An empirical examination of risk equalisation in a regulated community rated health insurance market

Despite universal access entitlements to the public healthcare system in Ireland, over half the population is covered by voluntary private health insurance. The market operates on the basis of community rating, open enrolment and lifetime cover. A set of minimum benefits also exists, and two risk equalisation schemes have been put in place but neither was implemented. These schemes have proved highly controversial. To date, the debate has primarily consisted of qualitative arguments. This study adds a quantitative element by analysing a number of pertinent issues. A model of a community rated insurance market is developed, which shows that community rating can only be maintained in a competitive market if all insurers in the market have the same risk profile as the market overall. This has relevance to the Irish market in the aftermath of a Supreme Court decision to set aside risk equalisation. Two reasons why insurers’ risk profiles might differ are adverse selection and risk selection. Evidence is found of the existence of both forms of selection in the Irish market. A move from single rate community rating to lifetime community rating in Australia had significant consequences for take-up rates and the age profile of the insured population. A similar move has been proposed in Ireland. It is found that, although this might improve the stability of community rating in the short term, it would not negate the need for risk equalisation. If community rating were to collapse then risk rating might result. A comparison of the Irish, Australian and UK health insurance markets suggests that community rating encourages higher take-up among older consumers than risk rating. Analysis of Irish hospital discharge figures suggests that this yields significant savings for the Irish public healthcare system. This thesis has implications for government policy towards private health insurance in Ireland.

REDUCING DIESEL DEPENDENCE IN NUNAVUT: INTEGRATING RENEWABLE ENERGY TECHNOLOGIES THROUGH POLICY ACTIONS

In the last fifty years, Nunavut has developed a deep dependence on diesel for virtually all of its energy needs, including electricity. This dependence has created a number of economic, environmental and health related challenges in the territory, with an estimated 20% of the territory’s annual budget being spent on energy, thereby limiting the Government of Nunavut’s ability to address other essential infrastructure and societal needs, such as education, nutrition and health care and housing. One solution to address this diesel dependency is the use of renewable energy technologies (RETs), such as wind, solar and hydropower. As such, this thesis explores energy alternatives in Nunavut, and through RETScreen renewable energy simulations, found that solar power and wind power are technically viable options for Nunavut communities and a potentially successful means to offset diesel-generated electricity in Nunavut. However, through this analysis it was also discovered that accurate data or renewable resources are often unavailable for most Nunavut communities. Moreover, through qualitative open-ended interviews, the perspectives of Nunavut residents with regards to developing RETs in Nunavut were explored, and it was found that respondents generally supported the use of renewable energy in their communities, while acknowledging that there still remains a knowledge gap among residents regarding renewable energy, stemming from a lack of communication between the communities, government and the utility company. In addition, the perceived challenges, opportunities and gaps that exist with regards to renewable energy policy and program development were discussed with government policy-makers through further interviews, and it was discovered that often government departments work largely independently of each other rather than collaboratively, creating gaps and oversights in renewable energy policy in Nunavut. Combined, the results of this thesis were used to develop a number of recommended policy actions that could be undertaken by the territorial and federal government to support a shift towards renewable energy in order to develop a sustainable and self-sufficient energy plan in Nunavut. They include: gathering accurate renewable resource data in Nunavut; increasing community consultations on the subject of renewable energy; building strong partnerships with universities, colleges and industry; developing a knowledge sharing network; and finally increasing accessibility to renewable energy programs and policies in Nunavut.

The role of operations management in public sector policy and practice alignment: a local government analysis

In responding to the demand for change and improvement, local government has applied a plethora of operations management-based methods, tools and techniques. This article explores how these methods, specifically in the form of performance management models, are used to improve alignment between central government policy and local government practice, an area which has thus far been neglected in the literature. Using multiple case studies from Environmental Waste Management Services, this research reports that models derived in the private sector are often directly ‘implanted’ into the public sector. This has challenged the efficacy of all performance management models. However, those organisations which used models most effectively did so by embedding (contextualisation) and extending (reconceptualisation) them beyond their original scope. Moreover, success with these models created a cumulative effect whereby other operations management approaches were probed, adapted and used.

