Our final module, module six, looks at the policy level of the ecological model. It considers how policy change is needed to promote health by changing the environment in individuals, families, and communities. By changing the policy environment, the individuals, families, and communities, can be enabled to live healthier lives. First question arises as to what is a policy, and various definitions can be found. One is that policies are specific and implied statements of goals and objectives, as well as, the means by which these are intended to achieve the goals and objectives. It's not just a question of stating an intent, but also in supplying the finances to carry it out. Policies are established through a number of processes. Most obvious are the political processes involving legislatures, as well as informal political processes such as backroom bargaining and lobbying. Policies reflect priorities since it's not possible for an organization or a government to accomplish everything it wants to accomplish. So, policies can be made at the international level, the national, and at lower levels, even down to the district, or county level, where various bylaws are passed. It's important for us in public health to know how public policies are made when organizations set their policies. These often evolve into specific programs. An example, is the African Program for Onchocerciasis Control. It covers 19 countries in sub-Saharan Africa. A specific issue that makes the program happen, is part of the policy that says the WHO will collaborate with other donor agencies. The idea is to coordinate funding, so that individual countries and individual NGOs that had previously been involved in community distribution of ivermectin, for Oncho control, would have one source where they could go to get financial assistance, and one source to get clearance for their donations of ivermectin, or as it's also known Mectizan. So WHO, UNDP, World Bank, all these major donors came together as a result of this policy decision. More broadly speaking, WHO has reflected on what diseases can be eradicated and eliminated. As you know, smallpox was the first disease to be eradicated, and WHO had set a priority policy for that. WHO has set policies to eradicate Guinea worm. Elimination is reducing the prevalence and transmission of disease to the point where it is no longer public health significance, or a public health problem, where it's not making major negative effects on the economy and social life of a community. Even though, there may still be some low level transmission. And so again, WHO through the World Health Assembly, would be setting policies that Onchocerciasis will be eliminated through this program. The program itself, the African Program for Onchocerciasis Control, officially took off in December 1995 and by 1997, the first set of countries that had applied for these centralized funds that were coordinated by APOC took off. And so, now the first five years of functioning of this APOC, have taken place. And the organization is in the process of evaluating what it's doing. But here again, the policy for eliminating Oncho, the policy for addressing the problem resulted in a specific interagency, international, programme called APOC. Finally, within APOC itself, policies were set in terms of how the program would function. Any government, any NGO, anyone that's applying for support through APOC is required, having received the funds, to organize the community directed treatment as their way of delivering the ivermectin. So here again, a policy was used to establish APOC. APOC itself then develops further policies on how the program will be implemented. Priorities are settled by negotiation among interest groups. There are groups that want an industry sited in an area because of jobs, there are other groups that want to be sure the industry locates elsewhere, because of health and environmental pollution concerns. A policy becomes more than just a statement of intent and goodwill, a piece of paper, when actual resources are allocated. This dilemma is often seen in the US Congress. A law may have been passed, Congress may change political parties, and in subsequent years money is not voted to support a particular agency or program that was created legislatively some years before. It's not simply even a matter of voting resources, but actually allocating them, or putting money on the table so that the strategies can be carried out. One of the key elements of primary health care that is health education, often suffers from this particular problem. We have been able to investigate the functioning of health education services at local, and national, and state health departments, health ministries, in a number of African countries, and found that the process of budgeting is somewhat convoluted. As we looked at our organizational charts before, we saw an example in our previous lab of the Health Education Unit, being quite low in the organizational chart, often program units are expected to submit their budget requests to the heads of divisions or departments, who in turn go to the negotiating table on behalf of those units. A budget is made for the ministry. This budget is forwarded, it's approved, or not approved, an amount is set. And many times, we've seen that the proposals for budgeting including various program items for health education are improved in principle, but then the amount of money allocated may be quite low. Maybe half of what was requested, but by the end of a calendar year it may be discovered, that only 10, 20 percent of the budgeted amount was ever released for programming. And so, this issue of putting teeth into a policy by releasing money through budgeting, is a very important issue to consider. It's important therefore to make a distinction between policy makers, administrators, and managers. Policy makers are the people who make the statements of intent. They choose among the competing priorities and possibilities, they're the ones that actually allocate funds, vote for funds, they are found on boards, legislatures, and councils. Policy administrators are the executive heads of the implementing agency, or the implementing department of an organization. It's up to them to interpret how broadly or narrowly the policy statements should be carried out. They give operational guidelines for implementation. It's then left to program managers to run the program, to implement the policies, to carry out the strategies, on a day to day basis. They decide where staff will be allocated, where resources will be dispensed for carrying out the programs that have arisen from the policy. It may be that organizations, such as WHO, have established a policy statement for the eradication of Guinea worm. Several resolutions can be found on that. They initially set 1995 as the goal. That goal has passed, the number of cases worldwide is down considerably, from probably close to a million annually to below 100,000 and the bulk of cases are in only three countries, Nigeria, Ghana, and Sudan. One of which is difficult to work in because of a civil war. So success has been seen, but the date was missed. In particular countries individual countries priorities were set. During a donor's conference in Nigeria, the head of state represented by the vice president made an announcement that all local governments or districts that had Guinea worm should allocate 10 percent of their local government budgets for the eradication effort. And that all agencies, donor and government that were providing community water supplies should target endemic governments. This latter policy statement could have been easily implemented because the eradication program had already done national case searches that identified the location of villages that needed wells and water supplies. In fact, decisions at the local council level, at the district level, the people who