Understanding local concepts of equity to formulate public health policies in Burkina Faso

Equity is an essential health promotion concept and must be included at the heart of public health policy making. However, equity, which can also be referred to as social justice, is a polysemic and contextual term which definition must stem from the discourse and values of the society where the policies are implemented. Using a case study from Burkina Faso, we try to show that the non-acknowledgement of the local concept of social justice in the policy making process partly explains the resulting policies' relative failure to achieve social justice. Data collection methods vary (individual and group interviews, concept mapping, participant observation, document analyses) and there are qualitative and quantitative analyses. The four groups of actors who generally participate in the policy making process participated in the data collection. With no intention to generalise the results to the entire country, the results show that mass social mobilisation for justice is egalitarian in type. Health or social inequalities are understood by individuals as facts which we cannot act upon, while the inequalities to access care are qualified as unjust, and it is possible to intervene to reduce them if incentive measures to this effect are taken. We also observed a certain social difficulty to conceive sub-groups of population and fierce will to not destabilise social peace, which can be provoked when looking for justice for the impoverished sectors of the population. This research allows better understanding about the emic aspect of equity and seems to confirm the importance of taking into account local values, especially social justice, when determining public policy.     

Building communities that create health

Typically, public health policy, program design, and resource allocation are based on issue-specific, targeted interventions directed at specific populations or sub-populations. The authors argue that this approach fails to meet the goal of public health-to improve health for all--and that the key to health improvement is to create a social context in which healthy choices are the norm. The authors present as case studies two Pennsylvania cities that used multisectoral approaches to achieve community health improvements.     

Clearing the air and breathing freely: the health politics of air pollution and asthma.

This study examines the growing debate around environmental causes of asthma in the context of federal regulatory disputes, scientific controversy, and environmental justice activism. A multifaceted form of social discovery of the effect of air pollution on asthma has resulted from multipartner and multiorganizational approaches and from intersectoral policy that deals with social inequality and environmental justice. Scientists, activists, health voluntary organizations, and some government agencies and officials have identified various elements of the asthma and air pollution connection. To tackle these issues, they have worked through a variety of collaborations and across different sectors of environmental regulation, public health, health services, housing, transportation, and community development. The authors examine the role of activist groups in discovering the increased rates of asthma and framing it as a social and environmental issue; give an overview of the current knowledge base on air pollution and asthma, and the controversies within science; and situate that science in the regulatory debate, discussing the many challenges to the air quality researchers. They then examine the implications of the scientific and regulatory controversies over linking air pollution to increases in asthma. The article concludes with a discussion of how alliances between activists and scientists lead to new research strategies and innovations.     

The Implications of Fundamental Cause Theory for Priority Setting

Application of fundamental cause theory to Powers and Faden’s model of social justice highlights the ethical superiority of upstream public health interventions.In this article, I assess the ramifications of fundamental cause theory specifically in context of public health priority setting.Ethically optimal public health policy simultaneously maximizes overall population health and compresses health inequalities. The fundamental cause theory is an important framework in helping to identify which categories of public health interventions are most likely to advance these twin goals.In 1995, medical sociologists Bruce Link and Jo Phelan published an article titled “Social Conditions as Fundamental Causes of Disease.”1 Therein, the authors articulated a new theory explaining the criteria for a “fundamental” cause and how socioeconomic conditions qualify. In the interim, the literature on fundamental cause theory (FCT) has steadily grown, with at least 30 articles directly addressing the subject and almost 2000 citations of the original article.Despite the accumulating evidence base, to date, few attempts have been made to analyze the ethical implications of FCT. In this article, I aim to help fill that gap, and specifically argue for the significance of FCT in illuminating critical issues of priority setting and social justice in public health policy.2It is important to note that I do not offer a theoretical ethical analysis of FCT. Rather, my emphasis is on the practical ethical problem of priority setting in public health. Priority setting is an inherently value-laden inquiry, which is one reason why it is a central topic in public health ethics. It follows that, to evaluate public health priorities, some grounding in ethical theory is required even where the objective is to explore some of the practical ethical implications of FCT.     

