Table of contents

Part 3 - Practice: Improving Health

Chapter 14 Decision-making: Policies and Ethics in Health Care and Public Health

The policy cycle

Policy-making is a complex, involved, and continuous process. The history of tobacco illustrates how policies on tobacco production and consumption have changed since its arrival in Europe. It took nearly fifty years from the time Doll and Hill published a study showing the harmful effects of smoking tobacco17 to the passing of effective legislation against it in Canada.

Many policy analysts use the policy cyclepolicy cyclethe process by which an issue moves from its initial inception through to implementation. as a framework to understand the process of how policies come about.18 The policy cyclepolicy cyclethe process by which an issue moves from its initial inception through to implementation. describes how an issue moves from its initial inception through to implementation, evaluation and a new agenda. Table 14.3 summarizes the cycle; note the parallel between the policy cycle and the PDSA cycle of quality improvement.

Table 14.3: Problem solving and the policy cycle. From Howlett and Ramesh 199518

Five stages of the policy cycle and their relationship to applied problem solving

Stages in policy cycle

Phases of applied problem solving

Description and comments

Agenda setting

Problem recognition

How an issue comes to the attention of policy makers. The process is not always rational, and it can often be difficult to see why some issues rise to the top of political agendas while other, seemingly more important issues, remain unaddressed19

Policy formulation

Proposal of solution

Decision-makers (governments, health regions, hospitals, care teams etc.) formulate policy options. Government policy-making usually occurs behind the scenes and is carried out by professional policy analysts19


Choice of solution

How decision-makers decide what to do—or not do—about an issue

Policy implementation

Putting solution into effect

Putting the decisions into effect. Not as simple as it sounds, as it usually entails changing habits and ingrained ways of doing things

Policy evaluation.

Monitoring results

(all too often neglected) Examining implementation and outcomes to check if the policy has been properly implemented and if the desired outcomes were achieved18,20

It is tempting to think of policy-making as an ordered process that moves forward, logically, through each step of the cycle. However, the real world is not so rational. Sometimes policies are formed without consideration of possibly better alternatives or without formulation of the problem. The reality is that the process can begin at any of the steps and does not always move in logical sequence through all the steps. Those who want to change policy must always be on the look-out for opportunities and influences that will help advance their position. Achieving policy change generally requires more tenaciousness, patience and persuasive argument than scientific evidence.

In some cases, although evidence is used to inform the policy-making process, budgets and the feasibility of implementation dictate choices. Even if budgets and implementation are not obstacles to acting according to evidence, the questions asked of the evidence and how the replies are interpreted can result in widely different viewpoints.

Politics of prevention …

Politics of prevention

For the story of petroleum companies opposing the banning of lead in gasoline

visit the University of Ottawa website at:

For the history of Canadian tobacco policy, please visit the National Collaborating Centre for Healthy Public Policy website at:

Industry: a political for…

Industry: a political force

Industry succeeds in selling products long after they are shown to be a probable hazard to health. Here are some of the methods they use:21

1. Public Relations

Express a concern for the health of the users of the product. In 1954, the US tobacco industries produced a statement saying that their top executives accept an interest in people’s health as their basic responsibility. Obviously, people with such an interest would never sell a harmful product.

Stress personal responsibility and the freedom of the individual. Industry claims to provide choice for individuals: "Just because we have electricity doesn’t mean that you have to electrocute yourself." Of course, industry claims, advertising simply informs.

Funding civic activities and demonstrating social responsibility. In 2000, the Philip Morris tobacco company spent $115 million on social causes in the U.S. and a further $150 million to publicize its beneficence. This $265 million was 1.7% of the company’s domestic tobacco revenues.

2. Influence government and key organizations

Election campaign contributions. Some companies contribute funds to all the major parties in order to buy favour with the candidate who wins the election.

Lobbying. Many companies retain the services of lobbyists who plead the company’s cause to those in power.

Revolving door between private organizations and public bodies and government. Industry may hire scientists as advisors in an attempt to colour the interpretation of results of scientific study. Jobs can be promised to members of government.

Funding for "grass roots" groups. Some companies fund pressure groups that masquerade as consumer groups.

3. Create doubt and influence the results of scientific enquiry

Dispute generally accepted scientific results. Harshly criticize studies that find against their interests and discredit the source of the study.

Fund scientific projects to produce good will and influence reporting of results. Studies funded by industry are more likely to report results in favour of the industry than studies not funded by industry.

4. Product marketing

Target youth. Influencing the habits of young people can ensure that products are consumed for a lifetime.

Product placement. The common method is for the hero of a movie or television show to be seen using the product on screen. Other forms would include the presence of fast food, junk food, and soft drinks in schools or hospitals, which are assumed to endorse the products sold on their premises.

Offer "safer" versions of the product. "Light" cigarettes are generally only light when smoked by the machines that measure nicotine and tar content. When humans smoke them, the smoker’s fingers block the ventilation holes. Low fat cereal alternatives often have higher sugar content than the original products.

Create addiction. The tobacco industry has modified nicotine levels to make their products more addictive.

However, industrial interests can also benefit health, the following is an example:

Suncor – a major industry employer in the Fort McMurray area of Alberta, has been extracting petroleum products from the surrounding oil sands since the 1960s. Approximately half of its 12,000 employees are in the Fort McMurray. Within this, largely isolated, environment, health and safety are important to the industry and to the population. To address worker safety, mandatory drug/alcohol screening takes place along with third party transport to work (bus pickup and delivery). Family health is addressed by a well-supported employee and family assistance program.

To improve health and wellness among workers, families and the community, Suncor has sponsored a Community leisure facility for use by all in the city of 100,000. This facility is well used by people of all ages, and encompasses programmes directed towards families.

It is understood that the underlying motives of these actions may be to entice workers and families to stay within the municipality. Besides this intended outcome, the use of the leisure facility also benefits individual and community health. Linkages between communities and industry are possible, and can be beneficial for the worker, family and municipality.

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