advocating for change: understanding how to impact health policy

7/27/2019 Advocating for Change: Understanding How to Impact Health Policy

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Health ExChange Academy

Advocatingfor Change

Understanding How toImpact Health Policy


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1 Advocatingfor Change | Understanding How to Impact Health Policy

Aaor Change

Understanding How toImpact Health Policy

What is advocacy?

How is it important or your work and

building the community you serve?

How is advocacy done?

Who are the players?


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Foreword

Te Caliornia Endowment places a strong emphasis on policy change activities,

including advocacy, with the belie that policy change is necessary to make meaningul

and lasting improvement in the health o Caliornians. Although no single policy or

system change will achieve the ultimate goal o a healthier Caliornia, Te Endowment

rmly believes that everyone has a role to play and that all organizations can participate

in the advocacy process.

o that end, Te Endowments Public Policy Department and the Center or Healthy

Communities have developed Advocating or Change as part o the Centers HealthExChange Academy. Designed to provide you with the undamentals o advocacy and

the tools to put that knowledge into practice, Advocating or Change is the rst in a

series o trainings to help sta at nonprot organizations become more eective leaders

in improving community health.

Special thanks are due to Harry Snyder, an advocate well-known or his prior work at

Consumers Union, or writing this manual. Te training program itsel was developed

by Harry and the team at the National Community Development Institute: OmowaleSatterwhite, Shiree eng and Diana Lee.

It is our hope that this manual and training will help you in your work in advocating or

improved health outcomes in Caliornias most underserved communities.

Sincerely,

Robert K. Ross, M.D.

President and Chie Executive Ocer

Te Caliornia Endowment


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1. HeAltH Policy AdvocAcy: An intRodUction 1

2. AdvocAcy StePS to MAke cHAnge HAPPen 6

Getting the FactsResearch and Data Collection 6

Building SupportOrganizing and Coalition Building 10

Making a PlanDevelop Goals and Strategies 14

Communicating Your Message

Inorming the Public and Decision Makers 18

3. AdvocAcy PlAceS WHeRe deciSionS ARe MAde 28

Changing the Law 28

Working with Government Agencies 30

Working with Health Care Institutions 32

Working with Private Companies 34

Using the Ballot Box: Te Initiative and Reerendum Process 36

Using the Courts 37

Direct Group Action 39

4. ReeRenceS 42

5. WoRkSHeetS 57

able o Contents


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Advocatingfor Change | Understanding How to Impact Health Policy 1

Hah P AaAn Introduction

Tis manual will help grantees o Te Caliornia Endowment and oth-

ers understand advocacy, the world o health policy advocacy, how

advocacy is done, and what part each person can play. Health policy

consists o the rules governing health issues, or example, requirements

or culturally and linguistically appropriate health services, worker

saety practices, or limits on air pollution. Tese rules or public poli-

cies decide how a diverse population receives appropriate health care,

what worker saety protections will be required, and how much pol-

lution can be released into the air. Policy change is a shi in the rules

that allows or new ways o doing things, such as more culturally andlinguistically appropriate health services, stronger measures to prevent

repetitive stress injuries, or stricter standards or release o pollutants.

Advocacyis a way to change both the health policy rules and resource

allocation decisions o government and private institutions.

In order to bring about better health, it is important that people who

are working to improve the health o Caliornia residents know the

processes or changing the policies and practices o government and

private institutions. Service providers, whether they are caseworkers,

public health educators or clinicians, know rsthand the roadblocksto delivering those services. Tey are in a strategic position to identiy

problems, to understand the ways that will work to solve the problems,

and to engage their clients and constituents in the process. Researchers

and health policy specialists also have concrete ideas about how to im-

prove health. Tose with hands-on experience and other expertise bring

credibility, enthusiasm and commitment to the process o improving

and protecting health in Caliornia. Te Caliornia Endowment wants

the people and organizations that are aected by and understand health

problems to have the tools to solve them. Understanding health policy

and health policy advocacy is the rst step to gaining those tools.

Advocacy projects to improve any aspect o health can have the add-

ed benet o building the capacity o communities to move their own

agendas. Tese projects can include low-cost housing, more and better

jobs, a cleaner environment, or saer streetsall o which can contrib-

ute to improving community health. Building community capacity to

Never doubt that

a small group o

thoughtul, committed

citizens can change

the world. Indeed, it

is the only thing that

ever has.

Margaret Mead

1


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eect change should be built into every advocacy campaign, both to

strengthen the campaign and to consciously build skills or the uture.

Advocacy can be done in many ways, including: seeking changes in

government agency policy or practice, working with private businesses

or health care institutions, changing laws, introducing ballot initiatives,

taking direct group action, and, when necessary, litigation. Oen, one

or more o these strategies is used to bring about better health or to

protect what is now working eectively. Te same our steps to make

change happen are used in every place where health policy decisions

are made. However and wherever health advocacy work is done, you

will need to complete these steps:

1. Get the acts.

2. Organize support.

3. Defne the problem and make your plan.

4. Communicate a clear and compelling story o what

is wrong and what should be done.

Tese pages explain the basic steps involved i you become part o an

advocacy campaign or better health. Te Reerences section at the end

o this manual provides resources or additional, in-depth guidance.

