(P002) Public Health Policy Making Process - Basic Concepts

It’s a pleasure to be with you. The title of this session is “The Public Health Policy Making Process Basic Concepts.” There are no disclosures for this presentation.

Objectives include: Define policy; Review the 12 sections of a standard policy document; Discuss the 3 steps of the policy sequence; Review the 3 “Perspective Eras” in the United States and their impact on policies; Review the structures of the House and Senate; Review the Congressional policy process; Review the federal budget timeline; Review the structure of the Executive branch; Review the various influences that impact executive policies; and Discuss key advocacy approaches and concepts to influence federal policies.

Let’s begin by considering the definition and some key attributes of policy. Policy is generally adopted by a governance body within an organization. Many organizations develop policies, including local, state, and the federal governments, private businesses like insurance companies, schools, faith-based and other non-profit organizations, etc. For this session, we will focus on government organizations, and particularly the federal government system, since government is a key player in the development of most policies that impact the health and wellness of populations. Policy is a statement of intent, an authoritative decision by a governance body or group that has the power to implement that intent and decision. Policy defines a deliberate system that directs or influences the actions, behaviors, and decisions of others. Policy is implemented through rules, regulations, procedures, and protocols and must be enforced to be effective. This session will deal specifically with the development of public policies that reach beyond the individual to the general population.

It’s important to recognize that public policy problems are not addressed only by government interventions. A good example of that would be the occasional influenza vaccine shortages experienced in the United States. Historical responses included government policies to encourage public research capacities and provide production incentives like tax cuts and subsidies. Other solutions relied on private company policies including decisions to increase investment in private research, development of more efficient vaccine production processes, building new plants to enhance production capacity, etc. These private company policies were adopted to increase company profits but also at the same time played a central role in solving influenza vaccine shortage problems. Government and private policies working in a coordinated way are often necessary to solve complex public health problems.

Let’s briefly discuss policy documents for a few minutes. Policy writers “have the important task of reaching the intended audience with policies that are clear, easily read, and provide the right level of information to the individuals specifically affected by the content.” General considerations for writing a policy document include: Use language that reflects the policy’s intent; Avoid words like “may” and “should” that imply choice versus definitive strong words like “must” or “will”; Use as few words as possible to state a case; Be concise; Avoid redundant language; Ensure that clarifying statements truly clarify and not confuse or alter the policy’s meaning.

The slide lists 12 sections that commonly comprise a policy document. The first two sections include the policy title and a policy number if applicable. The brief description should be an overall summary statement of the policy and not include specific details. The fourth section is approval information and includes: The date the policy or revision takes effect; Who approved the policy; The responsible individual, office, department, agency, etc.; Primary policy contact information including email, address, phone number, etc.; List policies this current policy supersedes if any; State when the policy was last reviewed or updated, as applicable. Section 8 specifies who the policy applies to. Section 9 concisely states the reason for the policy. The information in this section answers the question as to why the policy is needed. Key areas to address may include: Legal or regulatory reasons; A description of conflicts or problems the policy will resolve; and The overall policy benefits. This section should not include the history of how the policy was developed or any procedural steps. The Introduction should include an explanation of the steps that were taken to develop the policy.

The Policy Statement is the most important section of the administrative policy document and should include: Who is the primary audience? Who needs to follow the policy? In what situations does this policy not apply? Are there exclusions or special situations? What are the major conditions or restrictions related to this policy? What is the expected outcome of the policy? Here are a few helpful rules for writing policy statements: Sentences and paragraphs must be clear and understandable for the given audience; Acronyms can be used if spelled out completely the first time the phrase is used; Use strong action words like “will”, “must”, “are responsible for”, etc. The policy statement should not include background details on the policy nor should it contain procedural steps. Section 9 is definitions. Define unfamiliar or technical terms; Define terms with special meanings. Section 10 provides additional policy-related information including: Related Policies, Procedures, Forms, Guidelines, and Other Resources. This section provides information that supports the policy. Procedures should be listed in the order in which they are carried out. If there is no particular order, procedures should be listed alphabetically. No matter how well policies are written, there will always be questions; therefore, a subsection of frequently asked questions and their respective answers should be included in a policy document. The 11th section is history, providing readers with a record of significant policy-related changes by date. The last section is a list of key words that aid search functions.