Using grounded theory to generate a theoretical understanding of the effects of child custody policy on women's health promotion in the context of intimate partner violence

Women's health is frequently influenced by social and structural factors, largely beyond women's control, and often entrenched in public policy. Although health is acknowledged to be socially determined, the ways that social conditions affect health are rarely explicated. Grounded theory is a useful method for discovering how structural conditions influence patterns of behavior. We used grounded theory to generate a theoretical understanding of how justice system policy and services related to child custody influence health promotion processes of women and their children after leaving abusive male partners/fathers. In two diverse Canadian provinces, we interviewed single mothers who had left abusive partners as well as frontline workers and policymakers in the justice system. We identified the key dimensions of policy and services that influence the ways in which women and their children promote their health in the context of varying levels of ongoing intrusion as information, eligibility, accessibility, timeliness, human resources, safety, and diversity. In this article, the interplay between theses policy and service dimensions and women's health promotion after leaving abusive partners is discussed and suggestions are made for strengthening "healthy" custody policy.     

Social justice and social responsibility: towards a value-base for global public health

Public health and social justice have been seen as one and the same thing, in that public health is - of its very nature - socially just. In this paper, the relationship between public health and social justice is explored through reflecting upon the definitions of the two. Work being undertaken in Scotland in relation to prison health shows that public health action can be intended to have a socially just consequence. However it is not always possible to show that social justice was always the intended outcome of a public health action, as economic intentions can often result in similar public health intervention. In seeking to set out a values base for Global Public Health, the reflection allows two overarching values to be proposed: equality and mutuality.     

Water privatization and public health in Latin America.

OBJECTIVES: This study had two objectives: (1) to determine what the public health and development literature has found regarding the public health outcomes of water privatization in Latin America and (2) to evaluate whether the benefits of water privatization, if any, outweigh the equity and justice concerns that privatization raises. METHODS: Using a standard set of terms to search several databases, the authors identified and reviewed articles and other materials from public health and development sources that were published between 1995 and 2005 and that evaluated the public health effects of water privatizations in Latin America from 1989 to 2000, based on (1) access to water by the poor and/or (2) improvements in public health. Next, the authors examined the experiences of three cities in Bolivia (Cochabamba, El Alto, and La Paz) in order to illuminate further the challenges of water privatization. Finally, the authors considered the equity and justice issues raised by the privatization of water. RESULTS: The literature review raised persistent concerns regarding access to water by the poor under privatization. The review also suggested that the public sector could deliver public health outcomes comparable to those of the private sector, as measured by access rates and decreasing child mortality rates. In terms of social equity and justice, privatization marked a troubling shift away from the conception of water as a "social good" and toward the conception of water--and water management services--as commodities. CONCLUSIONS: Our results indicated there is no compelling case for privatizing existing public water utilities based on public health grounds. From the perspective of equity and justice, water privatization may encourage a minimalist conception of social responsibility for public health that may hinder the development of public health capacities in the long run.     

Umweltgerechtigkeit als Thema für Public-Health-Ethik

Environmental justice is a topic at the interface of social, environmental, and health policy. It is concerned with unequal socio-spatial distributions of environmental exposures, the effects of such unequal distributions (e.g., on health), and approaches to their prevention, clean-up or compensation. Environmental justice has some overlap with public health, which is still little recognized. Environmental justice is relevant for the new discussion on public health ethics, as ethical conclusions differ, to some degree, between public health and environmental justice, despite similar topics and often identical effect variables.     

Evaluating the impact on public policy of foundation-sponsored programs in the health professions

The leaders of national philanthropic foundations have long been active in informing public policy makers about their organizations' accomplishments and lessons learned in health care and other issues. The public policy context also is seen increasingly as an important factor influencing changes in the health care market. This article outlines how public policy was monitored and evaluated in a recent initiative in health care by a prominent national foundation. The markers of policy change in the evaluation of this initiative represented a mixture of the initiative's efforts to inform policy makers, the success the participant projects had in making policy makers aware of the initiative's goals, and actual changes in policy outcomes.     

Involving older people in research: methodological issues

The policy imperative to increase public participation in health and social care research, planning and service delivery raises significant questions about optimum approaches, methods and the extent to which this policy can influence change in practice. This paper highlights the key policy literature on user involvement and participatory research methods to establish the context for a partnership research project exploring perceptions of risk in relation to falls from the perspectives of older people, carers, and health and social care professionals. The paper reports the methods used in developing user involvement in the research at a number of levels, including project management, and a consumer panel working alongside the research team and influencing the dissemination in local falls prevention strategies. The authors draw out the issues related to the context and method of involvement, and discuss the impact on research quality and local service development in health and social care.     