Tese sources include inormation or the sustained course o action

needed to remedy serious problems inherent in an advocacy campaign.

Changing health policy is hard work and can take time, but it is essentialor improving your communitys health. Examples o prior campaigns

are used throughout the manual to demonstrate how the work is actu-

ally done; they show the concrete results and improvements in health

that advocacy can bring about.


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Advocacy Works on Many Levels

r sm m, sumr a ur a-

as aru ha Mdas a kra s

pru a mar prus ha ar -

rbu h rw bs h a.

Aas a a ar sras

b wh pub rsarh aa a

aass hhh h a asps

h mpas pras a prus. law-sus wr hra a sm ass .

Pub prss a msras wr h.

nw rm aws a ruas wr

suss a ru. Aas wr

a m wh mpa us. A hs

aa sras, whh wr arr u

arus pas whr ss ar ma

(u amsra as a h

saur), wr rbu b h mpas

a m wh as a uss. Bu wh

a accumulation o pressure, bh Mdas

a kra h au hr

s ar hr ps, rsu

hr prus, a ha hr mar

pras am a hr. eah h

aa rs rbu ha p-

s a kra a Mdas, whh w a

br hah.

HoW cAn yoU BeAn AdvocAte?

Te skills that already make you successul

knowing what is important to your work, working

with others, planning your eorts and communi-cating what needs to happenare the same skills

used or advocacy. People and organizations pro-

viding health services oen work to change the

rules so they can serve people more eectively or

serve more people. Researchers and health policy

analysts identiy causes and potential solutions

to save lives, reduce disease or make health care

more ecient. Many people do not recognize that

they are already advocates when they work to im-

prove the delivery o health care or to get more

money or a budget.

Each person and organization uses their own style

to advocate. Tey use the style they are comort-

able with and that has been eective or them in

their work. You dont need to go to court or hold

a demonstration to be advocating, and you dont

need to be a health policy advocate to advocate.

Advocacy is working on behal o others to make

systems better or to protect what is now working.

o be eective, advocacy involves a broad range

o people with dierent skills and commitment o

time, rom academics to community activists.

It is important to understand that changing the

policies o public and private institutions can help

solve health-related problems. It is also important

to know how those changes are infuenced and

what your role can be in helping to bring about

improvements in health through advocacy. Te

Caliornia Endowment is committed to helping

grantees and others in the essential work o im-

proving local, state, ederal, as well as corporate

policies aecting health.

Hah P Aa: A iru


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Restrictions on Legislative Advocacy

lbb has m ma r

sm smh, suh as bb a

r ur ar rsaura r b-

b h mar p a hah ur

mmu.

Hwr, h ra ira Ru Sr

s bb r spa. Ahuh

bb s a mpra mp ms

aa ampas, aa mpasss a

muh brar ra as. A aa

r ha s m h iRS s

sr bb.

thr ar w s bb: r a

rassrs. dr bb has hr ms

a s as

1) a mmua wh a sar

2) abu a sp p sa

3) ha prsss a w ha sa.

grassrs bb s a mmua wh h

ra pub ha ss fu hm

a a b u a sp a a-

, suh as as pp wr hr s-

ars. th mmua mus as b abu a

sp p sa a prss a w

ha sa.

th iRS ss ms h amu m

ha ma b sp bb b a 501()(3)raa ha has ma h 501(h)

(s Rrs p. 45 r Aa r

Jus). Hwr, s mpra ursa

ha hs ms app -bb

hah aa suh as ua a

a abu a mpra hah ssu,

wr a amsra rua r

ra mmu suppr.

i s as mpra ursa ha h iRS

ruas ar pr -

sa aa r bb b pr r-

aas, ahuh pra uas ar

prhb rm bb r sa ra

u r bb purpss. Ar

h Aa r Jus, crss has sa

ha fu sa s a apprpra

a ma a r harab ra-

as. i 1976, pass sa

pub hars h rh bb up

pras hr aua purs.

kw h rus. r mr rma hw

501()(3) raas a aa a bb

, s Aa r Juss Worry-

Free Lobbying or Nonprofts, whh srbs

hw pr rups a bb wh h

iRS ruas.


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An AdvocAcy teMPlAte

Tis emplate is an overview o the two major parts o the world o health policy advocacy described in this

manual: Advocacy Steps to Make Change Happen and Advocacy Places Where Decisions Are Made. Te

illustrationAdvocacy Worldon this page provides a way to visualize all the parts o any advocacy campaign

and how they work together. Te sections that ollow discuss the our Advocacy Steps to Make ChangeHappen essential to any advocacy campaign and the Advocacy Places Where Decisions Are Made in which

the steps are used. Almost every campaign to change health policy will require: 1) knowing the acts, 2)

getting others involved, 3) making a plan, and 4) communicating with others about the problem and how

and why it needs to be solved. Tese our key Advocacy Steps to Make Change Happen are necessary or

any eort to change policy. Tis is true whether you go to court or to the legislature, or choose another

Place Where Decisions Are Made or your campaign to improve health. Examining the Considerations and

Pluses and Minuses described in Advocacy Places Where Decisions Are Made will help you decide which

way o working is the best strategy or your campaign.

