41 Open-door policy: a window into creation, implementation, and assessment

Jonathan Thigpen, PharmD

Introduction

The needs of the public necessitate that public health leaders create policies, which are rules or plans of action meant to guide behavior and enact change. Of course, creation is only the first step of a policy’s lifespan. Implementation and assessment of the policy are crucial components as well. These three general stages (creation, implementation, assessment) are critical for a successful policy. Failure in any of these stages will likely result in an unsuccessful policy, resulting in negative health outcomes and wasted money and effort.

Given the challenges presented, policymakers rely on a variety of methods and tools to create well-reasoned, successful policies. The Centers for Disease Control and Prevention (CDC) Policy Process, for example, provides standardized steps for creating a policy and consists of the following five domains:¹

1. Problem Identification: Determine the root cause of a public health problem and write a problem statement. This is the step where you decide you want to go on a policy journey.
2. Policy Analysis: Identify possible policy options and pick the one you think is best. Here, you are considering several destinations and decide between them.
3. Strategy and Policy Development: Plan how to develop, draft, and enact your policy. In this step, you are choosing the route to your destination.
4. Policy Enactment: Follow official procedures to get your policy authorized. This is when you actually depart on your journey.
5. Policy Implementation: Plan for successful policy implementation and achieve the desired outcomes. This is successfully traveling to your destination.

The CDC’s Policy Analytical Framework is a supplemental tool that focuses on domains one (Problem Identification), two (Policy Analysis), and three (Strategy and Policy Development).² The Framework is especially helpful for conducting a “policy analysis,” which according to the CDC, is a step-by-step process “identifying potential policy options that could address your problem and then comparing those options to choose the most effective, efficient, and feasible one.”³

Case

Case Questions

1. Problem Identification: Using the CDC Policy Analytical Framework as a guide, describe the public health problem you are addressing in your policy. (Identify the Problem or Issue – Step 1)

2. Policy Analysis: Develop a policy to address this public health problem. Choose and answer two framing questions and one question from each criterion in “Table 1: Policy Analysis: Key Questions.” (Identify and Describe Policy Options – Step 2a)

3. Policy Analysis: What are two other viable policies (different approach, opposing viewpoint) that could be considered? Describe these “other” policies and answer the same two framing questions and criteria questions from “Table 1: Policy Analysis: Key Questions” that you answered for your policy. (Identify and Describe Policy Options – Step 2a)

4. Policy Analysis: Using the answers you provided in questions two and three, complete the “Table 2: Policy Analysis Table.” Compare the three policies (yours and the two “others”). What are the strengths/weaknesses of each policy? (Assess Policy Options – Step 2b)

5. Policy Analysis: Which policy is best and why? Utilize the “Table 2: Policy Analysis Table” to guide your decision. (Prioritize Policy Options – Step 2c)

Author Commentary

Successful public health policy can be difficult to achieve because public health is extremely complex and multi-faceted. Every public health issue has both individual-level (e.g., health beliefs) and external (e.g., environment) factors that influence it, many of which require massive buy-in, advocacy, and resources to address. Unfortunately, even when policies are built to accommodate complexity and the many determinants of the issue at hand, they may then fail because they alienate stakeholders (e.g., many citizens do not benefit directly while paying for the policy) or become too costly and unwieldy. Decision-makers must remember to include community stakeholders (e.g., those most impacted by the policies) in the decision-making process. Failing to do so will ultimately lead to ineffective policies, distrust, little buy-in, and lack of sustainability.⁴ Even further complicating the task is that policy developers themselves are often to blame for ineffective policies, due to their own biases, lack of creativity and collaboration, and/or poor reasoning.⁵

The CDC policy process and analytic framework are meant to mitigate some of these barriers and provide a sound approach to public health policy. Regardless of practice area, pharmacists are frequently asked to design, implement, and assess policies to increase the health of the public and make better use of resources.⁶

Patient Approaches and Opportunities

Pharmacists play an important role in dictating public health policy because of their unique position in the community and their medication expertise. Pharmacists can lead policy change, both within their immediate community and even at the state and federal levels. Consider, for example, the opioid epidemic. There have been many policies created to mitigate the epidemic that seek to address one of the following four critical areas: restricting opioid supply, improving prescribing practices, reducing opioid demand, and reducing harm.⁷ Pharmacists have been especially involved in a key policy aimed to reduce harm by increasing access to naloxone for opioid overdose. Efforts have been largely successful, and many states have since adopted naloxone access laws and seen their opioid-related deaths decrease by 9-10%.⁸

There are many approaches to public health policy design, implementation, and assessment. A common theme among available methods is to utilize a standardized approach (e.g., often via “steps”). The key to remember during this is that public health issues are complex. So, it would be unwise to tackle these issues in a disorganized way. Do not get frustrated if you feel that your policy is incomplete or small in scope. Rather, and more importantly, focus on the quality of the policy you create and becoming more confident in the process.