Public health ethics

Viewing public health as a political and social undertaking as well as a goal of this activity, the authors develop some key elements in a framework for public health ethics, with particular attention to the formation of public health policies and to decisions by public health officials that are not fully determined by established public policies. They concentrate on ways to approach ethical conflicts about public health interventions. These conflicts arise because, in addition to the value of public health, societies have a wide range of other values that sometimes constrain the selection of means to achieve public health goals. The authors analyze three approaches for resolving these conflicts (absolutist, contextualist, and presumptivist), argue for the superiority of the presumptivist approach, and briefly explicate five conditions for rebutting presumptions in a process of public justification. In a liberal, pluralistic, democratic society, a presumptivist approach that engages the public in the context of a variety of relationships can provide a foundation for public trust, which is essential to public health as a political and social practice as well as to achieving public health goals.     

Improving the contribution of public health to NHS decision making: development of an instrument

Recent policy pronouncements have raised expectations that public health practitioners will be increasingly involved in NHS decision making. This is a complex task which requires the bringing together of appropriate data and values. The authors developed an instrument, to aid decision making, which seeks to make explicit the values held by key health decision makers at local level. We report on the evolution of the project and the development of the instrument. This work is then placed within the context of the current renaissance in British public health, as the instrument could be useful when public health issues are being decided by or with partners within the National Health Service (NHS), the local authorities or the wider community.     

Mass Media, Secular Trends, and the Future of Cardiovascular Disease Health Promotion: An Interpretive Analysis

Mass media roles in promoting cardiovascular health in the context of lessons learned from major U.S. community studies, changing media technology, and emergent models of media-community partnerships are discussed. Three principal issues are explored: (1) implications of the current expansion, convergence, and harmonization of mass media technology;(2) recent trends in media coverage of heart disease and population practices; and (3) implications for the future relationship between the media and public health in cardiovascular health promotion. It is concluded that classic campaign models focusing on individual-level change have evolved to recognize environmental-level influences on behavior. Emergent public health campaign models have moved toward “agenda-building,” in which the focus is on a more unified approach to influencing public and community agendas for social, behavioral, and policy change. Recent developments among the commercial mass media may offer new opportunities for public health partnerships to promote cardiovascular health.     

基于新公共行政理论的政府补偿与监管机制改革评价

目的 以新公共行政理论为指导,分析闵行区公立医疗卫生机构管理者对政府补偿与监管机制改革政策的评价。方法 对闵行区所有公立医疗卫生机构进行问卷调查,并对部分医疗机构管理者进行问卷调查和定性访谈。结果 医疗机构和管理者认为补偿与监管机制改革政策在促进社会公平、提高机构反应性、代表公众利益、机构代表参与以及体现社会责任五个维度均有一定体现。结论 政府补偿与监管机制改革未来需要关注特需医疗服务和基本药物制度的政策导向,以保障公立医疗卫生机构公益性的实现。     

Guidance for considering ethical, legal, and social issues in health technology assessment: application to genetic screening

OBJECTIVES AND METHODS: Many authors have argued that ethical, legal, and social issues ("ELSIs") should be explicitly integrated into health technology assessment (HTA), yet doing so poses challenges. This discussion may be particularly salient for technologies viewed as ethically complex, such as genetic screening. Here we provide a brief overview of contemporary discussions of the issues from the HTA literature. We then describe key existing policy evaluation frameworks in the fields of disease screening and public health genomics. Finally, we map the insights from the HTA literature to the policy evaluation frameworks, with discussion of the implications for HTA in genetic screening. RESULTS AND CONCLUSIONS: A critical discussion in the HTA literature considers the definition of ELSIs in HTA, highlighting the importance of thinking beyond ELSIs as impacts of technology. Existing HTA guidance on integrating ELSIs relates to three broad approaches: literature synthesis, involvement of experts, and consideration of stakeholder values. The thirteen key policy evaluation frameworks relating to disease screening and public health genomics identified a range of ELSIs relevant to genetic screening. Beyond straightforward impacts of screening, these ELSIs require consideration of factors such as the social and political context surrounding policy decisions. The three broad approaches to addressing ELSIs described above are apparent in the screening/genomics literatures. In integrating these findings we suggest that the method chosen for addressing ELSIs in HTA for genetic screening may determine which ELSIs are prioritized; and that an important challenge is the lack of guidance for evaluating such methods.     