Hah P Aa: A iru

Aa Wr

SolUtionS

Sps Macha Happ

BuildingSupport

Communi-cating Your

Message

Makinga Plan

Gettingthe Facts

Legislature

GovernmentAgencies

BallotInitiatives

Courts

Businesses& OtherOrganizations

Pas Whrdss Ar Ma

DirectAction

Health CareInstitutions


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getting tHe ActSReSeARcH And dAtA collection

o change health care you need to be able to show there is a problem

with the current situationor example, lack o coverage or cure, lack

o services, or lack o inormation.

Dening the problem requires getting and understanding the acts.

Finding out what is wrong and analyzing why there is a problem also

helps you identiy potential solutions. o improve health care you willbe asking the public, the media and decision makers to rely on what

you say and then to take the action you recommend or solving the

problem. Your credibility will be on the line and with it your ability

to be eective. You must know all you possibly can about the situation

you want to change, including viewpoints on all sides o the issue, in

order to give a complete and accurate picture.

Getting the acts and analysis you need is usually pretty straightorward.

You will probably already have much o the basic inormation you need,

as well as the contacts and connections to obtain additional inormationand help. You can rely on the skills and experience you are using eec-

tively now to do the additional research and act nding. o start your

work, you will need to present clear answers to the ollowing questions.

Who is being hurt and/or what needs to be corrected?

How are they being hurt? How can you describe the problem? For

example, is the problem lack o coverage, inormation, or cultur-

ally appropriate care; no money or prescriptions; no transporta-

tion to health care; or an unhealthy environment?

How serious and/or widespread is the problem?

If le unaddressed, will the problem get better or worse?

If worse, how so?

Why does the issue matter?

How has the community been aected?

Aa Sps Macha Happ

o change health care

you need to be able to

show there is a prob-

lem with the current

situationor exam-

ple, lack o coverage or

cure, lack o services,

or lack o inormation.

2


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Advocacy Steps to Make Change Happen

o design an eective campaign strategy, you should know the ollowing:

> i h prbm s -sa, wh has

b rs?

> Wha as r raas ar rspsb?

> Wha aws r rus app?

> Wha rass ar us pa h sua?

> Wh ws abu h prbm?

> Wh hs hr s a prbm?

> Wh hs hr s prbm?

> Wha ar h sus?

> Wha ar h ps h sua?

> Wh bs?

> Wha as, a, ha b a?

> Wha rprs r ws aus ha hr b?

> Wha has happ hr aras? Ha

wrab sus b u?

Getting a government agency to gather the needed acts and do

other research is oen the rst eort in an advocacy campaign.

Community groups build their case by using government data and

reports to add to the inormation they gather rom the community

and other resources. Te thoroughness o your presentation o the

acts, including showing that people are being harmed, along with

your analysis o the problem, will infuence the public, the media

and the way ocials respond to your request or change. Being able

to describe specic solutions makes your case even stronger.

Getting the Facts

on Leadi 1992, PodeR, a rassrs

rup ra ams r

rma a m

jus h Mss dsr

Sa ras, ra ha

ma hr wr sur-

rm a ps. th

rsarh a u su-

s ha shw a-bas

pas wr h aus

a ps hr a

ha ma hms h Ms-

s dsr wr r a

a a-bas pa.

Us hs rma, awh hr aa a a sur-

s, h wr sussu

a cmprhs e-

rma la Ps

Pr aw a prram

r a Sa ras.


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Whr h irma

Tere are dozens o inormation sources with answers to the previous

questions.

Books, Newspapers and Periodicals

Read the available literature on the problem and its history, not only toknow everything you can, but also to identiy those who may be helpul

and those who may be part o the problem.

Te Internet

A search o the World Wide Web may uncover inormation about

your problem and provide links to organizations on the same issue

in other sites.

Government Reports and Documents

Your eorts will gain credibility i they are supported by inormation

rom government sources. A credible campaign makes it dicult orothers to deny that a problem exists. You may have to le a Freedom o

Inormation Act (FOIA) or Public Records Act request to get the mate-

rials you need (see Reerences pp. 42 and 48).

Organizations and Individuals

It is extremely important to learn the views o other organizations and

individuals interested in health issues. Youll want to coner with like-

minded individuals and organizations not only to get the benet o their

experience but also to enlist their support. You should also explore the

positions o potential opponents, not only to better understand theirperspectives but also to help you incorporate eective arguments against

their positions into your action and your media materials (see Reer-

ences pp. 44 and 45).


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Academic Sources

Schools o public health and other academic institutions can pro-

vide a great deal o unbiased research and analysis to help you clariy

a problem and identiy solutions. Tese and other organizations are

not ivory towers, but practical resources looking to help communities

solve health problems. It is also possible that graduate students may bewilling to assist you in nding acts and existing studies to guide you.

(For a thorough list of academic institutions specializing in public

health, see Reerences p. 47.)

Data Sources

Tere are research organizations and data sources that are intended to

be helpul and accessible to community groups. Tey can direct you to

search engines and other sources or nding inormation relevant to

your communitys health issues. Te Caliornia Health Interview Sur-

vey (www.chis.ucla.edu) and the Urban Institutes Health Policy Center(www.urban.org/content/PolicyCenters/HealthPolicy/Overview.htm)

are good places to start.

