Evidence Based Health Policy: Utopian Dream, Oxymoron, or Democratic Wish

Transcription

1 Evidence Based Health Policy: Utopian Dream, Oxymoron, or Democratic Wish Michael M. Rachlis MD MSc FRCPC LLD Montreal May 30, 2012 Canadian Association of Health Services and Policy Research

2 Outline The view of the role of evidence in policy has evolved over time We need to better understand the policy environment so we can more accurately diagnose its problems and more strategically apply the solutions An example improving equity with tax reform How this might this work with health care 2

3 Evidence makes policy: The truth will set you free!

4 The "Root" Method (a.k.a. "Rational- Comprehensive" (See: Specify all ends Specify weights for all the ends. In other words, indicate how important the various goals are relative to each other. [Note the assumption that different parties will be able to agree on the relative importance of the various goals.] Examine all possible sets of means. [Note the assumption here that we can think of all possible sets of means.] Evaluate each set of means against ends, assigning a score to how well the given set of means achieves each end. [Note the assumption that we have the ability and resources to do these evaluations.] For each set of means, calculate its overall measure based on the weighted average of its scores on achieving the different ends. Choose the set of means with the highest weighted score.

5 The "Branch" Method (a.k.a. "Incremental") (See: Ends and means are intimately intertwined, i.e., we often know our ends only from consideration of the means we are contemplating. Only a few means are considered and only those which don't represent too much of a departure from the status quo. (Thus the name, "branch method", where each policy branches off to another.) Evaluation of means is crude -- many consequences are ignored. Choice among the means is determined by agreement among interested parties rather than by summary indicators arising from the analysis. Agreement is the only empirical indicator of virtue, because values are not usually clear-cut or even shared.

6 Evidenced-based Policy is an Oxymoron

7 There is a remarkable consistency and repetition in the findings and recommendations for improvements in all the information we reviewed. Current submissions and earlier reports highlight the need to place greater emphasis on primary care, to integrate and coordinate services, to achieve a community focus for health and to increase the emphasis on health promotion and disease prevention. The panel notes with concern that well-founded recommendations made by credible groups over a period of fifteen years have rarely been translated into action. Ontario Health Review panel

8 The ideal health system would emphasize the prevention of poor health. It would be patientcentric and would feature co-ordination along the complete continuum of care that a patient might need. Primary care would be the main point of contact, but there would be much less emphasis on treating patients in hospitals. All professionals would exercise the full scope of their skills in their work; nurses, for example, would administer vaccines, and nurse practitioners would manage chronic illnesses such as diabetes and high blood pressure. Payment schemes and information gathering would support the patient-centric notion. Commission on the Reform of Ontario s Public Services p 18

9 The Democratic wish for Canadian health care

10 The people taking charge of their own communities in the face of a distant and usurptive state James Morone. The Democratic Wish: Popular participation and the limits of American Government

11 Regionalization in the 1990s: The Democratic Wish for Canadian health care Method -- Direct citizen participation in politics Assumption -- people agree with each other (when they have the same facts) Context people dwell in communities

12 The Four stages of a call to the people Begins and ends in policy stalemate The call to the people provokes a popular response Implementation of new institutions Return towards equilibrium (stalemate)

13 We need to better understand the policy environment so we can more accurately diagnose its problems and more strategically apply the solutions

14 Improving equity with tax reform

15 Freedom begins with breakfast Frequent borrowed saying of Justice Emmett Hall

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18 Healthcare Policy, 7(3) 2012: The Undisciplined Economist. A Casualty in the Class War: Canada's Medicare.. RG Evans.

19 Gov't tax and non-tax receipts (%GDP) CAN US G7 Avg Data from:

20 Canadian and US Govt Outlays as % of GDP % GDP Data from: : and 20

21 The shrinking Canadian public sector Overall Canadian government revenues have fallen by 5.8% of GDP from 2000 to 2010, the equivalent of $94 Billion in lost revenue No Canadian government deficits AND first dollar universal pharmacare, long term care and home care AND regulated child care for all parents who want it AND free university and college tuition AND build 15,000 units of affordable housing units every year AND buy the new fighter jets 21

22 Doctors for Fair Taxation goals 1. Change the conversaiton about tax fairness 2. Convince the Ontario government to increase personal income taxes on high earners 3. Convince the Ontario government finance committee to review other fair revenue opitons for the Ontario budget 2013

23 D4FT strategy 1. Generate political buzz because of the compelling man bites dog aspect of our story 2. Convince the Ontario NDP to ask the Government to increase personal income taxes on high earners as part of their support for the budget 3. Convince the Ontario government finance committee to review other fair revenue opitons for the Ontario budget 2013

24 Doctors for Fair Taxation argument 1. Canada is becoming a more unequal economic society 2. This means more health inequalities and lower overall health status 3. Taxes have been cut a lot in the last years (never mind since 1970). Taxes have especially cut from the poor to the extent that the poorest pay a higher rate of tax than the richest Canadians. 4. As physicians we see the adverse health impact of inequality in our patients and our communities. 5. If governments now find themselves in a deficit crisis then they should raise income taxes in a progressive fashion on the highest earning Canadians 6. It s a matter of fairness and the health of our country 7. Tax us! Canada is worth it!