In the United States, policies have been key to the shaping of individual healthcare and public health improvements. The Constitution of the United States does not generally give the national legislative or executive branches the power to protect the public’s health. The responsibility of protecting the public’s health is primarily assigned to states. For example, the President or Congress cannot require states to create emergency preparedness plans, but Congress can provide financial incentives, through federal grants, by offering money in exchange for states developing emergency preparedness plans that meet federal guidelines. There are exceptions to this generalization. For example, in 2020, the executive branch of the federal government, by executive order, limited travel from countries challenged by CoVid-19 coronavirus infections to attempt to control the spread of this virus to the United States.

There are generally three effective policy sequence steps. The first step is adoption of the policy by the governing body’s legislative process. The governing body commonly determines who will be assigned to develop the appropriate rules, regulations, and policy enforcement. The second step is the development of appropriate rules and regulations by the assigned agencies or departments. The third step is determining how the policies, rules, and regulations will be enforced. Enforcement commonly includes the definition and application of penalties and may, depending on the policy, include law enforcement agencies and the court system. Enforcement penalties may be defined by governing legislation or determined during the development of rules and regulations. For example, a governing body may pass legislation to improve school immunization rates. The governing body may assign the state departments of health and public instruction to develop rules, regulations, and enforcement actions including penalties for non-compliance to implement this policy across the state. Ultimately, effective health policies result in improvements in the health of the public. In this example, improved school immunization rates should result in reductions in vaccine-preventable diseases and complications in school-aged children. Enforcement of policies is essential. Great policies are impotent if not enforced.

Choices made by policymakers and legal decisions handed down through the courts impact all aspects of the health system including how healthcare is accessed, how medicine is practiced, how medical care and medicines are paid for, etc. Policymakers are often tasked and expected to find the appropriate balance between rules, regulations, and legal powers and the ability of private individuals and corporations to exercise rights that allow them to thrive, free of overly intrusive government interventions. This search for the appropriate balance often results in significant tension, discussion, and activism around why and how government should or should not regulate private individuals and corporations in the name of protecting the health, safety, and welfare of the public. That balance is defined generally by states through two types of policy legislation also known as police powers and include: 1. Policies that define the functions and powers of public health agencies and 2. Policies that directly protect and promote public health.

Developing good health policies requires an adequate understanding of complex issues associated with health and wellness. Public health often conducts research and provides information and reports to policymakers to help inform their decisions on these complex issues. That research is essential for good policy development since the drivers of healthy behaviors are complicated, influenced by all the social determinants of health and include such things as economic stability, social and community context, the environment, multiple healthcare-associated factors, education, emotional and spiritual issues, etc.

Health policy and law in the United States has been influenced by three sequential eras including: 1. The professional autonomy; 2. The social contract; and 3. The free market perspective eras. The professional autonomy era lasted from approximately 1880 to 1960. During this era, policy and lawmakers allowed physicians to control the delivery of healthcare including: payments, clinical licensure, defining standards of treatment, the type and amount of information provided to patients, the determination of medical negligence, etc. The social contract era was from approximately 1960 to 1980. This era was associated with the belief that the healthcare system controlled by physicians was detrimental to patient care and healthcare financing and that healthcare policy and law can and should enforce a “social contract”, by engaging several stakeholders including not only physicians, but also patients, society in general, employers, etc. This social contract era significantly reduced physician domination of healthcare policy and law. The free-market era started in approximately 1990 and continues to the present. This era supports the concept that the healthcare system will operate more efficiently in a deregulated environment that encourages commercial competition and consumer empowerment. There will likely be other perspective eras in the future as approaches to healthcare and wellness policy and law evolve.