Public Health Understandings of Policy and Power: Lessons from INSITE

Drug addiction is a major public health problem, one that is most acutely felt in major cities around the globe. Harm reduction and safe injection sites are an attempt to address this problem and are at the cutting edge of public health policy and practice. One of the most studied safe injection sites is INSITE located in Vancouver, British Columbia. Using INSITE as a case study, this paper argues that knowledge translation offers a limited framework for understanding the development of public health policy. This paper also argues that the experience of INSITE suggests that science and social justice, the meta-ideas that lie at the core of the public health enterprise, are an inadequate basis for a theory of public health policy making. However, on a more positive note, INSITE also shows the value of concepts drawn from the ways in which political science analyzes the policy process.     

The Ottawa Charter at 25

The Ottawa Charter for Health Promotion was created 25 years--a whole generation--ago, and this tribute to the Charter and some of its key authors was given at the CPHA Conference in June 2011. The Charter placed on the agenda for health promotion and public health a set of issues and challenges that we are still a long way from fully addressing. Among the key ideas and values in the Charter are peace, social justice and equity, ecosystem health, empowerment, a 'whole of government' approach and the settings approach. The implementation of these concepts are now challenges for the next generation of health promoters.     

RURAL HEALTH IN QUEENSLAND: A CHANGING FOCUS

ABSTRACT: This paper describes the development of Queensland's rural health policy approach over the past 5 years. The period is marked by significant political, structural and philosophical changes at state and departmental levels. The regionalisation of Queensland's public health services and introduction of strategic management, a commitment to social justice principles and a social view of health, and the acceptance of 'rurality' requiring a special focus have been key factors in the rural health policy arena. Queensland's policy formulation process was also influenced by national developments in the emergence of a national rural health strategy. In addition, the recognition that outcomes for rural communities reflect decisions made by a number of agencies has seen the creation of new and influential rural policy co-ordinating bodies with a total Government focus.     

War on Drugs or War against Health? The pitfalls for public health of Puerto Rican drug policy

Puerto Rico has followed the United States in adopting drug policy sustained on a criminal justice model that limits the opportunities to address problematic drug use through public health interventions. Demand for illegal drugs is controlled by criminalizing drug use and applying jail sentences for drug offenses. These strategies marginalize drug users and reduce opportunities to minimize health risks applying public health measures. Production and sale of illegal drugs is criminalized with the intent of dissuading drug use, with adverse unintended health effects that impact both drug users and non-drug users in the community. The present work reviews the assumptions of the punitive prohibitionist model and its outcomes that present themselves as public health challenges in Puerto Rico. It also presents those principles that should sustain pragmatic drug policy to address problematic drug use from a health and social perspective.     

Poverty,policy, and pathogenesis: Economic justice and public health in the US

This paper addresses public health and access to care for the urban poor in the context of US urban, economic, and industrial policy. The pathogenic deterioration of 'inner city' neighbourhoods is a direct result of political and economic strategies to facilitate capital accumulation and consolidation, manifested in geographic patterns of uneven development that mirror the relationship between First and Third World countries. The deleterious public health effects of these trends include reduced access to care; medical indigence in the wake of deindustrialization and the restructuring of the blue-collar workforce; and the spread of social epidemics such as AIDS, violence, and substance abuse. Contemporary health policy and 'reform' debates, however, have virtually ignored the pathogenic role played by economic and social inequality in the etiology and dispersion patterns of disease. To confront the health crisis that currently threatens poor and minority communities in the US, economic justice must be explicitly acknowledged as a public health issue, alongside more traditional concerns such as access to care, immunization, vector control, and behaviour modification. It will be necessary to challenge political and economic policies that shore up corporate power at the expense of community development; spur capital accumulation at the expense of social programs and economic opportunity for the poor and politically disenfranchised; and actively facilitate the continued exploitation of, and withdrawal of resources from, the nation's most vulnerable citizens and their communities.