You can use Getting the Facts: Researching the Problem on

p. 58 o the Worksheets to guide your work.

Information on Getting the Facts can be found on p. 48 in

Reerences.


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10

A single individual or

organization can take

action, but the likeli-

hood o success is ar

greater i a coalition o

groups and individuals

join in the work.

BUilding SUPPoRt oRgAnizing And coAlition BUilding

A single individual or organization can take action, but the likelihood

o success is ar greater i a coalition o groups and individuals join in

the work.

ora a ca Bu

Organizingis working with individuals in the community to develop a

broad-based understanding o what is wrong, what needs to be done,

how to work together, and who else will be working or change, and

also seeks to motivate people to join in the campaign. Coalition build-

ingis the work done to get groups to work together in a campaign.

Organizing and coalition building are two sides o the same coin: get-

ting broad-based support or improving health.

ora gas

Te purpose o organizing is to increase the number o individuals in-

volved in and supporting the movement or change. You will want to

educate and inspire people in the community and others concerned

about health to join in and work or change. Tere is strength in num-

bers because your problem solving will be more relevant, you will

increase the capacity o your community to solve its problems, and you

will strengthen the communitys political clout to bring about change

in the uture.

Sussu ca cmps

As you start your work, try to include individuals and organizations

that are widely recognized and respected, both within your community

and by the larger public. Having a prominent person as a leader and

strong organizations as members can make it easier or others to join

the coalition. As you go orward with building a coalition, try to reach

out to politically diverse groups to participate in a coordinated and

structured eort. Remember that the broader the political representa-tion, the more powerul the eect. It is much harder to dismiss an eort

that is supported by a wide range o organizations, particularly i those

organizations are oen not on the same side. Most groups working or

better health may be willing to be part o the community eort i you

recognize that dierent organizations can help in dierent ways, ways

that are consistent with their individual priorities and resources.

Aaor Change | Understanding How to Impact Health Policy


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Your coalition should include organizations and individuals who have

experience with health-related issues and with the community. Te

success o a coalition depends on many actors:

> er mus ha h sam uama a, a ar

a ar-up pa, a a u ps a sra.

> A pars a ar ursa hw h a

w u.

Leadership must have the time, skills, experience, resources

and coalition support to do the job.

Each coalition members level of participation should be well

dened. (Can an organization only sign on, send a letter of

support, supply resources or can it participate fully?)

Distribution of work should be undertaken according to

each member organizations strength, resources, capacity,organizing experience, research, use of media, negotiation

skills or leadership.

There must be a commitment to full, thorough and

frequent communications.

Assigned decision-making authority should be agreed to

by all members.

A dened style for the campaign (e.g., in-your-face,

diplomatic, high media visibility) and the sharing of credit

are part of the plan. Accountability of each group for its part of the whole

effort should be in place.

> A mmbrs mus mm b r h hau a

suppr r ss rss u h jb s .

n s u r s as.

> th a mmbrs mus prs a u r, wh

sa spar rprsas wh ha

s-ma auhr.

> th a mmbrs shu ruar assss hr prrss

a mpa.

> A susss w b bra a aw b

a mmbrs.

Basic Coalition

Principles Clear agreement on

mmm ssu

Clear agreement on

p aa

Clear agreement on

a sruur

Clear agreement on

rs r mmbrs Clear agreement on

rsurs mm

Tasks delegated to

bs-qua pp

Clear communication,

a ruar

Actively build capacity/

ss mmbrs a

rups

Share credit, share

rs, shar sbas

Regularly review strate-

s, rs, mmua-

a hr a

pras


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Coalitions can be as ormal as those

with a letterhead and a separate oce

or as inormal as an agreement to sup-

port a single goal. No matter how you

work, you want supporters to sign on as

sponsors o the eort. But i a coalitionpartner does not want to join ully in the

work, a letter o support or testimony at

a public hearing should be welcome.

Coalition members need to be con-

cerned about the organizational needs

and capacity o all supporters, and not

assume that every group can participate

in the ront line o the campaign.

tssChanging the health system is di-

cult work and community coalitions

must support a shared vision o what to

do and how to do it. Your act nding

and analysis may lead you to think you

know what is wrong and what needs

to be done. But or eective coalition

building, you may want to present the

community members with the inor-mation and have them decide what

they think are the problems and solu-

tions. In this way, they are making key

decisions and taking ownership o the

campaign. It is a strategic decision that

helps build a solid coalition. I there is

no agreement on a solution or i com-

munity members or organizations cant

agree on roles, leadership, control o

resources or strategy, the work is muchmore dicult and less likely to succeed.

Negotiating agreement on these issues

may require patience and compromise.

Caliornia Coalitions Pay O

i 1994, csumrs U bj wh a pr

hah surr ha a r-pr busss

rprs. i appar ha h asss h

pr wu b absrb h w busss,

rsu a ss harab ars ha u b

us mpr hah cara. dsp h bs

rs csumrs U, h rm appr

h ha whu arss a h rups

rs. i rr u h sru, csumrs

U rah u a hp rm a a

mr ha 90 rups rm hruhu cara

rprs srs, hr, sumrs, mrs,

a w-m a ah-bas mmus.

th bra-bas, rs mmbrshp h a was

a ar mssa ha ma pp rm ma wps

huh smh was wr a ha smh

b pr h pub rs.

