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Policy Evaluation

Policy Evaluation. Exploring the Dynamic and Democratic Dimensions of Health Protection Policies. Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics. Edinburgh Evaluation Summer School Edinburgh, Scotland

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Policy Evaluation

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  1. Policy Evaluation Exploring the Dynamic and Democratic Dimensions of Health Protection Policies Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics Edinburgh Evaluation Summer School Edinburgh, Scotland June 6, 2007

  2. Appreciating the Unique Character of Evaluative Inquiry Evaluation Research SystematicMethods Questions of Fact (descriptions, associations, effects) Questions of Values (merit, worth, significance) “It is easier to find facts than it is to face them.” Centers for Disease Control and Prevention. What procedures are available for planning and evaluating initiatives to prevent syndemics? Syndemics Prevention Network, 2001. Available at <http://www.cdc.gov/syndemics/overview-planeval.htm>.

  3. Picture a Neighborhood Where… • Conditions are not supportive of healthy living • People are either afflicted by or at risk for numerous mutually reinforcing health problems • Citizen leaders are making an effort to alleviate afflictions and improve living conditions, but their power is limited • More could be done through better local organizing and with effective assistance from outside allies (e.g., philanthropy, government) James Nachtwey in Sachs J. How to end poverty. Time Magazine 2005 March 14. How does public health policy typically proceed in such circumstances? Which forms of policy planning and evaluation are most relevant and promising?

  4. Policy Planning & EvaluationEngages Questions of Social Navigation Historical Markov Forecasting Model Data Prevalence of Diagnosed Diabetes, US 40 Where? 30 Million people 20 What? How? • Markov Model Constants • Incidence rates (%/yr) • Death rates (%/yr) • Diagnosed fractions • (Based on year 2000 data, per demographic segment) 10 Trend is not destiny! Who? Why? 0 1980 1990 2000 2010 2020 2030 2040 2050 Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164. Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.

  5. A Field in Transition Modern public health policy—and evaluation—are becoming more… • Inter-connected(ecological, multi-causal, dynamic, systems-oriented)Concerned more with leverage than control • Public(broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability • Questioning(evaluative, reflexive, critical, practical)Concerned with creating and protecting values like health, equity,dignity, security, satisfaction, justice, wealth, and freedom in both means and ends

  6. Framework for Program Evaluation “Both a synthesis of existing evaluation practices and a standard for further improvement.” Left Unexamined… • Singular “program” as the unit of inquiry (N=1 organizational depth) • Dynamic aspects of program effectiveness (e.g., better-before-worse patterns of change) • Democratic aspects of public health work (e.g., alignment among multiple actors, including those who are not professionals and who may be pursuing other goals) • Evaluative aspects of planning Milstein B, Wetterall S, CDC Evaluation Working Group. Framework for program evaluation in public health. MMWR Recommendations and Reports 1999;48(RR-11):1-40. Available at <http://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf>.

  7. Are We Posing Questions About Attribution or Contribution? “…if a program’s activities are aligned with those of other programs operating in the same setting, certain effects (e.g., the creation of new laws or policies) cannot be attributed solely to one program or another. In such situations, the goal for evaluation is to gather credible evidence that describes each program’s contribution in the combined change effort. Establishing accountability for program results is predicated on an ability to conduct evaluations that assess both of these kinds of effects.” p.11-12 Calls into question the conditions in which one focuses on a “program” as the unit of analysis

  8. Serious Challenges for Planners and Evaluators • Locating categorical disease or risk prevention programs within a broader system of health protection • Constructing credible knowledge without comparison/control groups • Differentiating questions that focus on attribution vs. contribution • Balancing trade-offs between short- and long-term effects • Avoiding the pitfalls of professonalism (e.g., over-specialization, arrogance, reinforcement of the status quo) • Harnessing the power of intersectoral and citizen-led public work • Defining standards and values for judgment • Others…

  9. Topics for Today • Health Protection Policy in a Dynamic and Democratic World • Concepts, keywords, structures • Looking Backward, Looking Forward • Retrospectively evaluating past policy • Prospectively crafting/evaluating future policy • Highlighting One Promising Methodology • System Dynamics simulation modeling • Questions and Discussion Throughout

