State of the art in research on equity in health

This essay provided the introduction to a workshop in Bellagio, Italy, on the subject of translating research into policy for equity in health. The essay first defines equity in a way that facilitates its assessment and monitoring and then summarizes evidence from existing research. Directions for developing policy strategies follow from these principles. The role of health services in influencing the distribution of health in populations is discussed in the special context of primary-care-oriented health systems that are, at the same time, more effective, more efficient, and more equity producing than is the case for specialist-dominated health systems.     

Finding audiences, changing beliefs: the structure of research use in Canadian health policy

The impact of research information depends on its ability to change beliefs or policy assumptions within the relevant audiences. As a hybrid of American and British systems, Canada's chosen decision-making structure for policy-making and its legislative framework for health insurance make these audiences unclear and not readily accessible. This factor and historical characteristics of the research community which made them only partially responsive to the values of decisionmakers provide an explanation for the limited past use of research information in Canadian health policy. More recently, improved responsiveness by researchers and an emerging definition of the audiences by legislative policymakers are bringing about a gradual increase in the potential impact of research at the levels of administrative and clinical policy. Because of continuing decision-making constraints on legislative policy, however, impact at this level is predicted to remain diffuse, with only cautious acceptance of the changes in beliefs implied by research.     

Providing health insurance in rural china: from research to policy

The focus of this case study is utilizing research to influence policy in a large developing country. Our experiences involve the lack of health insurance for China's rural populations and how our research helped shape China's recent policy attention and efforts on this issue. More than 80 percent of China's 700 million rural residents have no health insurance. This has been the case for the past thirty years, since the collapse of the once-successful Rural Cooperative Medical System after the economic reforms of the early 1980s. In 2002, the Chinese government announced a new rural health financing policy to provide health insurance for its rural populations, financed by a matching fund with contributions from central and local governments, as well as from individual households. This article documents the authors' experiences in addressing several critical questions for converting research results into policy actions, including the following: How are researchers to address policy relevant questions? How are they to acquire the attention of top policy makers to a specific problem? When is the issue at hand serious but not yet critical? And lastly, how are researchers to develop policy recommendations that stand a good chance of being accepted and enacted? Major lessons learned include the need to better understand the mandates and institutional constraints of the policy makers, the appropriateness of timing of both research result and policy efforts, how to use a country's cultural context to garner support of the government, how to enhance the policy's impact by combining formal and informal channels of communication for research dissemination, and the importance of following the policy process through the implementation phase to ensure the original objectives are achieved.     

The third way in mental health policy: negative rights, positive rights, and the Convention

Mentally disordered patients may be said to have rights in two senses: negative rights to freedom from arbitrary detention or interference with their person; and positive rights to expect a certain minimum standard of service, be that in terms of treatment as an in-patient, or as a patient in the community. The Labour government has appointed a 'scoping group' to carry out a root-and-branch review of the Mental Health Act 1983. The 1983 Act was mainly concerned with in-patient treatment. The group is to look at the scope for introducing further compulsory powers in the community, enhancing the rights of carers and relatives, and is to take account of recent British and Strasbourg case law. The primary impact of the Convention on psychiatric patients has been in relation to protection against arbitrary detention under Article 5, unsoundness of mind being one of the permitted grounds of deprivation of liberty under Article 5(1)(e). This article explores the potential impact of Convention rights in developing what Gostin referred to in the early 1980s as a 'new legalism'. The new legalism linked concern for traditional rights to due process and review by the courts or other external bodies with the 'ideology of entitlement' to adequate treatment and services. The article outlines the current policy context of mental health services and looks at the development by the European Court of Human Rights of positive Convention rights to services out of Article 5, whose purpose seems at first sight to be the protection of due process rights. It examines the relevance of Convention rights to community powers.     

The determinants of health policy, a case study: regulating safety and health at the workplace in Sweden

This article analyzes and criticizes the " technocratic " view of occupational health and safety policies, which sees the values of the personnel in "post-industrial" regulatory agencies as the most important determinant of those policies. It takes an alternate position, which explains occupational health and safety policies as primarily resulting from the different degrees of political power of the two major classes (capital and labor), and from the set of influences exerted on the regulatory agencies by the instruments (e.g., parties, unions, trade organizations) of those classes. It shows how an analysis of the historical evolution of those classes in Sweden and their conflict in both civil and political societies explains Swedish occupational health and safety policies better than a mere analysis of the regulators' views. And it concludes that the occupational health and safety policies in Sweden are not identical to those in the U.S.--as the " technocratic " theorists assume--but rather offer more protection to the workers than U.S. policies do. This situation is a result of labor having more power in Sweden than it has in the U.S. The different class formations and class behavior in the two societies are compared, and the implications of this comparison for occupational health and safety policies are discussed.     

Immigrant workers: health, law, and public policy

Immigrant workers are a large segment of the lower echelon of the U.S. labor force, and as many as 3.6 to 6 million of these workers and their families are living in the U.S. illegally. This paper examines who the recent immigrants are: explains why their current situation in the U.S. is an important public health matter; discusses the ethical and policy issues stemming from their health needs and from illegal status; and concludes with a brief look at some implications of the Simpson-Mazzoli Immigration and Reform Act, currently before Congress. The paper suggests that the illegal status of undocumented workers intensifies their health risks; that the immigrants' responsibility for budget short-falls in public services is not as clearcut as frequently assumed; and that legislation aimed at regulating the status of immigrant workers in the U.S. is unlikely to solve many of the central problems.     