Wr hr, h a ssu rprs, a

p, a h ma a as, a

prs a hars a ms. rm

h a a aa hr r a su

ma h pub, h ma a rm s

mars pa a. th a ampshwha h ua rup u . th rm

ha s ru a rqur ha h harab

ars b h r mpr hah cara.


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R as

When the opposition to your eorts is strong and perhaps hostile, you

need to maintain internal accord. Allies, partners, co-workers or sup-

porters who become unhappy and break away rom the agreed-upon

plan may undercut your work. Warning signals should go up i

coalition communications are not up-to-date.

information is not fully shared and available.

dierences of opinion among coalition members

are not resolved and set aside.

Rmmbr

Tis is a campaign. Your audience is not just the legislature or courts

or an agency, it also includes the media and the general public. I your

campaign involves a large, diverse coalition o groups and individuals,

the media (especially editorial boards) and the public will perceive that

there is a broad consensus on the problem and the solution.

Tis is building your community. In addition to solving a specic

health problem, advocacy campaigns are used to build the communitys

capacity to work together or better health.

A strong coalition o groups and individuals makes the work easier,

more exciting and more likely to succeed.

You can use Building Support: Inviting Others to Join on p. 62 o

the Worksheets to guide your work.

Information on Building Support can be found on p. 49 in

Reerences.

I your campaign

involves a large, diverse

coalition o groups and

individuals, the media

(especially editorial

boards) and the public

will perceive that there

is a broad consensus

on the problem and

the solution.


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Every advocacy

campaign to improve

health, whether it is

a statewide or local

eort, requires a plan

to get rom the prob-

lem to the solution

and includes a road

map o the steps to be

taken along the way.

MAking A PlAn develoP goAlS And StRAtegieS

Every advocacy campaign to improve health, whether it is a statewide

or local eort, requires a plan to get rom the problem to the solution

and includes a road map o the steps to be taken along the way. A cam-paign can be any sustained work or better health. Tis can include a

campaign or a hospital to provide appropriate cultural and linguistic

health services or a campaign or universal health care. Big or small,

health campaigns are important and their success depends on the ol-

lowing elements being spelled out in your plan:

1. A clearly defned problem

2. A clearly defned solution and interim goals

3. An assessment o resources

4. A clear strategy

d h Prbm

It is essential that the community aected by a perceived health issue

dene and agree on the problem they think needs to be xed. For ex-

ample, dierent people may have diering views on the nature o the

asthma problem, with one concerned about the environmental pollut-

ants causing asthma attacks and another concerned about inadequate

care and lack o medications to prevent and mitigate attacks. Although

both concerns are important, the dierences must be resolved through

community consensus to determine the exact problem the coalition

wants solved, along with a united position o working together to reach

that goal. Dening the problem is a way o bringing people together. It

is also the way you can test whether or not you are going aer the right

solution. Having your problem clearly in ocus helps you avoid being

divided, stay on task and communicate to others exactly what must be

xed. In this case, the community might agree that the problem is too

many children are suering rom asthma.


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d h Su a irm gas

You must decide what solution will meet community needs or im-

proved health with clearly dened short-term goals and nal goals that

will solve the problem. Using the example o asthma, the community

might decide that the state needs to adopt laws to signicantly decrease

air pollution and that the county should provide comprehensive pre-ventive and treatment services through asthma clinics. argets or the

denition o a signicant decrease and or what constitutes compre-

hensive services are essential. Clear targets help dene a bottom line

so you can be sure that you continue the campaign until you achieve

undamental change, and so that you know when you get there.

Examples o short-term goals might be: to educate and organize

community members; to orm a coalition o community and other

interested groups; to conduct surveys and research to document the

problems; and, using the media and the Internet, to build support andcreate public pressure or change. Tese are measurable short-term

goals that allow the coalition to see that it is moving orward toward

the twin objectives o decreased pollution and creation o new clinics.

Meeting these interim goals will demonstrate to the community and to

the public that this campaign is serious about diminishing the impact

asthma is having on the community. Planning should include specic

timelines or reviewing interim goals so that the coalition will regularly

assess its progress and make changes, i necessary, about how to go or-

ward. Regular evaluation o how you are doing is a way to ensure that

the coalition is working toward success.

Assssm Rsurs

Part o the planning process is to assess the resources o the commu-

nity and potential coalition members, particularly the ability to work

together. Is there a history o working together or working separately?

Can there be agreement on leadership? Are there enough people with

enough skills and experience to succeed? In addition to leadership, you

need people with the skills to do surveys and to gather acts and inor-

mation that can be used to document the problems. Someone will needto be able to get people out or meetings, as well as or news coner-

ences and other community events. You will need speakers who can

represent the community or coalition. Is there a way to pay or supplies


22/90


and out-o-pocket expenses, places to meet, and computers to use? Are

there phones to call the media and to call the community or meetings?

Is there someone who can manage e-mails and a Web site? I necessary,

you can ask those who have these capabilities to join the campaign.