The quote on this slide adequately captures the importance of policy and law for public health. “Policy and legal considerations are not only relevant in the context of major health care and public health problems going forward, they are critical to the daily functioning of the health system, and to the health and safety of individuals and communities across the range of everyday life events.”

Let’s now consider the federal policy-making process. Article 1 of the Constitution states that Congress is the national law-making body and is granted “All legislative powers” and the right to enact “necessary and proper laws.” In the United States, there are two chambers of Congress: the Senate and the House of Representatives, known simply as the House. Both the Senate and the House develop legislation to levy taxes, collect revenue, pay debts, provide for the general welfare, regulate interstate and foreign commerce, establish lower federal courts, and declare war. The Senate, in addition to the above, ratifies treaties and confirms public officials nominated by the president.

The Senate has 100 members, two from each state. Senators are elected for 6-year terms, and must be at least 30 years old, have been a US citizen for at least 9 years, and be a resident of the state they represent. The House of Representatives has 435 members. They are elected from congressional districts defined by population; therefore, more populous states have more representatives. Each congressional district represents approximately 710,000 people. For example, in 2020, North Dakota has one representative where California currently has 53. House members have 2-year terms. Two-year terms often translate into members focusing more on short-term issues that will impact their re-election. Representatives are commonly in a perpetual campaign mode. Representatives must be at least 25 years old, a US citizen for at least 7 years, and a resident of the state they represent. Due to the six-year terms of Senators versus two-year terms of members of the House, Senators are generally more concerned with longer-term policy issues than members of the House. This is important to consider when developing policy advocacy strategies.

The Vice President presides over the Senate. In the Vice-President’s absence, the President Pro Tempore presides, though this is generally a ceremonial position. The Vice-president can vote to break a tie. The Senate has majority and minority leaders and majority and minority whips who are selected by their respective parties. The majority and minority leaders speak on behalf of their party. The majority leader assigns bills to committees and schedules Senate floor action of bills. Both the majority and minority leaders work on committees, direct strategies, and seek to keep their respective parties unified. The majority leader may block bills by not scheduling them for consideration by the Senate. The minority leader is not able to schedule floor action and bills since that is the role of the majority leader only. The majority and minority whips track legislation, mobilize support for leadership positions, keep track of how members will vote, and assist the majority and minority leaders in accomplishing their party’s strategy.

The Speaker of the House presides over the House of Representatives. The Speaker of the House is elected by House members by a simple majority vote. This generally means that the Speaker will be a member of the majority party. After a candidate is elected, they are sworn in by the Dean of the House, who is the longest-serving member of that body. The Speaker assumes the position of President of the United States in the absence of a President and Vice-President. The Speaker’s duties include: prioritizing and scheduling bills, assigning bills to committees, naming members of joint and conference committees, etc. As with the Senate majority leader, the Speaker of the House can block bills by not scheduling them. The House also has majority and minority leaders and majority and minority whips selected by their respective parties. The House majority leader does not preside over the House since that is the job of the Speaker. The House majority leader works with the Speaker to coordinate party strategies and the legislative schedule. The House minority leader and majority and minority whips function like those in the Senate.

Let’s now consider Senate and House committees for a few minutes. Committees are considered the “workhorses” of Congress. This is where key decisions on bills are made. Committee activities include: Hold hearings; Coordinate with other branches and constituent groups including the president, the administration, and various lobbyists; They draft legislation and amendments; Educate Congressional members on bill details; Introduce and discuss committee bills on the floor; Influence House members for support; Provide oversight of the executive branch, etc. Committee work provides an excellent opportunity for policy advocacy work and influence. Standing Committees in the Senate and House are generally permanent committees. There are currently 20 standing committees in the House and 21 in the Senate. Some key functions of committees include authorization and appropriations functions. Authorization means that the committee may create or authorize programs or agencies. Appropriation provides the committee with authority to approve funding. As expected, the most powerful and popular committees are those with appropriating authority. Policies must be appropriately funded to be effective. This slide provides a list of key appropriating committees in the Senate and House. These are important committees to engage in advocacy efforts.