were actually going to carry out the program and allocate the fund backfired on this policy. Rural districts are quite poor. So we talked about in our example of the PVO that wanted to implement child survival programs. The districts had very little leeway because most of the money that they got from their federal subvention went for staff salaries, and very little extra was raised because the communities were poor. So they couldn't allocate 10 percent unless they fired some of their staff. Also, as was noted, became very difficult to target water supplies because the implementing agency was in the Ministry of Health. Water supply programs were in Ministry of Works in a rural special directorate for rural development and in the control of various agencies such as you UNDP, UNICEF. Some of these, like UNICEF, actively worked with the task force. Others did not. And so even though policies were made, at the end, the actual program managers, who had to carry out the work at the local government level, did not have the resources to do so. Also, even at the local government level, it turned out that because of shortage of staff, the Guinea worm coordinator may also have been the malaria control coordinator and may have also been the onco-psychosis control coordinator. And he or she may not have had much time or staff to allocate. And so the program may not have been efficiently administered. So although very promising statements may be made by national policy makers, implementation of the policy on the ground may look quite different. As we have been conducting diagnosis at the other levels of our ecological model, our individual, educational diagnosis, our community diagnosis, our organisational diagnosis. We also need to conduct a policy diagnosis to learn how the process happens. What are the priorities? How it can be influenced? Policy diagnosis includes efforts to understand the actions and motivations of people at these three policy levels. Those who establish the policies, those who interpret the policies, and those who are expected to carry them out. This diagnosis must find out what their knowledge sources are. How do they make their decisions? Where do they get input? Do they, by chance, have access to research? Do they get information from lobbyists? Do they get information from the community? It's important to realize that policy relevant research does not often have immediate impact on government decisions because of the many pressures on politicians to make their decisions. New technical knowledge, things like iodized salt, creep into the policymaking process and gradually alter the assumptions and concepts of the people who make policy. One of our former heads of department, the Department of Preventive Medicine at the University of London, who is retired now, came back to give a lecture. And he addressed this issue with researchers in Nigeria, who are in the forefront of looking at the importance of iodized salt in Nigeria and had conclusive results of its benefits. And yet it wasn't until 11 years later that government through the Ministry of Health acknowledged this and develop policies that would help encourage those companies that produced or imported salt to take this up. Often times, as they say, the prophet in his own land is not recognized. It was back in the 1950s that the issue of growth monitoring of children, the importance of salt-sugar solution during diarrhea was recognized and pioneered in a hospital in the western part of Nigeria because at that time, there were staff from places such as London, who moved to different parts of the developing world. They shared these ideas. They published these ideas, and eventually, organizations like UNICEF and other Ministries of Health, picked up on the ideas and brought them back to Nigeria. And it wasn't until 1984 that a policy of oral rehydration and salt-sugar solution made at home became part of the normal health care policy. Policy knowledge reflects subtle shifts, diffusion of ideas, or issue of diffusion of innovation and ideas and communities can also be applied in the policy arena, with the particular exception or particularly characteristic that much is at stake, in terms of policy maker decisions because of resource allocation. And so it's not simply a matter of ideas eventually spreading from one member of a legislature to another, but also, an idea gaining salience and political worth. Researchers in Mexico documented that policymaking depends on the political context, not necessarily on the need or health relevance of the particular problem. They found not only did researchers have small input, but under certain political conditions, the public itself had very little input into policymaking. Interestingly enough, the government of Mexico is just in the process of changing. For the first time in over 70 years, a different party is in power and this may make it possible for the researchers' hopes that democratic changes in the country would make it possible for more public input, included in that more input by researchers and research findings into policymaking. They also noted that policymaking in developing countries in particular depends in large degree on the influence of donor agencies. One can possibly even see this in the US in terms of the influence of money that's made available by federal government programs, and whether county health departments or state health departments accept the strings attached in order to get the money. Prior to the late 1980s, there was no clearly stated policy in Nigeria on malaria. But because a number of donor agencies were concerned about malaria control, experts were assembled and a malaria policy was developed and later adopted by the National Council of Health, which includes health ministers from all the different states. Programming, such as family planning, Guinea worm control is often instigated because foreign money is made available, foreign expertise is offered, and ministries go along with these programs, not that there is an need, not that Guinea worm does not need to be eradicated, not that high parity and maternal mortality are not serious problems, but focus on these to the exclusion of other problems has been a common observation. Policy formation goes through different stages according to one model. Stage model sees sequential steps of gathering information, making decisions, designing strategies, determining funding, involving different institutions and actors along the way. The stage model is useful for identifying the times and places and different tactics for influencing policy. But it can also be misleading in the sense that the policymaking process is not linear. The multi-stream model looks at the different flow and timing of policy action and variety of inputs. Various interpretations of the problem that needs policy, priority policy attention, alternative solutions, political pressure occur throughout the policymaking system, just like force field. And over time, one force or another may be stronger. At some point, a priority or compelling problem is linked to a strategy or solution that meets the test of political feasibility and has accepted. This merger in time and place of resources and needs results through a sustained effort by policy entrepreneurs or advocates for policy change. In fact, in addition to using a stream metaphor, one can use a web metaphor. The policymaking and learning occur within a web of interacting forces, involving multiple sources of information. Again, information that may be persuasive, information that comes from people with an agenda, that policymaking takes place in the context of complex power relationships and changing institutional arrangements. Different agencies come and go. Agencies provide much of the technical component. Legislatures change every so many years. Different issues arise in the environment. Lobbying groups change over time.