Most o the logistical needs can be provided by local churches, com-

munity organizations and individuals. But peoples time or the actual

research and community surveys, or organizing and communicating,

or draing notices o meetings, etc., must be realistically assessed. Te

actual out-o-pocket dollar costs can be minimal, rom zero to a ew

hundred dollars or telephones and copying. It is the people time that

is needed most.

It is possible to nd unds or advocacy campaigns. Individual donors

may be willing to contribute to an eort to solve a community health

problem. In some cases, special public und-raising eorts can be initi-

ated to pay or a campaign such as placing an initiative on the ballot.

Foundations interested in systems change, civil society, environmental

justice or other aspects o health policy work can be consulted about

unding elements o an advocacy campaign or ongoing health advo-

cacy work. Oen coalition members, such as labor organizations, can

contribute needed unds or a campaign.

Depending on the strategy you choose, you may need one or more

individuals with special skills such as lawyers, experienced lobby-

ists, webmasters, und-raisers, campaign managers or media experts.

Usually, one or more o the coalition members who have worked as

advocates will have sta with these special skills. Te strategy you

decide on will depend, in part, on the resources you can count on or

your campaign.

Wha Sra a Whh Pa Whrdss Ar Ma W yu Us?

Advocacy strategy starts with where the campaign will ocus its eorts

to change the rules; that is, which place where decisions are made will

you choose to bring about change?

Advocacy strategy

starts with where the

campaign will ocus

its eorts to change

the rules; that is, which

place where decisions

are made will you

choose to bring

about change?


23/90



csras chs a PaWhr dss Ar Ma

Aer you have gathered together the acts and your analysis and a

working coalition is in place with the resources you need, the next step

is deciding whether to create public pressure, meet with government

ocials or take another course o action. One thing to consider is howmuch time the entire process will take. Can you act within the time

people (the community, the media and government ocials) expect to

see action? Can you expect a decision within the time rame you think

is reasonable?

You need to think about other issues as well: Is the coalition more com-

ortable starting o by talking to the company or agency beore creating

public pressure? Is health at imminent risk requiring immediate strong

action such as a public demonstration? Can you keep up with the work

required to handle the ollow-through steps, including presenting youracts and arguments at meetings and hearings in the capital, i legisla-

tion is introduced? Will the coalition take a backseat to lawyers i you

go to court? Will the coalition be perceived as weak i you dont go to

court?

In choosing a place where decisions are made, remember that you can

decide later to include an additional place where decisions are made

to increase pressure, maintain momentum, continue media and public

interest, and enhance your organizing and coalition building. Success-

ul campaigns oen involve coordinated work in more than one placewhere decisions are made at a time. But it is essential that the work in

dierent places where decisions are made be well-planned and coordi-

nated so that scarce resources are eciently used, decision makers are

held accountable, and the campaign presents a ocused and orceul

presence.

You can useMaking a Plan: Developing Solutions on p. 65 o

the Worksheets to guide your work.

Information on Making a Plan can be found on p. 50 in

Reerences.


24/90


Your campaign will

need to inuence the

public and decision

makers. A just cause

can be more powerul

than mountains

o money and all

the political contacts

in the world.

coMMUnicAting yoUR MeSSAgeinoRMing tHe PUBlic AnddeciSion MAkeRS

Your campaign will need to infuence the public and decision makers.

A just cause can be more powerul than mountains o money and allthe political contacts in the world. Te challenge is to cra a way to

communicate your concerns and goals so that they are understood and

believed, and move people to take the action you seek. Tere are our

oundations or successul communications.

1. You must oer accurate facts and respected analysis.

2. You must present a broadly acknowledged value.

3. You must tell a simple and compelling story.

4. You must reach the right audience.

Using accurate acts and respected analysis is important or the credibil-

ity o your campaign. Your credibility will aect your ability to organize

and build a coalition. It will also aect how you are viewed by the pub-

lic, the media and decision makers. It will be harder to earn support i

you exaggerate or omit essential acts.

A broadly acknowledged value is as direct as lowering the number o

atal auto accidents or providing health care or everyone. Everyone,

o every viewpoint, will support an issue directly related to improving

or maintaining health i it is clearly stated. Tere may be dierences

about whether the solution is easible, aordable, adequate or air, but

your campaign will have the broadest possible support i the underly-

ing cause is based on a broadly acknowledged value. Tose who oppose

your campaign will also be placed in the position o deending why

they will not nd a way to bring about better health.

Facts and values provide the oundation or telling a simple and compel-

ling story. When you add in the real people and institutions that have

been or may be harmed you complete the picture. Successul campaigns

are built on and ueled by making a case that people can understand

and relate to and want to see solved.

In reaching the right audience or your campaign, it is helpul to list

the people who can improve the health issue you are ocused on. Ten

decide what they each need to hear. Next, list the best means o having


25/90

Plain Facts

as mus b aura bu prs a wa ha ras ursa.

r amp:

th cr r Ashma Pr

[hpha] has ras a su

ha shws:

Air pollution from automobile

haus Mrps, cara,

w aras ppm.

It has increased by x% over

h as ar.

Current levels are more than

ub hah saars s b

sa rm.

Incidents of asthma in children

ur 12 ha ub h as

hr ars.