The House Ways and Means and Senate Finance Committees have jurisdiction over legislation concerning taxes, tariffs, other revenue-generating legislation, entitlement programs like Medicare and Social Security, etc. The Constitution requires that all taxation and appropriations bills must originate in the House. House rules require that all tax bills must first be addressed by the House Ways and Means Committee. House and Senate Appropriations Committees have responsibility for drafting federal spending bills. The House and Senate Budget Committees are tasked with creating an overall budget plan that guides tax and appropriation’s work. The House Rules Committee develops rules for floor debates, amendments, and voting procedures for all House bills. All House bills must be addressed by the Rules Committee before reaching the floor for debate and a vote. This slide lists key Senate health committees including: Finance; Appropriations; Health, education, labor, and pensions; and The committee on agriculture, nutrition, and forestry. As you can see, these committees and subcommittees are responsible for addressing legislative policies for key departments and their functions impacting public health and healthcare in the United States including: The Department of Health and Human Services; The Department of Treasury; The Food and Drug Administration; and The Department of Agriculture. The Departments cover such programs as Medicare and Medicaid, the Public Health Service, the National Institutes of Health, the Centers for Disease Control and Prevention, Social Security, the Indian Health Service, several food and nutrition support programs, and many more. This slide lists key House committees including: Ways and Means; Appropriations; and Energy and Commerce, their subcommittees and functions that address public health and healthcare policies. These last two slides are not exhaustive but are meant to demonstrate where many, if not most, Senate and House public health and healthcare policy discussions and planning take place. A main point is that Senate and House committees and subcommittees like these, their leaders, and members are essential points of engagement for public health and healthcare policy advocacy work.

Committees help Congress address complex issues. To do that, Committee members need assistance to understand these complex issues and make well-informed decisions. That Congressional assistance is provided in several ways. The Congressional Budget Office that provides: Cost estimates of bills; Estimates of how federal mandates will impact states and local governments; and Provide forecast data and trends. The Government Accountability Office is an independent, non-partisan agency that advises Congress and the executive branch on efficient and effective ways to use federal resources. The Congressional Research Service conducts non-partisan research on legislative issues. The Medicare Payment Advisory Commission is an independent office that advises Congress on Medicare issues. Another essential source of assistance and influence for Senate and House members, committees, and subcommittees is the work of staff members. Staff members are tasked with gathering and analyzing data, compiling reports and summaries, and briefing members on these complex issues and potential legislative solutions. With that reality in mind, it is a wise advocacy strategy to plan for regularly engaging with the Senate and House member’s office, committee, and subcommittee staffs. These staff members have significant influence on the public health and healthcare policy decisions of committees and subcommittees.

This slide outlines the national legislative process for bills in the United States. All bills must be introduced by a Congressional member of the House or Senate. The bill is then read in the respective chamber and assigned to one or more committees. Bills are assigned for committee work by the majority leader in the Senate and the Speaker in the House. Rarely, procedures may be invoked that allow bills to be presented directly to the floor without committee passage. The bills are then debated in the assigned committees. Committee members may hold hearings, “mark up” bills by changing or deleting language and add amendments. If there is insufficient support for the bills, they may die during the committee process. If a majority of the committee members approve of a bill, it then goes to the full chamber for debate. If a majority of a chamber approves a bill, it is then sent to the other chamber for consideration. The other chamber may pass the exact bill or a different version of it. If the other chamber does not pass any version of this bill, it dies on the chamber floor. If there are differences in bills passed by the House and Senate, these bills are then referred to a conference committee to hopefully find a mutually acceptable resolution for the differences, a consensus. The conference committee is composed of members from both the Senate and the House. If no consensus is reached, the bill dies in the conference committee. If a consensus is reached, the new version of the bill is sent back to both chambers for a vote. If either chamber does not approve of the new version of the bill, it dies. If both the House and Senate pass the new version of the bill, it is sent to the President for consideration. At this point, four things can happen to the bill: 1. The President may sign the bill into law; 2. The President may veto the bill. A Presidential veto can be overridden by a 2/3 vote by both the House and Senate; 3. If the President fails to sign a bill within 10 days of receiving it, when the House and Senate are in session, it automatically becomes law; 4. If the President fails to sign a bill within 10 days of receiving it, when the House and Senate are not in session, it does not become law without his or her signature.