Improving allied health professionals' research implementation behaviours for children with cerebral palsy: protocol for a before-after study

BACKGROUND: Cerebral palsy is a permanent disorder of posture and movement caused by disturbances in the developing brain. It affects approximately 1 in every 500 children in developed countries and is the most common form of childhood physical disability. People with cerebral palsy may also have problems with speech, vision and hearing, intellectual difficulties and epilepsy. Health and therapy services are frequently required throughout life, and this care should be effective and evidence informed; however, accessing and adopting new research findings into day-to-day clinical practice is often delayed.

METHODS/DESIGN: This 3-year study employs a before and after design to evaluate if a multi-strategy intervention can improve research implementation among allied health professionals (AHPs) who work with children and young people with cerebral palsy and to establish if children's health outcomes can be improved by routine clinical assessment. The intervention comprises (1) knowledge brokering with AHPs, (2) access to an online research evidence library, (3) provision of negotiated evidence-based training and education, and (4) routine use of evidence-based measures with children and young people aged 3-18 years with cerebral palsy. The study is being implemented in four organisations, with a fifth organisation acting as a comparison site, across four Australian states. Effectiveness will be assessed using questionnaires completed by AHPs at baseline, 6, 12 and 24 months, and by monitoring the extent of use of evidence-based measures. Children's health outcomes will be evaluated by longitudinal analyses.

DISCUSSION: Government, policy makers and service providers all seek evidence-based information to support decision-making about how to distribute scarce resources, and families are seeking information to support intervention choices. This study will provide knowledge about what constitutes an efficient, evidence-informed service and which allied health interventions are implemented for children with cerebral palsy.

TRIAL REGISTRATION: Trial is not a controlled healthcare intervention and is not registered.

Active2010 and the Ontario School System: A Top-Down Policy Implementation Analysis

In 2004, the Ontario Ministry of Health Promotion and Sport (MHPS) established Active2010: Ontario’s Sport and Physical Activity Strategy. Active2010 demonstrates a strong provincial government policy emphasis regarding sport participation and physical activity (PA), and identifies the school system as a primary vehicle for enhancing PA levels. This study examines the sport and PA initiatives MHPS is undertaking within the school system. Theoretical context regarding neo-liberalism in Canada and Canadian sport frames this study, while a revised version of Van Meter and Van Horn’s (1975) top-down model of policy implementation guides the research process. A case study of the school-based PA system is conducted which relies on the analysis of 11 semi-structured interviews and 47 official organizational documents. Four emergent categories of Jurisdictional Funding, Coercive Policy, Sector Silos, and Community Champions are identified. Additional insight is provided regarding neo-liberalism, provincial level government, interministerial collaboration, and government/non-profit sector partnership.

Assessment of the impact of government animal welfare policy on farm animal welfare in the UK

The paper presents the method and findings of a Delphi expert survey to assess the impact of UK government farm animal welfare policy, form assurance schemes and major food retailer specifications on the welfare of animals on forms. Two case-study livestock production systems are considered, dairy and cage egg production. The method identifies how well the various standards perform in terms of their effects on a number of key farm animal welfare variables, and provides estimates of the impact of the three types of standard on the welfare of animals on forms, taking account of producer compliance. The study highlights that there remains considerable scope for government policy, together with form assurance schemes, to improve the welfare of form animals by introducing standards that address key factors affecting animal welfare and by increasing compliance of livestock producers. There is a need for more comprehensive, regular and random surveys of on-farm welfare to monitor compliance with welfare standards (legislation and welfare codes) and the welfare of farm animals over time, and a need to collect farm data on the costs of compliance with standards.

What next for children's services? Can policy at a local or national level have any significant impact on the outcomes for children and their families?