The University Public Policy Center has

u a -ar su ha shws

a r bw ar pu a

ashma hr ur 12.

ths ar h ps as ha ar

h prbm. ths

as b sabsh h bra

aw au ha ras

ashma hr s usrab a

s h sa r a smp

a mp sr h ua

hr sur a sas

ha a b pr.



each audience hear the acts and the story that will move

them to support your eort. Is your audience the public,

opinion leaders, decision makers or potential allies? Do

they need to understand the problem, or i there is gener-

al agreement on the problem, do they need to understand

a solution, why the solution will work and who supportsit? And then, what is the best communication strategy?

Is it the media, print, electronic, Internet, or is the best

method personal meetings, group orums or perhaps a

demonstration?

Keep in mind that the communication goal is not a 60-sec-

ond evening news story or a meeting with an important

ocial. You want more; you want to drive public support

and decision-maker action to move your communitys

health agenda orward.

k Suss rs esabsh h Prbm

Communication eorts should rst concentrate on es-

tablishing that there is a problemwhat it is and who is

being aectedbeore trying to encourage a particular

solution. In some cases, those who are on the ront lines

o health, such as providers or health policy experts, do

not realize that not everyone sees the problems they are

conronting every day. Until a clear and convincing dem-

onstration o the problem has been established, the public,

the media and decision makers will not give credence to,

or may even be conused by, a discussion o how to solve

the problem. Tat is why telling a simple and compelling

story is important; it establishes the problem in peoples

minds and motivates them to nd a solution.

I public opinion leaders, allies, the media and decision

makers know about the problem, including who is being

aected and how they are being aected, you have com-

municated well. ry to ensure that each audience hears

your messagerst about the problem and then about the

solution.

Building support means communicating with the public

by talking to individuals, groups, opinion leaders and de-

cision makers directly, as well as by using the media and


26/90

Saving Food

A amp mmuawas h h pr cara sumrs

wh rsh, whsm pru a h ws

s. cara rwrs, aruur -ps a

h sa dparm Aruur ha sp-

sr h passa saus p prs r

ru hh b ma a s mr ha

h ms sabsh ah ar, whh wr

bas h s h rp. o ar, wh

a bumpr rp pums a hr s ru

was pr, sumr, sr a h a-

as rsaw ha husas s ru

wu b sr r r baus

sa aws.

th ass ahr as ha shw ha

a rmus amu rsh, b ru was

b was rr p prs

hh. th rups as shw ha a ar-

a m supp ru wu rsu

subsaa hhr prs. irma surs

u ha pp w r mra ms

wh wa bu rsh ru r hmss

a hr hr wu b ab s.

csumr, sr a h aa rups

h up wh a w rwrs a rars

wh wa b ab s a h ru

rw. Wr hr, h ra a -

ru a b ha sa, nh aw arsr h sa rsh b ru. ths a-

ua apur a w h au a

h sr h h a h sam m.

th ur ua ss mmua

wr pa:

1. th as: dsr wu

p prs hh a sumrs hab bu a a hah ru.

2. th ap au: Pp shu b ab

bu hahu, arab .

3. th sr: A rma a arm-

rs, rars a sumrs ar wr

hr r hs mm .

4. th rh au: th a

sussu mmua s mssa

h pub, whh pu prssur

sars a a.

th sp s prs h ampa

pp wh a hp ah h rsu u wa.

th rma a armrs, rars a

sumr rups us h ma, mmu

ms, frs, pr rr bas aprs--prs a mmua h

ru prbm. th aruur usr a h

cara dparm Aruur ba

w a h sru hah ru was

.



27/90



the Internet. Communication is reaching people with inormation to

convince them to support your work or better health. Te creation

o tools such as act sheets, background papers, question and answer

handouts, and similar short documents is essential or communicating

your issues. Developing these materials helps you decide how best to

present the issues in dierent and eective ways. Once you have them,these materials can be used in all o your strategies or communica-

tion. Tey can be used or door-to-door canvassing o neighborhoods,

distributed to the media, put up on a Web site or handed out to elected

ocials.

ta wh Pp

A good deal o organizing and coalition building is done by getting

the message out person-to-person, through house and block meetings,

through door-to-door canvassing, by passing out inormation in ront

o supermarkets and at fea markets, and other ways o reaching indi-

viduals. In some communities, church meetings, passing out or posting

one-page fyers, talking to youth groups, or visiting senior centers are

eective ways to reach people. One project to address domestic violence

sent organizers to Laundromats to reach women in the community to

nd out their views, experiences and needs. It worked, and an eective

program was developed.

Tere are many ways to reach out to educate and convince individuals

that there is a problem they should care about. Tink through who is

likely to be aected by the problem and where you can meet and talk

with them. You can build public awareness and personal involvement

by talking to people as individuals. Tis kind o interaction allows you

to learn what inormation helps people understand the issues and be-

come convinced o the cause. You can learn what acts and arguments

are important to people, which can help you develop ways to present

your best case.

Tere are many

ways to reach out to

educate and convince

individuals that there

is a problem they

should care about.


28/90


ta op lars a ds Mars

Direct communication with opinion leaders and decision makers is a

crucial means o building support or your position and getting people

with the power to eect change to act on your behal. An opinion leader

can be a person respected and looked to or leadership by his or her

community, such as the director o a local program, a local pastor, thepresident o the womens committee or an elected ocial. Tese infu-

ential people can take a leadership role in a community eort to work

or better health. An opinion leader can be asked to help right rom the

beginning and may even be the right person to lead or be the spokes-

person or the coalition. Such a person can give more visibility and

importance to your coalition and can help convince others to join.

