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Effective Advocacy in Public Health How Do Victims of Their Own Success Get Action?

Effective Advocacy in Public Health How Do Victims of Their Own Success Get Action?. Terrence Sullivan PhD Cancer Care Ontario. Association of Local Public Health Agencies January 31, 2003. What Are the Current Health Reform Imperatives? Where are the Promising Areas for Public Health?

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Effective Advocacy in Public Health How Do Victims of Their Own Success Get Action?

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  1. Effective Advocacy in Public HealthHow Do Victims of Their Own Success Get Action? Terrence Sullivan PhD Cancer Care Ontario Association of Local Public HealthAgencies January 31, 2003

  2. What Are the Current Health Reform Imperatives? • Where are the Promising Areas for Public Health? • How Does Public Health Make Itself Relevant in Reform Planning • What Can we Do to Raise our Profile?

  3. Provincial Reform Exercises • Alberta - Premier’s Advisory council (Mazankowski) • New Brunswick - Premier’s Advisory Council • Ontario - Health Services Restructuring Commission (Sinclair) • Quebec - Commission d’etude sur les services de sante et les services sociaux (Clair) • Saskatchewan - Commission on Medicare (Fyke)

  4. National Reform Exercises • National Forum on Health • Standing Senate Committee on Social Affairs, Science and Technology (Kirby) - Interim Report (v. 1-5) and Final Report (v. 6) • Commission on the Future of Health Care in Canada Report (Romanow)

  5. Common Themes • System financing • Primary care reform • Regionalization • Pharmaceuticals • Health human resources • IT, performance measurement and quality • Governance and accountability

  6. Promising Reform Imperatives - KIRBY

  7. Promising Reform Imperatives Cont’d

  8. Promising Reform Imperatives • Draft In Confidence and Without Prejudice • January 21, 2003 First Ministers= Accord on Health Care Renewal • Primary Health Care: Ensuring Access to the Appropriate Health Provider When Needed………(part of the health reform funde) • Additional Reform Initiatives. “The federal government is committed to providing funding in support of this work” ...:A Healthy Nation • An effective health system requires a balance between individual responsibility for personal health and our collective responsibility for the health system. Coordinated approaches are necessary to deal with the issue of obesity, promote physical fitness and improve environmental health. Health Ministers are to focus their work on healthy living strategies and other initiatives to reduce disparities in health status. First Ministers further recognize that immunization is a key intervention for disease prevention. They direct Health Ministers to pursue a National Immunization Strategy.

  9. Consensus on…. • Primary care reorganization • Regionalization of service delivery • Population health focus • Evidence-based decision making • Improved information information systems

  10. Controversy over... • Role of private financing and for-profit delivery • Federal-provincial relations and governance issues

  11. How Does Public Health Make Itself Relevant in Reform Planning? Strategy: • Hitch our Wagon to emerging reform areas where consensus exists • chronic disease • healthy living • immunization • Weigh in on Controversial Areas • public private issues • fed/prov • governance • Be Timely and Use Policy Brokers

  12. Finance Allocation Delivery Public Tax Pooling by Provincial Health Ministry/ Health Insurance Plan Provincial or Federal $ to Hospitals vs. Community Care vs. Education and Training Municipal Public Health Services Private Not-for-Profit Charities, Foundations and some Health Research Agencies Regional Health Authorities to Hospitals vs. Home Care vs. Primary Care Public Hospitals Community Health Centre For-Profit Private Insurance Private Group Benefit Managers Managed Care Corporations (in the U.S.) Cosmetic Surgery Clinics Some Home Care Nursing Homes Private Labs Public Private Muddles in Health Care

  13. Figure 1Incidence of Taxation and Public Health Care ConsumptionBy Economic Family Income DecileManitoba 1994

  14. Comparison of mortality between private for-profit and private not-for-profit hospitals and hemodialysis centers: a systematic review and meta-analysis P.J. Devereux et al, Hospitals: CMAJ 2002, 166:1399-1406 HemoDialyisi: JAMA, 2002, 288: 2449-2457

  15. Relative Risk of Hospital Mortality: Adult Patients Favours Favours Private Private For-Profit Not-For-Profit Number of Number of Study % Weight Hospitals Patients ! Shortell 653 144,159 1.43 ! Keeler 220 4,937 0.04 ! Hartz 2,368 3,107,616 11.38 ! Manheim MH 1,252 1,537,660 9.78 ! Manheim FS 1,617 2,228,593 2.59 ! Kuhn 2,580 3,353,676 12.34 ! Pitterle 3,482 4,529,206 14.11 ! Mukamel 1,653 5,298,812 17.21 ! Bond 3,224 4,210,468 12.66 ! Yuan Medical 3,316 7,386,000 11.90 ! Yuan Surgical -- 4,396,000 5.05 ! Lanska 799 16,983 0.00 ! McClellan 2,875 181,369 1.48 ! Sloan 2,360 7,079 0.03 Totals 26,399 36,402,558 100.00 ! Random Effects Pooled Estimate 0.7 0.8 0.9 1 1.1 1.2 1.3 Relative Risk and 95% CI

  16. How important is a relative risk increase of 2% • Canadian statistics for 1999-2000 • 108,333 Canadians died in hospital • If we converted our private not-for-profit hospitals to private for-profit hospitals • this would result in an extra 2200 deaths a year • This increase is in the range of how many patients die in MVAs, from colon cancer, or suicide each year

  17. Relative Risk of Mortality in Hemodialysis Patients All Studies Included in the Systematic Review Favours Private Favours Private For-Profit Not-For-Profit Author RR 95% CI Oldest Data ! Plough 0.71 0.49 - 1.02 Farley 1.11 1.04 - 1.18 ! Garg 1.18 1.02 - 1.37 ! Irvin(1) 1.09 1.07 - 1.12 ! Irvin(2) 1.16 1.09 - 1.23 ! McClellan 1.09 0.83 - 1.44 ! Port 1.06 1.01 - 1.12 ! Irvin(3) 1.05 1.03 - 1.07 ! Newest Data Random Effects Pooled Estimate for All 8 Studies ! RR = 1.09 (95% CI, 1.05 - 1.12) Random Effects Pooled Estimate for 4 Selected Studies ! RR = 1.08 (95% CI, 1.04 - 1.13) 0.4 0.6 0.8 1 1.2 1.4 1.6 Relative Risk and 95% CI

  18. How important is a relative risk increase of 8% • United States statistics for 2001 • 208,000 patients receive in-centre hemodialysis • 75% receive their care in private for-profit facilities • 20% die every year • Therefore likely 2,500 (range 1,200 to 4000) excessive premature deaths annually in US for-profit dialysis centres • Canadian statistics for 1999 • 12,715 hemodialysis patients • 1,966 died • If we converted our private not-for-profit dialysis centres to private for-profit centres we would expect approximately 150 (range 80- 250) excessive premature deaths annually

  19. What Can we Do to Raise our Profile? • Tactics: • Dramatize Threats • Walkerton, North Battleford, • bioterrorism, toxic spills, rise in obesity • Back these up with Data • Celebrate Victories and Champions • Define Common Agenda & Mandate Controversial and Dramatic Action (e.g. more Pete Sarsfields!) • Concerted Action with Province/Feds • Effective Public Affairs Management

  20. The growing burden of cancer in Ontario 1990 - 2020

  21. Survival following diagnosis of all cancer sites combined by region of residence SRR = the ratio of the 5 yr relative survival rate for each region divided by the 5 yr RSR for Ontario as a whole LCL, UCL : lower and upper 95% confidence limits Source : The Ontario Cancer Registry December 2002.

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