  10. Defining Keywords Policy is… • The plans, programs, principles, or more broadly the course of action of some actor(s), which may include a degree of deliberate inaction as well • Explicit or implicit rules for deciding how to respond to circumstances and pressures • Priorities guiding resource allocation Policy evaluation is… • The systematic process of determining—and improving—the merit, worth, or significance of decisions about what to do, or not to do, in a given domain • The articulation and assessment of alternative possible futures, each corresponding to a different policy Adapted from: Milio N. Glossary: healthy public policy. Journal of Epidemiology and Community Health 2001;55(9):622-623. Forrester JW. Policies and decisions. In: Industrial Dynamics. Cambridge, MA: MIT Press; 1961. p. 93-108. Bennett T, Grossberg L, Morris M. New keywords: a revised vocabulary of culture and society. Malden, MA: Blackwell Pub., 2005. Scriven M. Evaluation thesaurus. 4th ed Newbury Park, CA: Sage Publications, 1991.

  11. Continual, Iterative Process of Policy Planning & Evaluating ASSESSMENT Many Methodologies… Surveys Needs Assessment Asset MappingFrame analysis Concept mapping Network analysis Time-trend analysis Many Methodologies… CommunicationsAuditingLaw EnforcementLeadership & Organizing Power mapping Non-violent action Social Navigation POLICYDEVELOPMENT Many Methodologies… Pilot and Demonstration Theories of Change Health impact assessment Simulation modeling Futuring or Storytelling ASSURANCE Policy is our general approach toward a particular problem or area of concern… Assuring Healthful Conditions for All Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988. Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002.

  12. Defining Keywords Artist: Boyce Watt Policy vs. Decisions • Policy usually involves a series of specific decisions, programs, actions • But the distinction is blurry • Policy makers never start from a blank sheet of possibilities • Ad hoc decisions may together add up to forceful implicit policy “Policy is the selection of non-contradictory means to achieve non-contradictory ends over the medium to long term. Policy is the thread of conviction that keeps a government from becoming the prisoner of events.” -- Michael Ignatieff Walt G. Health policy: an introduction to process and power. Atlantic Highlands, NJ: Zed Books, 1994. Ignatieff M. The grey empitness inside John Major. The Observer 1992 November 15; 25.

  13. Events Pattern Structure R Melting Water Water Temperature Level Economic Activity& Emissions Flood Damage Events

  14. Tools for Policy Planning & Evaluation Events Time Series Models Describe trends • Increasing: • Depth of causal theory • Robustness for longer-term projection • Value for developing policy insights • Degrees of uncertainty Multivariate Stat Models Identify historical trend drivers and correlates Patterns Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Structure

  15. Consider the Track Record… • Low tar and low nicotine cigarettesLead to greater carcinogen intake • Fad dietsProduce diet failure and weight gain • Antibiotic & pesticide useStimulate resistant strains • Road building to ease congestionAttracts development, increases traffic, delays, and pollution • Air-conditioning useRaises neighborhood heat • Forest fire suppressionBuilds deadwood fueling larger, hotter, more dangerous fires • War on drugsRaises price and attracts supply • Suppressing dissentInspires radicalization and extremism Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

  16. Policy Resistance is… Defining Keywords “The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.” -- Meadows, Richardson & Bruckmann Meadows DH, Richardson J, Bruckmann G. Groping in the Dark: The First Decade of Global Modelling. Wiley: New York, 1985.

  17. Seeking High-Leverage Policies “Give me a firm place to stand and I will move the earth.” -- Archimedes Wall painting in the Stanzino delle Matematiche in the Galleria degli Uffizi (Florence, Italy). Painted by Giulio Parigi in the years 1599-1600. Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.

  18. Public Health Work Literally Involves Redirecting the Course of Change 684,000 fewer deaths in 1998 alone Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 700 Rate if trend continued 600 500 Peak Rate 400 Age-adjusted Death Rate per 100,000 Population 300 • Overall Decline is Linked to… • Reduced smoking • Changes in diet • Better diagnosis and treatment • More heath services utilization 200 Actual Rate 100 50 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke -- United States, 1900-1999. MMWR 1999;48(30):649-656. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm>

  19. One Observer's View… “Public health is probably the most successful system of science and technology combined, as well as social policy, that has ever been devised…It is, I think, a paradigmatic model for how you do concerned, humane, directed science.” -- Richard Rhodes Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002.