The federal budget process is complex and intimately linked with the appropriations process. This process is a key tool for the President and Congress to express their policy agendas through the funding mechanism. Budget and appropriations documents include narratives along with charts and graphs that explain why programs are being funded and what the government hopes to achieve through those programs. These budget and appropriations documents along with their narratives provide valuable information to guide policy advocacy strategies. The Congressional Budget and Impoundment Act of 1974 along with other subsequent amendments to that Act defines a process that requires coordination and collaboration of several Congressional committees in crafting an overall budget plan. The federal budget includes two types of spending: discretionary and mandatory. Discretionary spending is funding that must be appropriated annually in order to continue. Mandatory spending is funding that must be appropriated as a matter of law. Examples of mandatory spending would include entitlement programs like Medicaid, Medicare, and Social Security. Congress must provide adequate funding to meet these entitlement obligations as defined in their authorizing legislation. This slide lists the federal budget timeline for the congressional appropriations and budget process. Even though there are opportunities to advocate throughout the whole appropriations and budget process, influence in the earlier stages may have the greatest impact.

Congressional members are influenced by many constituents including: The voters who elected them; Their party’s positions on issues; and The views of the President are particularly important if they are popular and of the same party. Presidents are often adept fundraisers and can significantly help member’s campaigns who support them and their policies. The voters who elect members generally have the greatest influence. Congressional members often prioritize their home constituents, which often improves their approval ratings. High approval ratings deter challengers. The President is required to submit a budget proposal to Congress by the first week of February. This is a request and not binding on Congress. In March and April, the House and Senate budget committees craft a budget plan during public meetings called “mark-ups”. When “mark-ups” are completed, budget committees send a budget resolution to their respective chambers. Each chamber then debates and passes a budget resolution defining how their chamber would spend federal funds in various categories, like defense, agriculture, transportation, public health, education, etc. The budget resolution contains budget totals, spending breakdowns, reconciliation instructions, budget enforcement mechanisms, and budget policy statements. Members representing each chamber then meet via a conference committee and develop a conference report that reflects a consensus or compromise between the House and Senate on an overall budget resolution. By mid-April, the House and Senate develop and pass a concurrent budget resolution. This concurrent resolution is binding on the House and Senate, providing a blueprint for revenue collection and spending. This resolution is not yet law and therefore the President is not bound by its parameters. The House and Senate budget and appropriation’s committees hold hearings. Other committees also review the budget as it relates to their committee’s jurisdiction and provide the budget and appropriation’s committees with their “views and estimates” for appropriate spending for the coming fiscal year. The Congressional Budget Office and other committee assistance offices provide the budget and appropriation’s committees with reports, analyzing the president’s budget request and providing other relevant budget information including economic forecasts. In May, the appropriation’s committees write bills based on funding and reconciliation instructions included in the concurrent resolution. The appropriations committees make decisions on bill content regarding discretionary funding and changes in laws that will impact mandatory spending to meet budgetary goals as outlined in the concurrent resolution. Appropriation’s committees develop reconciliation language as necessary. The House and Senate develop a conference committee report on reconciliation. This reconciliation report results in reconciliation legislation if deemed necessary. By June 15th, conference committee reconciliation legislation is debated and passed by the Senate and House and submitted to the President for his or her signature. The President must sign reconciliation bills to become law. By September 30th, both the House and Senate appropriation’s bills have passed their respective chambers, differences resolved via conference committee work, final drafts debated and passed and sent to the President for his or her signature. The fiscal year starts October 1st. If appropriations bills are not passed and signed by the President by October 1st, Congress may pass a continuing resolution that allows the government to continue to spend money. If Congress does not pass a continuing resolution or if the president vetoes it, a government shutdown occurs, where all non-essential activities of federal agencies stop until appropriate funding is approved.

