Whats missing from health policy The role of citizens

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Whats missing from health policy? The role of
citizens
Professor Brian Oldenburg School of Public
Health and Preventive Medicine, Monash
University AIHPS
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Summary

• Current status
• Concepts and practice
• AIHPS research findings
• Will the future be any different?

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The shaping and development of health policy
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NHHRC Report

• Informed consumer deliberation (such as citizens
  juries) BUT there are many techniques and
  approaches to citizen engagment
• Person/Patient-centred health care system BUT
  it is not just about consumers of health, health
  is everybodys business and responsibility
• Service delivery BUT its is not just about
  service delivery and health care, it is about
  citizens being really involved with policy and
  decision making for health

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Is it a new era in Australia?

• Will anything really change?

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Citizens can be

• Drivers
• Collaborators
• Contributors
• But there are many levels and instances
  wherethey can be one or take on all these roles
• As an Individual
• Within a Program
• Within an Organisation
• As a Community

AIHPS National Citizen Engagement Forum
Brisbane 2008
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Source Health Canada Policy Toolkit for Public
Involvement in Decision Making
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AIHPS work program evidence base for citizen
engagement

• Review and assess current practices for engaging
  consumers
• Contribute to the development of more effective
  consumer engagement strategies
• Focus at the level of health policy vs delivery
  of health services
• Consumer engagement in Australian health policy
  Investigating current approaches and developing
  new models for more consumer participation (AIHPS
  Report)

AIHPS National Citizen Engagement Forum
Brisbane 2008
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What has been missing from citizen engagement in
Australia?

• Poorly understood, inconsistently practiced, and
  under theorised
• Poorly defined
• A mindset, not just a technique
• Requires organisational commitment and a
  high-level champion
• An ongoing process, not a fixed time event
• Citizens need to be confident their input will be
  valued
• Citizens usually need background information
• Different approaches offer different
  opportunities for policy development

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Traditional engagement/consultation vs
deliberation

• Much traditional engagement (consultation)
  involves gathering information from citizens.
  Citizens might inform policy, but policy makers
  still continue to control the decision-making
  process
• Deliberative processes of engagement offer
  opportunities for citizens to really participate
  in issues identification, policy development and
  decision making

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Deliberative engagement

• An approach to decision-making in which citizens
  consider relevant facts from multiple points of
  view, converse with one another to think
  critically about options before them and enlarge
  their perspectives, opinions, and understandings
  (Deliberative Democracy Consortium, 2007)

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Deliberative engagement forums

• Guiding principles
• Participants have an opportunity to learn about
  an issue and discuss and develop their ideas
• Participants represent a broad cross-section of
  the community including lay people, people
  directly affected by the issue, and topic experts
• Participants work in small groups, guided by a
  facilitator
• Participants receive background information prior
  to and a summary soon after the forum
• Participants are given a commitment that their
  input will be valued and taken seriously

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AIHPS current projects using deliberative
engagement

• 1.Listening to citizens views about chronic
  disease prevention and health promotion (2009)
  (with VicHealth)
• 2.Being healthy. Staying well. What can you do?
  (2009) (with Bupa Australia)
• 3.Preventive Health and the role of the private
  health insurer (2009) (with Australian Unity)
• 4. Citizen engagement Listening to citizens
  views about Australias health system and
  prevention (2009-2011) (ARC Linkage)
• www.aihps.org

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1. VicHealth Project

• 2 deliberative forums in May 2009 Bendigo
  Melbourne
• Outcomes
• Participants expected government to take a role
  in programs to encourage disease prevention and
  health promotion including promotion,
  education, support programs and regulation
• Participants viewed individual responsibility as
  of key importance
• Participants were conscious of equity issues and
  social influences
• In a budgeting exercise, participants were
  conflicted when faced with a choice between
  funding prevention VS inpatient service

