decade are examined as a case study. RESULTS: Soon after being elected, the Blair Government commissioned an independent inquiry into health inequalities, signalling the priority it gave to addressing this longstanding challenge. It chose to take a 'whole-of-government' approach, combining actions that addressed both personal risk factors and the social determinants of health. This approach reflects the long-established tradition in England of routinely measuring disparities in health outcomes and correlating them with socio-economic status and underlying social determinants of health. Over the same period, the Howard Government also outlined its 'whole-of-government' approach to addressing the most extreme and persistent health inequalities between indigenous and non-indigenous Australians. In contrast, its approach focused primarily on modifying risk factors and improving service provision. This approach reflects the different historical circumstances in Australia and a different tradition in the collection of health data, focused more on health service access and personal risk factors. CONCLUSIONS: This case study offers some insight into the ways in which the production and presentation of evidence can influence and shape governmental responses to public health problems. The usefulness of available evidence is dependent upon the type of data that is produced routinely by government, as well as more deliberate decisions concerning public health research funding. Researchers can maximize the influence of research evidence on the policy process by engaging in the policy-making process, presenting research in ways that fit with the political context of the day, and, where necessary, using research evidence in public health advocacy in order to influence political priorities more directly.     

Health inequalities and the health of the poor: what do we know? What can we do?

The contents of this theme section of the Bulletin of the World Health Organization on "Inequalities in health" have two objectives: to present the initial findings from a new generation of research that has been undertaken in response to renewed concern for health inequalities; and to stimulate movement for action in order to correct the problems identified by this research. The research findings are presented in the five articles which follow. This Critical Reflection proposes two initial steps for the action needed to alleviate the problem; other suggestions are given by the participants in a Round Table discussion which is published after these articles. The theme section concludes with extracts from the classic writings of the nineteenth-century public health pioneer, William Farr, who is widely credited as one of the founders of the scientific study of health inequalities, together with a commentary. This Critical Reflection contributes to the discussion of the action needed by proposing two initial steps for action. That professionals who give very high priority to the distinct but related objectives of poverty alleviation, inequality reduction, and equity enhancement recognize that their shared concern for the distributional aspects of health policy is far more important than any differences that may divide them. That health policy goals, currently expressed as societal averages, be reformulated so that they point specifically to conditions among the poor and to poor-rich differences. For example, infant mortality rates among the poor or the differences in infant mortality between rich and poor sectors would be more useful indicators than the average infant mortality rates for the whole population.     

What does social justice require for the public's health? Public health ethics and policy imperatives

Justice is so central to the mission of public health that it has been described as the field's core value. This account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so particularly by focusing on the needs of the most disadvantaged. This Commentary explores how social justice sheds light on major ongoing controversies in the field, and it provides examples of the kinds of policies that public health agencies, guided by a robust conception of justice, would adopt.     

What is a national health policy?

Unfortunately, most nation states have taken "health policy" to mean "medical care policy." Medical care, however, is only one variable in a nation's health equation. The article describes what the main components of a national health policy should be, including (1) the political, economic, social, and cultural determinants of health, the most important determinants of health in any country; (2) the lifestyle determinants, which have been the most visible types of public interventions; and (3) the socializing and empowering determinants, which link the first and second components of a national health policy: the individual interventions and the collective interventions. The author discusses the indicators that should be used for each component and for each intervention. The feasibility of this approach depends to a large degree on the political will of the national authorities and the broad understanding of the actual determinants of health. A good first step is the National Health Policy plan developed by the Swedish social democratic government. This article builds on and expands on that model.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally. This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews. The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping 'policy networks' which cut across the traditional donor-government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives. This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise - and find new ways of making sense of - the complexity of forces affecting aid delivery.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally.

This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews.

The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping ‘policy networks’ which cut across the traditional donor–government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives.

This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise – and find new ways of making sense of – the complexity of forces affecting aid delivery.     

What does prevention and rehabilitation research contribute to health policy?

Rational health policy calls for a close collaboration between health-related political organizations and scientific communities, in particular public health sciences and health economics. Based on selected examples, this contribution highlights the benefits of primary and secondary prevention measures with re-spect to two widely distributed chronic diseases, coronary heart disease and depressive disorders. These examples refer to (1) lifestyle changes in secondary prevention of coronary heart disease, (2) theory-based measures of worksite health promotion, and (3)early detection and optimised treatment of depressive disorders. The relevance of interdisciplinary research on prevention and rehabilitation is emphasized by increasing pressures that arise from the current health care system.     

Global health priorities - priorities of the wealthy?