In England at both strategic and operational levels, policy-makers in the public sector have undertaken considerable work on implementing the findings of the Every Child Matters report and subsequently through the Children's Act 2004. Legislation has resulted in many local authorities seeking to implement more holistic approaches to the delivery of children's services. At a strategic level this is demonstrated by the creation of integrated directorate structures providing for a range of services, from education to children's social care. Such services were generally under the management of the Director of Children's Services, holding statutory responsibilities for the delivery of services formally divided into the three sectors of education, health and social services. At a national level, more fundamental policy developments have sought to establish a framework through which policy-makers can address the underlying causes of deprivation, vulnerability and inequality. The Child Poverty Act, 2010, which gained Royal Assent in 2010, provides for a clear intention to reduce the number of children in poverty, acknowledging that ‘the best way to eradicate child poverty is to address the causes of poverty, rather than only treat the symptoms’. However, whilst the policy objectives of both pieces of legislation hold positive aspirations for children and young people, a change of policy direction through a change of government in May 2010 seems to be in direct contrast to the intended focus of these aims. This paper explores the impact of new government policy on the future direction of children's services both at the national and local levels. At the national level, we question the ability of the government to deliver the aspirations of the Child Poverty Act, 2010, given the broad range of influences and factors that can determine the circumstances in which a child may experience poverty. We argue that poverty is not simply an issue of the pressure of financial deprivation, but that economic recession and cuts in government spending will further increase the number of children living in poverty.

From policy to practice: the development of an integrated health promotion plan for children's services at Plenty Valley Community Health Inc.

Current changes in the funding of health promotion in community health in Victoria require community health agencies to integrate health promotion with service delivery. This provides both opportunities and challenges for community health staff. Members of the Children’s Service Team at Plenty Valley Community Health Inc. addressed these changes by developing an integrated health promotion plan. The approach used involved identifying client pathways and then integrating opportunities for health promotion interventions into these pathways. Staff perceptions of the process involved in developing the plan were examined. The use of client pathways to integrate health promotion into everyday practice proved a successful approach for members of the Children’s Services Team, and provides a useful model for health promotion planning in community health that helps staff to see the relevance of health promotion to their practice, and engages staff in the planning process. Members of the Children’s Services Team reported that the process involved in developing their integrated health promotion plan was a very worthwhile experience that allowed them a strong sense of ownership of the plan.

A systematic policy approach to changing the food system and physical activity environments to prevent obesity

As obesity prevention becomes an increasing health priority in many countries, including Australia
and New Zealand, the challenge that governments are now facing is how to adopt a systematic
policy approach to increase healthy eating and regular physical activity. This article sets out a
structure for systematically identifying areas for obesity prevention policy action across the food
system and full range of physical activity environments. Areas amenable to policy intervention can
be systematically identified by considering policy opportunities for each level of governance (local,
state, national, international and organisational) in each sector of the food system (primary
production, food processing, distribution, marketing, retail, catering and food service) and each
sector that influences physical activity environments (infrastructure and planning, education,
employment, transport, sport and recreation). Analysis grids are used to illustrate, in a structured
fashion, the broad array of areas amenable to legal and regulatory intervention across all levels of
governance and all relevant sectors. In the Australian context, potential regulatory policy
intervention areas are widespread throughout the food system, e.g., land-use zoning (primary
production within local government), food safety (food processing within state government), food
labelling (retail within national government). Policy areas for influencing physical activity are
predominantly local and state government responsibilities including, for example, walking and
cycling environments (infrastructure and planning sector) and physical activity education in schools
(education sector). The analysis structure presented in this article provides a tool to systematically
identify policy gaps, barriers and opportunities for obesity prevention, as part of the process of
developing and implementing a comprehensive obesity prevention strategy. It also serves to
highlight the need for a coordinated approach to policy development and implementation across
all levels of government in order to ensure complementary policy action.

The burden of physical activity-related ill health in the UK

Background: Despite evidence that physical inactivity is a risk factor for a number of diseases, only a third of men and a quarter of women are meeting government targets for physical activity. This paper provides an estimate of the economic and health burden of disease related to physical inactivity in the UK. These estimates are examined in relation to current UK government policy on physical activity.

Methods: Information from the World Health Organisation global burden of disease project was used to calculate the mortality and morbidity costs of physical inactivity in the UK. Diseases attributable to physical inactivity included ischaemic heart disease, ischaemic stroke, breast cancer, colon/rectum cancer and diabetes mellitus. Population attributable fractions for physical inactivity for each disease were applied to the UK Health Service cost data to estimate the financial cost.