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Deliberative forum background information
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Prevention background information
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• BUDGETING FOR HEALTH IN WELLSVILLE
• You are a diverse committee of community
  representatives in the region of Wellsville in
  Victoria. Your job is to advise on the allocation
  of a newly announced health stimulus package.
• Your committee membership includes
• Representatives of the local Health Advisory
  Committee
• Representatives from the medical community
  including doctors, allied health professionals,
  and hospital managers
• A public health expert from the local university
• Community leaders, including a priest, a school
  principal, and a member of the Chamber of
  Commerce
• Two community representatives who responded to an
  advertisement in the local paper.
• Wellsville is a rapidly growing region in
  Victoria. It includes one major regional town
  (with a hospital and a university) and a large
  agricultural community. The region is recognised
  as being innovative in its policies and efficient
  in the ways that policies are implemented. The
  community has an average unemployment rate of
  around 4. The community includes people from a
  great diversity of backgrounds, including a
  rapidly growing migrant population and a
  significant Indigenous community.
• The Health Minister has recently announced a 10
  million health stimulus package for Wellsville.
  The package is designed to meet the regions
  growing health needs. The hospital faces critical
  bed shortages, waiting lists for elective surgery
  are above the state average, and there is a
  significant shortage of health professionals
  (particularly GPs). The health of Wellsville
  residents is on par with people from other
  regional areas of Victoria. Chronic disease is a
  growing and significant issue particularly type
  2 diabetes and cardiovascular disease. Rates of
  obesity and overweight are estimated to be above
  the national average, with 70 of adults and 30
  of children being either overweight or obese (the
  national averages are 60 for adults and 25 for
  children). Because of its rapid growth,
  Wellsville is lacking in community
  infrastructure.
• Your task is to allocate the 10 million
  available for health initiatives in the region.
  The attached list of priorities has been
  developed by your committee. All are needed. You
  need to decide which priorities to fund.

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Wellsville Monopoly spending money
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2. AIHPS-Bupa Australia-funded project

• 2 deliberative forums in August 2009 in
  Parramatta, Sydney
• 2 central topics
• Strategies for maintaining health
• Electronic health records

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Outcomes (1)

• Strategies for maintaining health
• Strong support for a system of community-based
  well-being centres or health clinics
• Support for an increased focus on health checks,
  testing and prevention throughout life
• The need for ongoing and improved education,
  promotion and regulation about healthy choices
  and risk factors
• The importance of initiatives within the
  community and workplaces
• The responsibility of government to regulate and
  educate, but the responsibility of individuals to
  make choices about their own health

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Outcomes (2)

• Managing health records strong support but
  concerns about
• Confidentiality and privacy
• Health professionals use and access
• Use and access by other authorities and
  organisations
• Ability to use the system
• Management and oversight
• Using the system to support prevention

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Reviewing deliberative methods (1)

• Highly effective for identifying the values and
  priorities of citizens about complex health
  policy issues
• Highly enjoyable for participants and the health
  experts involved
• Empowering for participants a great sense that
  their views are taken seriously and will help to
  inform policy
• Participants highly engaged in the content

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Reviewing deliberative methods (2)

• Recruitment of participants is a challenge
  (achieving diversity and recruiting a reasonable
  number of participants)
• Diversity is a challenge need enough diversity
  to hear a range of views, but great diversity in
  a group makes it difficult to go into detail on
  issues
• Recruiting and training facilitators is a
  challenge

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Reviewing deliberative methods (3)

• Organisation and planning involves extensive work
  (particularly developing the activities)
• Timing and program for the forums is tightly
  controlled helps the groups to focus on key
  issues, but may direct the discussion
• Methods are new and not fully appreciated by
  funders and planners. Lack of quantitative
  outcomes can be a challenge for people trained in
  health

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Reviewing deliberative methods (4)

• Impact of the outcomes on policy making not yet
  clear
• Methods have great potential for influence (e.g.,
  DPI in WA)
• Untested so far in health, and AIHPS research not
  yet filtered into the policy environment
• More likely to have impact if conducted in
  collaboration with government and with high-level
  buy-in

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Future AIHPS projects using deliberative
engagement

• 1.Listening to citizens views about chronic
  disease prevention and health promotion (2009)
  (with VicHealth)
• 2.Being healthy. Staying well. What can you do?
  (2009) (with Bupa Australia)
• 3.Preventive Health and the role of the private
  health insurer (2009) (with Australian Unity)
• 4. Citizen engagement Listening to citizens
  views about Australias health system and
  prevention (2009-2011) (ARC Linkage)
• www.aihps.org

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Summary What is required?

• Build a culture of commitment to engagement
  within organisations
• Demonstrate the success of engagement and the
  return on investment
• Build engagement into all aspects of planning and
  policy work, rather than leaving it until the end
• Develop the skills needed to make decisions about
  the best engagement approach for each issue and
  to implement new approaches

AIHPS Consumer project final report page 47
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• Comparative case examples of techniques used in
  other sectors from Australia and overseas
• Move beyond traditional tokenistic approaches and
  use the voice of citizens in other ways where
  it is a joint and informed learning experience
• A whole-of-health emphasis rather than just a
  focus on health services

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Health Reform Learning from experience and
politics

• ..History demonstrates that an organized
  social movement for reform is necessary to
  overcome opposition from special interest
  groups..
• Jonathan Ross, Am J Public Health 99 779-786