Health has gained importance on the global agenda. It has become recognized in forums where it was once not addressed. In this article three issues are considered: global health policy actors, global health priorities and the means of addressing the identified health priorities. I argue that the arenas for global health policy-making have shifted from the public spheres towards arenas that include the transnational for-profit sector. Global health policy has become increasingly fragmented and verticalized. Infectious diseases have gained ground as global health priorities, while non-communicable diseases and the broader issues of health systems development have been neglected. Approaches to tackling the health problems are increasingly influenced by trade and industrial interests with the emphasis on technological solutions.     

What are the health effects of fat?

In order to answer the question which health benefits are to be expected from dietary fat, we have to differentiate between different kinds of fat with varying fatty acid composition. Saturated fatty acids are commonly judged to have a negative health impact as they lead to increased serum cholesterol levels and a higher risk of coronary heart disease. Therefore, all recommendations stress the importance to limit the intake of saturated fatty acids. Monounsaturated fatty acids, on the other hand, have a positive impact on the serum lipid profile, lead to decreased LDL-oxidation and favorably influence the metabolism of diabetics. However, it is essential that monounsaturated fatty acids be mainly supplied by plant oils like rape seed or olive oil and not by foods that are simultaneously rich in saturated fatty acids. Concerning polyunsaturated fatty acids, it is important to increase the supply of n-3 fatty acids (ratio of n-6:n-3: about 5:1) as there is substantial evidence for their protective effects. If the fatty acid composition of the diet is optimized, even a total dietary fat content of 35% of total energy intake can be adequate as long as there is enough physical activity and the diet is rich in plant-derived foods like vegetables, fruits, cereals, potatoes, beans and legumes.     

Whiners and deniers – What does self-rated health measure?

Self-rated health is a widely used measure of health typically obtained from a question, “How do you rate your health?” Despite the measure’s popularity, debates continue as to what exactly self-rated health captures. This study augments the rich literature on the construct of self-rated health using a unique measurement approach. We conceptualize self-rated health as consisting of two components: latent health and reporting behaviour. We operationalize a preference-standardized health-related quality of life as a measure of latent health, and its systematic deviation from self-rated health as a measure of reporting behaviour. Using the 2005 Canadian Community Health Survey, we assess comparatively how the deviations between self-rated health and latent health, measured by the Health Utilities Index Mark 3, vary systematically by demographic, socioeconomic, and cultural factors. We present reporting behaviour by these factors in terms of pessimism and optimism relative to the assessment of the average Canadian. Our analysis shows reporting behaviour statistically and clinically significantly varies by age and socioeconomic status: those aged 80+ years and those with less income and education exhibit optimism about their health. In addition, our analysis indicates a tendency for persons with healthier lifestyles to be slightly pessimistic about their health. Our results imply that it may be misleading to take self-rated health at face value as a measure of health status for applications where preferences should be standardized. For this popular measure to continue to play an important role in population health research and policy development, its users must acknowledge and understand the determinants of self-rated health, including reporting behaviour.     

Adverse selection in the German Health Insurance System – the case of civil servants

At the beginning of their career, civil servants in Germany can choose between the social health insurance (SHI) system and a private plan combined with a direct reimbursement of the government of up to 70 percent. Most civil servants chose the latter, not only but also because they have to cover all contributions in the social system themselves, while regular employees get nearly 50 percent from their employers. The city state of Hamburg decided to change the system by paying half of the contributions if civil servants choose the social plan. We use a stochastic microsimulation model to analyse which socio-economic types of civil servants could benefit from the Hamburg plan and if this changes the mix of insured persons in the SHI system. Our results show that low income and high morbidity types as well as families have a substantially higher incentive to choose SHI. This reform might thereby increase the adverse selection of high risk cases towards SHI.     

What is the appropriate health policy content in a program curriculum?

Faculties of graduate health administration programs have considerable flexibility in applying curriculum guidelines established by the Accrediting Commission on Education for Health Services Administration (ACEHSA) to help achieve their self-determined missions. When a program's mission includes preparing graduates for eventual careers at the strategic levels of healthcare organizations, specific health policy content is appropriate. In determining this curriculum content, faculties can be guided by the need to prepare graduates to accomplish three policy-related activities that are vital to successful strategic management: 1. comprehend and understand relevant governmental health policy aspects of a healthcare organization's external environment, including assessing the impact of these aspects of the environment on the organization; 2. lead strategic responses to the challenges and opportunities emanating from the governmentalhealth policy aspects of an organization's external environment; and 3. participate in shaping, to the organization's benefit, the governmental health policy aspects of its external environment. Curriculum design options for providing this content are discussed.