Let’s now spend a few minutes discussing the executive branch of the federal government. Article 2 of the US Constitution establishes the executive branch of the federal government and grants the head of the executive branch, the President, executive powers. The President and his or her Vice President are the only nationally elected public officials and can serve a maximum of two 4-year terms, which may or may not be consecutive. The President must be at least 35 years old, a natural-born citizen of the United States, and a resident of the country for at least 14 years. To effectively run the executive branch, the President relies on Executive Office agencies and staff including: The White House staff and the White House chief of staff; The National Security Council; The Office of Management and Budget; The Council of Economic Advisors; The Council on Environmental Quality; The Office of the US Trade Representative; The Office of National Drug Control Policy; and The Office of Science and Technology Policy. The directors of these executive office agencies are appointed by the President and do require Senate approval. The exception is the White House staff and Chief of Staff.

Of staff who are appointed directly by the President and do not require Senate confirmation.

In addition to the Executive Office agencies and staff, the President also has 15 cabinet departments whose directors are appointed by the President and require confirmation by the Senate, including: The attorney general, The secretaries of agriculture, commerce, defense, education, energy, health and human services, homeland security, housing and urban development, labor, state, the interior, treasury, transportation, and veterans affairs.

Presidential roles include: Chief of State, representing the country and values of citizens of the United States on the world stage; Chief Executive Officer, managing the executive branch and cabinet agencies; Commander in Chief of the Armed Forces—the top-ranking military official in the nation.

Key powers of the President include: The ability to appoint federal judges, to sign treaties with foreign nations, and to appoint ambassadors as United States liaisons with other nations. These powers are subject to oversight, advice, and consent of the US Senate.

This slide lists some key ways the President can influence policy in the United States. The President can set the nation’s agenda by using the visibility and importance of the office to capture media attention and present messages and issues to the public. The President, from a Bully Pulpit, is often able to influence public support, forcing resistant politicians to support his or her agenda. Davidson said, “Framing agendas is what the Presidency is all about.” Having said that, agendas are often driven by events, not politicians. External events, like the 2019 coronavirus situation, often drive national and international concerns, attention, and agendas, forcing political systems and politicians, like the President, to prioritize and address those situations.

With policies that are generally controversial or where there are significant divisions and policy disagreements among the President’s party, the President may decide to promote those policies behind the scenes, out of the public’s eye, often carefully but forcefully informing Congressional members of his or her policy preferences. Presidents may be able to influence policy outcomes by using a combination of promises and threats with key Congressional members. Presidents can also exercise presidential powers including the power of vetoing legislation and using executive orders. Vetoing legislation essentially rejects a bill. The president may also influence legislation by just threatening to veto it. Threatening a veto is particularly valuable in situations where legislation is expected to pass with a slim majority since it would take a 2/3 majority vote to override a presidential veto. Since George Washington, only 3% of legislation has been vetoed by a president.

Presidents also have the power to issue executive orders. Executive orders are legally binding for administrative agencies under control of the Executive Office. Executive orders direct those agencies on how they are to implement laws. If Congress believes an executive order is inappropriate, they have two avenues of action: amend the law or challenge it in court. If the law is amended, the President can veto that legislation, and Congress would need a 2/3 majority vote to override that veto. If Congress challenged it in court, they would argue that the President’s actions exceeded his or her constitutional powers.

A President’s policies are influenced by constituents and legacy. Presidents have several constituents to consider. A major constituency is the general electorate or country as a whole, including voters who voted for and against the President. Presidents, along with vice presidents, are the only nationally elected positions; therefore, the President is constantly seeking ways to increase personal and party support, particularly important when seeking a second term in office. The President represents a political party and must consider the views and platform of that party when developing a policy agenda. The influence of and impact of policies on foreign governments and international relationships must be considered. The President must also consider the policy agendas of the majority party and leadership in the Senate and House. This is particularly challenging when the leadership party is not that of the President’s, often requiring delicate negotiations and compromise. How the media interprets and portrays policy issues is a major influence on policy. Lobbying and influence from focal interest groups is important, and specifically applies to large, nationally influential organizations like American Medical Association, the National Rifle Association, American Public Health Association, Oil and Gas organizations, Environmental groups, etc.