The science commons in health research: structure,function, and value

The “science commons,” knowledge that is widely accessible at low or no cost, is a uniquely important input to scientific advance and cumulative technological innovation. It is primarily, although not exclusively, funded by government and nonprofit sources. Much of it is produced at academic research centers, although some academic science is proprietary and some privately funded R&D enters the science commons. Science in general aspires to Mertonian norms of openness, universality, objectivity, and critical inquiry. The science commons diverges from proprietary science primarily in being open and being very broadly available. These features make the science commons particularly valuable for advancing knowledge, for training innovators who will ultimately work in both public and private sectors, and in providing a common stock of knowledge upon which all players—both public and private—can draw readily. Open science plays two important roles that proprietary R&D cannot: it enables practical benefits even in the absence of profitable markets for goods and services, and its lays a shared foundation for subsequent private R&D. The history of genomics in the period 1992–2004, covering two periods when genomic startup firms attracted significant private R&D investment, illustrates these features of how a science commons contributes value. Commercial interest in genomics was intense during this period. Fierce competition between private sector and public sector genomics programs was highly visible. Seemingly anomalous behavior, such as private firms funding “open science,” can be explained by unusual business dynamics between established firms wanting to preserve a robust science commons to prevent startup firms from limiting established firms’ freedom to operate. Deliberate policies to create and protect a large science commons were pursued by nonprofit and government funders of genomics research, such as the Wellcome Trust and National Institutes of Health. These policies were crucial to keeping genomic data and research tools widely available at low cost.

U.S. policy on health inequities: the interplay of politics and research

What is the relationship between scientific research and government action in addressing health inequalities in the United States? What factors increase the impact of scientific research on public policy? To answer these questions, we focus on racial and ethnic disparities in health status and health care in the United States. We first review the history of the disparities issue to elucidate how the continual and persistent interplay between political action and scientific research drives government policy. We then analyze two recent government-sponsored reports about racial and ethnic disparities to understand the strategic consequences of issue framing. We draw lessons about how disparities research can have a greater impact on public policy.     

Courts and health policy: judicial policy making and publicly funded health care in Canada

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.     

Making sense of the global health crisis: policy narratives, conflict, and global health governance

Health has become a policy issue of global concern. Worried that the unstructured, polycentric, and pluralist nature of global health governance is undermining the ability to serve emergent global public health interests, some commentators are calling for a more systematic institutional response to the "global health crisis." Yet global health is a complex and uncertain policy issue. This article uses narrative analysis to explore how actors deal with these complexities and how uncertainties affect global health governance. By comparing three narratives in terms of their basic assumptions, the way they define problems as well as the solutions they propose, the analysis shows how the unstructured pluralism of global health policy making creates a wide scope of policy conflict over the global health crisis. This wide scope of conflict enables effective policy-oriented learning about global health issues. The article also shows how exclusionary patterns of cooperation and competition are emerging in health policy making at the global level. These patterns threaten effective learning by risking both polarization of the policy debate and unanticipated consequences of health policy. Avoiding these pitfalls, the analysis suggests, means creating global health governance regimes that promote openness and responsiveness in deliberation about the global health crisis.     

American health policy: cracks in the foundation

Much American health policy over the past thirty-five years has focused on reducing the additional health care that is consumed when a person becomes insured, that is, reducing moral hazard. According to conventional theory, all of moral hazard represents a welfare loss to society because its cost exceeds its value. Empirical support for this theory has been provided by the RAND Health Insurance Experiment, which found that moral hazard--even moral hazard in the form of effective and appropriate hospital procedures--could be reduced substantially using cost-sharing policies with little or no measurable effect on health. This article critically analyzes these two cornerstones of American health policy. It holds that a large portion of moral hazard actually represents health care that ill consumers would not otherwise have access to without the income that is transferred to them through insurance. This portion of moral hazard is efficient and generates a welfare gain. Further, it holds that the RAND experiment's finding (that health care could be reduced substantially with little or no effect on health) may actually be caused by the large number of participants who voluntarily dropped out of the cost-sharing arms of the experiment. Indeed, almost all of the reduction in hospital use in the cost-sharing plans could be attributed to this voluntary attrition. If so, the RAND finding that cost sharing could reduce health care utilization, especially utilization in the form of effective and appropriate hospital procedures, with no appreciable effect on health is spurious. The article concludes by observing that the preoccupation with moral hazard is misplaced and has worked to obscure policies that would better reduce health care expenditures. It has also led us away from policies that would extend insurance coverage to the uninsured.     

Reducing racial and ethnic health disparities: exploring an outcome-oriented agenda for research and policy

Eliminating racial and ethnic disparities in health status and health care, a major focus of Healthy People 2010, remains on the national agenda and among the priorities for the administration of President George W. Bush. Even though the elimination of racial and ethnic health disparities challenges the whole nation, individual states are on the front line of many initiatives and are often the focus of important policy efforts. In addition, it is important to focus on states because they are already responsible for much of the health and public health infrastructure, and several states have developed initiatives dating back to the release of Margaret Heckler's report on the gaps in health outcomes by race in 1985. This article makes the case for an outcome-oriented approach and provides a summary of lessons learned based upon preliminary investigations into constructing and applying two indices, the disparity reduction profile to measure effort and the disparity index to measure outcomes.