  20. Immense Challenges Ahead World Population Growth United Nations Department of Economic and Social Affairs. Population Division. The world at six billion. Washington D C: Population Division Dept. of Economic and Social Affairs United Nations Secretariat, 1999. CNN. Sarajevo baby to be honored as 6 billionth person on Earth. CNN, 1999. Accessed July 5, 2003 at <http://www.cnn.com/WORLD/europe/9910/11/population.02/>.

  21. Resource Depletion & Related Conflict

  22. A Glimpse Into 2020 Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

  23. A Glimpse Into 2020 • Off the List • Measles • Malaria • Falls • Anemia • Malnutrition • On the List • War • HIV • Violence • Self-inflicted injury • Cancer of the trachea, bronchus, and lung Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

  24. Broad Dynamics of the Health Protection Enterprise - Health B Protection Taking the Toll Efforts B B - Responses Prevalence of Vulnerability, Risk, or Disease Obstacles to Growth R Resources & - Resistance Drivers of R Growth Reinforcers Broader Benefits & Supporters Prevalence of Vulnerability, Risk, or Disease 100% Values for Health & Equity Size of the Safer, Healthier Population PotentialThreats 0% Time The concepts and methods of policy evaluation must engage the basic features of this dynamic and democratic system

  25. A Complementary Science of Relationships True innovation occurs when things are put together for the first time that had been separate.– Arthur Koestler • Efforts to Reduce Population Health ProblemsProblem, problem solver, response • Efforts to Organize a System that Assures Healthful Conditions for All Dynamic interaction among multiple problems, problem solvers, and responses Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988. Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002. Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.

  26. Broad Street, One Year Later John Snow Heroic Success or Cautionary Tale? “No improvements at all had been made...open cesspools are still to be seen...we have all the materials for a fresh epidemic...the water-butts were in deep cellars, close to the undrained cesspool...The overcrowding appears to increase." Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

  27. Another Prototypical ExampleAttempts to Reform the U.S. Health Care Delivery System Number of Uninsured Americans, 1976-2003 Himmelstein, Woolhandler, Carrasquillo – Tabulation from CPS and NHIS “At least six times since the Depression, the United States has tried and failed to enact a national health insurance program.” – Lee & Paxman Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.

  28. Crafting Health Policies that will Succeed in a Large, Dynamic System Efforts to reform health care policy have been ineffective because of • Piecemeal approaches • Failure to address root problems • Inattention to the larger political and economic system “Most of the analytic strategies popular among academics, politicians, and policy makers fail to observe the system as a whole…to discuss processes of mutual change that are occurring, or to analyze how innovations fit into larger nonequilibrium dynamics that are developing.” -- Max Heirich Heirich M. Rethinking health care: innovation and change in America. Boulder, CO: Westview Press, 1999.

  29. Understanding Dynamic Complexity Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>. Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

  30. Changing Views of Population HealthWhat Accounts for Poor Population Health? 1840 1880 1950 1960 1980 2000 • God’s will • Humors, miasma, ether • Poor living conditions, immorality (e.g., ?) • Single disease, single cause (e.g., ?) • Single disease, multiple causes (e.g., ?) • Single cause, multiple diseases (e.g., ?) • Multiple causes, multiple diseases (but no feedback dynamics) (e.g., ?) • Dynamic feedback among afflictions, living conditions, and public strength (e.g., ?) Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006. Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

  31. Placing Health in a Wider Set of Relationships Health “Health Policy” Power to Act “Social Policy” Living Conditions This orientation explicitly includes within it our power to craft policies, along with an understanding of thechanging pressures, constraints, and consequences that shape it.

  32. Two Orientations Retrospective • What have been the observed consequences of prior decisions? • For whom? When? Why? At what cost? • Recommendations to continue or change strategy Prospective • What is the range of plausible consequences of policy options? • For whom? When? Why? At what cost? • Which alternative futures are most highly valued, or feared? • What must be done to move in the desired direction?

  33. Prospective Policy Evaluation Explicitly recognizes the evaluative aspects of planning: • Defining problems • Setting priorities • Developing options • Selecting strategies Risley J. Public policy evaluation. Kalamazoo, MI: The Evaluation Center, Western Michigan University; February 26, 2004. <http://www.wmich.edu/evalctr/evalcafe/risley022604slides.pdf>.

  34. When Faced with the Vast Scope of Public Health Threats… Narrow the Focus and Specialize • Identify problem • Formulate policy • Implement policy • Evaluate policy Breeding Ground for Disease (Karen Kasmauski, National Geographic, 2001). • Repeat steps 1-4, as necessary!