Another important influence on Presidential policies is the President’s desire to leave a positive legacy when leaving office. Historical legacy is often associated with the implementation of significant, bold, and unique policies. “Second term Presidents may be more willing to support more controversial goals (or policies) because they cannot run for re-election.” So, there may be more executive advocacy opportunities for bold policies during a President’s second term.

Accessing Presidents for advocacy work is not easy due to layers of security and administrative insulation from the general public. A practical policy advocacy strategy to influence the Chief Executive of the United States is to engage and influence as many Presidential influencer channels as possible, including: cabinet leadership, executive office agencies and White House staff, constituents, and the President’s legacy. This approach is not easy and requires strategic leadership, advocacy, cross-cultural communications, engagement, coalition and team-building skills, and a ton of patience to develop relationship strength and trust with those who have the attention and ear of the President to influence executive policy decisions.

Let’s now consider the state policy-making process. There is significant variation in how states structure their legislative, executive branches, agencies, and offices and how that influences policy development. For policy advocacy groups, it’s extremely important to understand the details of the state government structure and policy-making process within states to be effective. All states, like the federal government, have three branches of government: executive, legislative, and judiciary. Governors are the head of the executive branch and have, as defined by their executive powers, the authority to establish policies, appoint cabinet members, and, through state administrative agencies, develop and implement regulations and state laws, which are extremely important aspects of health policy. Unlike the federal government, most states require a balanced budget, meaning they can’t borrow money to cover operating deficits. This requirement to have a balanced budget often results in state officials having to make difficult choices that limit health and healthcare policies.

Let’s discuss advocacy for a few minutes. The definition of advocacy is to actively promote a cause or principle involving actions that will lead to a goal. So, why should public health advocate for anything? Avner lists several reasons for advocacy, including: People working together make a difference in changing laws and policies; advocacy is a democratic tradition; advocacy helps societies find real solutions; policy makers need the input of advocates to make good policy decisions; advocacy gives organizations and the public a voice.

This slide lists some key attributes of advocacy. As in the previous definition, advocacy actively promotes a cause or principle. It involves actions that lead to a goal. Policy advocacy is one strategy to help reach health and wellness goals. Advocacy groups are generally organized to address focused issues and have a limited but significant role in influencing the decisions of policy-makers. Advocacy groups “Make the case for their constituents before government, plying the halls of Congress, the executive branch, the courts, and the offices of other interest groups to provide a linkage between citizens and government.”

This slide lists a few key advocacy concepts. Seek to influence policy throughout the policy-making continuum; a multi-channel approach is usually more effective than just focusing on one area of that continuum; complete research to support policy recommendations. This may require collaborating with academic centers or other partners that have research skills and access to relevant data sources. Gain and maintain access to decision makers. This underlines the importance of spending adequate time to develop relationships and trust. Strong relationships and trust provide a solid base to weather the inevitable conflict associated with challenging and contentious policy issues. Develop persuasive arguments that are designed specifically to resonate with the intended recipients. To do this, advocates must fully understand the culture, perceived needs, and expectations of those recipients. Develop a detailed advocacy strategic plan that includes: Grassroots campaigns that encourage interested individuals from the general public to contact key political leaders and influencers; grass-tops strategies that seek to engage various leaders of communities, other organizations, etc. to advocate for policies; organize coalitions since numbers speak to leaders; develop media strategies that effectively transfer not just messages but appropriate meanings to target audiences. Advocacy strategies may also include providing funding for political candidates who are supportive of desired policies.

I would like to close this session with this statement: In democracies, advocate groups are an indispensable part of the policy-making process, providing a voice for the public.

In summary: It’s important to understand governmental structures and processes that impact policy development. Advocate throughout the continuum of governmental policy development. Employ key advocacy concepts to positively impact policy outcomes.