25 Tax us! Canada is worth it. Our plan calls for higher marginal tax rates for the top 10% (>$100K), 1% (>$170K), 0.1% (>$640K), and 0.01% (>$1.85M) These new taxes would raise about $3.5B for the federal government and $1.7B for the province

26 The campaign March 20 th communication to approximately MDs March 22 nd press conference 40 MDs have signed the petition Massive coverage The issue takes off

27 Dr. Tanya Zakrison, academic trauma surgeon

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29 The campaign March 25 th Lawyers for Fair Taxation is launched 80 MDs March 27 letter writing campaign to key government ministers and a full court press on NDP MPPs 100 MDs March 28 th D4FT makes the Huffington Post April 2 nd Op Ed Toronto Star 150 MDs April 3 rd interview on CBC Toronto morning show April 4 th Ontario NDP leader demands extra 3% tax on income beyond $500,000 in return for NDP support for the provincial budget April 18 th meeting with Premier s policy advisor 230 MDs

30 Toronto Star April 19, 2012 Ontario budget: Andrea Horwath s tax-the-rich scheme hugely popular, poll suggests More than three-quarters of people surveyed 78 per cent like her idea with only 17 per cent opposed and 5 per cent unsure, according to the Forum Research poll. It s hugely popular. You never see that that s huge, Forum president Lorne Bozinoff said Wednesday.

31 The campaign The pressure mounts on the premier from his own front bench April 23 rd Premier McGuinty agrees to raise taxes by 3% on incomes above $500,000

32 Getting items on the Policy Agenda (per Downs and Kingdon) The problem directly affects the majority of the population The problem is simple to understand (and resolve) The problem comes at a time when it can generate continuing, sustained, dramatic media coverage Policies get implemented when a window opens for them

33 Watch for those policy windows

34 External stable factors Geography Climate Values Interests Constitution Economic system External dynamic factors Weather Government Business Other subsystem s policies Information Producers Researchers Think tanks Pollsters Journalists Advocates Purveyors Media New media Think tanks Advocates Policy subsystem Formal Decision Making Informal Court decisions Coalition A Coalition B Legislation Resources Resources Regulation Strategies Strategies By laws Institutional Rules Agency Decisions Arbitration Policy Brokers Policy oriented learning Values How should the world work? Beliefs How does the world work? Interests How does the world work for me? Modified from Sabatier and Lomas Policies and Power Relationships

35 How could we inject more evidence into policy? 35

36 Encouraging policy-oriented learning per Sabatier relatively enduring alterations in thought or behaviour intentions that result from experience/and/or new information and are concerned with the attainment or revision of policy objectives The Advocacy coalition Framework. Innovations and Clarifications. In: Theories of the Policy Process. Ed: P Sabatier. Westview press. Boulder Colorado

37 Pre-conditions for policy oriented learning There are > 2 coalitions with conflicting positions The issue at stake is of moderate importance to both coalitions. There is a forum available for debate. This forum could be one meeting (e.g. a scientific congress). But, many times, the debate is conducted over multiple venues over an extended period of time. Learning is amplified if the forum is run according to professional norms and when the problem is amenable to quantification.

38 How this might this work with health care?

39 Most of health care s problems are due to antiquated, processes of care 39

40 Improving access is easy! With current resources Canadians could: Have elective specialty input within 7 days Have same day access to our regular family doctor or someone on the doctor s team Get elective surgery within two months Get better access to the system through community health workers 40

41 How about policy forums focussed on improving access? Ensure the right persons are in the room Ensure the right process Ensure the right follow up

42 Pre-conditions for policy oriented learning There are > 2 coalitions with conflicting positions The issue at stake is of moderate importance to both coalitions. There is a forum available for debate. This forum could be one meeting (e.g. a scientific congress). But, many times, the debate is conducted over multiple venues over an extended period of time. Learning is amplified if the forum is run according to professional norms and when the problem is amenable to quantification.

43 Make sure you re having the right conversation! Per Contandriopoulos and Brouselle (2010) don t ask what to do ask how to get 24/7 care for all Canadians

44 The alternative is that everyday is groundhog day 44

45 What does this mean for researchers? Work with other groups and coalitions to amplify your messages Promote policy forums which encourage true dialogue and debate Remember that Justice Hall wasn t afraid to voice his opinions!

46 Evidence Based Health Policy: Utopian Dream, Oxymoron, or Democratic Wish?

47 Evidenced-based policy is a wish for democracy!

48 Most Canadian doctors and governments didn t want Medicare

49 Medicare belongs to all Canadians

50 The cure for the ailments of democracy is more democracy. John Dewey. The Public and Its Problems

51 Summary The views of the role of evidence in health policy has evolved has evolved over time We need to better understand the policy environment so we can more accurately diagnose its problems and more strategically apply the solutions We need to implement new ways of injecting evidence into health policy 51

52 Medicare has been called a sacred trust and we must not allow that trust to be betrayed.