Results: Physical inactivity was directly responsible for 3% of disability adjusted life years lost in the UK in 2002. The estimated direct cost to the National Health Service is £1.06 billion.

Conclusion: There is a considerable public health burden due to physical inactivity in the UK. Accurately establishing the financial cost of physical inactivity and other risk factors should be the first step in a developing national public health strategy.

Folate fortification : a case study of public health policy-making

Introducing Evidence Based Health Policy: Problems and Possibilities, Section 1: What is the Problem?, 1: Competing Rationalities: Evidence based Health Policy, 2: Beyond Two Communities, Section 2: What does Evidence Mean?, 3: Evidence based Medicine - The Medical Profession and Health Policy, 4: Mind The Gap: Assessing the Quality of Evidence for Public Health Problems, 5: Health Policy and Normative Analysis: Ethics, Evidence and Politics, 6: What is New in Health Information? Evidence for Health Consumers and Policy Making, 7: From Evidence based Medicine to Evidence based Public Health, Section 3: Policy Case Studies, 8: The Viagra Affair: Evidence as the Terrain for Competing Partners, 9: Folate Fortification: A Case Study of Public Health Policy-Making in a Food Regulation Setting, 10: The Supply and Safety of Blood and Blood Products - Evidence, Risk and Policy, 11: The Development of Nurse Practitioner Policy, 12: Creating Healthy Public Policy for Oral Health: How was the Evidence Used?, 13: Regulation of Traditional Chinese Medicine in Victoria, 14: The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making, 15: Evidence-based Practice in the Australian Drug Policy Community, 16: Challenging the Evidence - Women's Health Policy in Australia, 17: Evidence and Aboriginal Health Policy, 18: The Limits to Technical Rationality in the Health Inequalities Policy Process, 19: Evidence-based policy: A Technocratic Wish in a Political World, Section 4: Is the transfer of evidence into policy possible?, 20: The Community Model of Research Transfer, 21: Getting Research Transfer into Policy and Practice in Maternity Care, 22: Improving the Research and Policy Partnership: An Agenda for Research Transfer and Governance, 23: Framing and Taming 'Wicked' Problems

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Separate spheres and public policy : the role of women in the development of children's services in Victorian local government, 1840-1992

The thesis is an explanation of the development of pre-school children's services (infant welfare, kindergartens and child care) at local government level in Victoria. The critical framework of analysis focuses on three dimensions of public policy: 1) the socio-historical environment; 2) the political processes involved in the development of the specific children's service; and 3) the major individuals and groups that exerted pressure for children's service, The argument is threefold. Firstly it is argued that the political environment of children's services has been dominated by the practice of separate spheres of public and private, in which the care of children is primarily the role of women. Secondly, it is argued that the political processes surrounding the development of local children's services have involved all levels of government in what is termed a local state. Thirdly, it is argued that the development of these children's services in local government has resulted mainly from the work of women both individually and collectively. Since the three services of infant welfare, kindergartens and child care all became a normal function of children's services at different times, the circumstances that surrounded each development exhibited different aspects of the three major arguments. The periodisation is broken into four phases: 1) the establishment of local government with no children's services in the nineteenth century; 2) the establishment of infant welfare services in local government in the early part of the twentieth century; 3) the incorporation of kindergartens into local government after the second world war; and 4) the incorporation of child care into local government in the 1970s and 1980s. The thesis concludes by arguing that the existence of children's services in local government in Victoria is testimony to the remarkable work of those women who have pursued the issue both individually and collectively. It has been the identification of children's services as a women's issue in Australian politics that has enabled women's groups at different times to influence the policy makers in diverse ways. However, while the establishment of children's services as a legitimate political concern brings the matter onto the public agenda, the separate spheres still remains a contested issue in the public policies of children's services.

Dancing with death : risk, health promotion and injecting drug users

The thesis investigated ambivalent attitudes towards death in injecting drug users, factors that may lead to such ambivalent attitudes and implications for health promotion campaigns. It was found that this relationship with death was principally attributable to government drug policy in Australia.