  35. Diseases of Disarray • Hardening of the categories • Tension headache between treatment and prevention • Hypocommitment to training • Cultural incompetence • Political phobia • Input obsession Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8. Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

  36. Dangers of Getting Too Specific • Conventional problem solving proliferates problems • Opens a self-reinforcing niche for professional problem solvers • Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected) Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.

  37. Examples of Nonviolent Action • Dismantling dictatorships • Blocking coups d’état • Defending against foreign invasions and occupations • Providing alternatives to violence in extreme ethnic conflicts • Challenging unjust social and economic systems • Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion • Resisting genocide “A phenomenon that cuts across ethnic, cultural, religious, geographic, socioeconomic and other demographic lines.” -- Albert Einstein Institution Albert Einstein Institution. Applications of nonvilolent action. Albert Einstein Institution, 2001. Powers RS, Vogele WB, Kruegler C, McCarthy RM. Protest, power, and change: an encyclopedia of nonviolent action from ACT-UP to women's suffrage. New York: Garland Pub., 1997.

  38. Systems Archetype + Problem B Symptom - + + Delay R - Unintended Consequence + “Fixes that Fail” Fix Characteristic Behavior: Better before Worse Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.

  39. “Fixes that Fail” in Public Health Vocabulary + R Delay - The Risk of Targeted Interventions + Health TargetedResponse B Problem - + What issues tend to be excluded? Exclusions +

  40. Some Categories of Exclusions Disparity & Disconnection Disarray Social Disorientation Conceptual Political Organizational Together, these forces may seriously undermine the effectiveness of health protection policy

  41. How Many Triangles Do You See? Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.

  42. Boundary Critique Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. -- Albert Einstein Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to Management Science. London: Thomson; 2002. p. 41-42. <http://www.geocities.com/csh_home/downloads/ulrich_2002a.pdf>. Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf

  43. Boundary CritiqueEqualizing Experts and Ordinary Citizens • “Professional expertise does not protect against the need for making boundary judgements…nor does it provide an objective basis for defining boundary judgements. It’s exactly the other way round: boundary judgements stand for the inevitable selectivity and thus partiality of our propositions. • It follows that experts cannot justify their boundary judgements (as against those of ordinary citizens) by referring to an advantage of theoretical knowledge and expertise. • When it comes to the problem of boundary judgements, experts have no natural advantage of competence over lay people.” -- Werner Ulrich Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268.

  44. “You Can Argue with Einstein” “For certain purposes, public judgment should carry more weight than expert opinion – and not simply because the majority may have more political power than the individual expert but because the public’s claim to know is actually stronger than the experts’...the judgment of the general public can, under some conditions, be equal or superior in quality to the judgment of experts and elites who possess far more information, education, and ability to articulate their views.” -- Daniel Yankelovich Yankelovich D. Coming to public judgment: making democracy work in a complex world. 1st ed Syracuse, NY: Syracuse University Press, 1991. p. 220.

  45. Boundary Critique Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf

  46. The term epidemic is an ancient word signifying a kind of relationship wherein something unknown (or unknowable) is put upon the people Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“ Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work Epi·demic A representation of the cholera epidemic of the nineteenth century.Source: NIH “The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.” -- Gil Elliot Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972. Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/ Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.

  47. The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena It acknowledges relationships and signals a commitment to studying population health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways Syn·demic Events System Co-occurring Confounding Connecting* Synergism Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006. Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>

  48. Health System Dynamics Public Work Society's Health Response Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions “One major task that CDC is intending to address is balancing this portfolio of our health system so that there is much greater emphasis placed on health protection, on making sure that we invest the same kind of intense resources into keeping people healthier or helping them return to a state of health and low vulnerability as we do to disease care and end of life care." -- Julie Gerberding Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Gerberding JL. FY 2008 CDC Congressional Budget Hearing. Testimony before the Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, United States House of Representatives; Washington, DC; March 9, 2007. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458. Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.

  49. Understanding Health as Public Work Citizen Involvement in Public Life - Vulnerable and Afflicted People Fraction of Adversity, Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) Public Work - Public Society's Health Strength Response Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier - Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions Social Division

  50. Evaluating Dynamic, Democratic Policies Public Work Citizen Involvement - in Public Life Public Society's Health Strength Response - Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier - Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions Vulnerable and Afflicted People Fraction of Adversity, Social Division Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) How can we learn about the consequences of alternative policies in a system of this kind?

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