You also want to communicate with the decision makers, people who

can take the policy action you need or bettering your communitys

health. You need to nd out who will infuence or make the decisionson your issues. Tey may be government sta, corporate executives,

hospital directors or personnel, elected ocials or potential unders.

Once you nd out who the key people are, arrange to reach them di-

rectly. When you communicate with decision makers you want to be

prepared with acts, inormation and analysis and have a coalition or

other strong support with you. Whether you arrange a lunch meeting,

an oce visit or a ormal hearing, your presentation should be planned.

You want to decide on:

> th purps h m

> th ma ps suss

> Hw srb h prbm ar

> Wha paprs r maras u w br

> Wh w a ur rup ur h m

> Wh w spa, wha ps a wha rr

> Wha h rup w as r

When meeting with decision makers it is important to stick with the

acts and not overstate the problem or use infammatory rhetoric.

When you commu-

nicate with decision

makers you want to

be prepared with

acts, inormation

and analysis and

have a coalition or

other strong support

with you.


29/90


30/90


cmm Was Rah h Ma

News Releases

A news release tells the story o what is wrong, who says so and what

should be done. News releases are usually no more than two pages and

are a good way to keep reporters and editors up-to-date on the progress

o the campaign and important events.

News Conerences

At news conerences people supporting your position talk to reporters

about the acts and analysis o the problem and the solution. Te speak-

ers have an opportunity to explain data, describe who is being hurt, and

explain why the proposed solution will work. Te purposes o the cam-

paign can be laid out, members o the coalition can be introduced and

reporters can ask questions. News conerences should be reserved or

unusually signicant events and complex subjects.

Reporters and Editors

It is important to call and meet with the people who decide i your

campaign is newsworthy and how it will be covered. Tese personal

conversations give you a chance to nd out what journalists think about

what you are doing. It also gives you a chance to nd out what others

are saying about your campaign.

Editorial Writers

You can try to get a newspaper or other media source to support your

position publicly and urge the action you seek. Present your acts andreasoning either over the phone or in an editorial meeting.

Letter to the Editor

You can respond to any related event by writing a short letter to the

editor o a newspaper with your comment or viewpoint. Tis can be a

reminder to the public and all concerned about your position and your

sustained involvement in activities related to the issue.

Opinion Piece

Newspapers and some radio and V stations will carry a well thought

out essay describing your issues. You need to contact the opinion editorto discuss what he or she is looking or, how long your piece can be and

when it can be run.

op p: nwspaprs a sm ra a tv sas w arr a

w huh u ssa srb ur ssus. yu a h

p r suss wha h r sh s r, hw ur


31/90



th R h ir

Te Internet is an ecient and inexpensive way to reach the public,

the media, and decision makers in government and corporations. Ad-

ditionally, with a little extra eort, the Internet can be used or und

raising. Te two main tools o Internet advocacy are e-mail and Web

sites. You can use e-mail to educate and enlist new supporters to yourcampaign, to communicate with coalition members, and to com-

municate with other campaign members by personal mail, listservs,

discussion orums and action alerts.

A Web site can be a powerul tool or communicating: your campaign

goals, plans, and identity; inormation on how to get involved, con-

tact and contribute to the campaign; how and when to contact decision

makers; and when to show up at meetings, rallies, and hearings. A

Web site provides the media and policymakers initial access to your

campaign and a way to ollow up and contact you directly or moreinormation.

Te Internet enhances and expands your campaigns communications,

which are essential to health policy advocacy. It is not, however, a sub-

stitute or the direct, personal contact needed to successully organize,

educate and persuade supporters, the media and decision makers. Re-

member not to overuse e-mail by inundating your supporters and the

media with an outpouring o nonessential inormation. You also need

to be aware that IRS rules or nonprot advocacy activities apply to the

use o the Internet. For more guidance see E-Advocacy or Nonprots:Te Law o Lobbying and Election-Related Activity on the Net, published

by Alliance or Justice. (For more on the Role of the Internet, see

p. 52 in Reerences.)

o be successul, your campaign must use every available method to

tell the story o how existing conditions are hurting people and how the

situation can be improved.

You can use Communicating Your Message: Getting the Word Out

on p. 70 of the Worksheets to guide your work.

Information on Communicating Your Message can be found on

p. 51 in Reerences.

Te Internet enhances

and expands your

campaigns communi-

cations, which are

essential to health

policy advocacy.


32/90


Advocacy PrinciplesGuidelines or SuccessHealth policy advocacy builds on many skills you now have. Success requires creativity, hard work and

perseverance. It can all be a bit easier i you keep this list o principles in ront o you as you advocate

or better health solutions.

Bas Prsa Prps

aua aura

ta hs

Rspsb (keep infammatory rhetoric in check)

Rsp s

Bas Wr Prps

Wr wh a a

d h prbm

Ha a pa wh rm as a a as

iu mmu bu

B fb abu sras

d huma pp

Bas campa Prps

ram h ssu a sr

Sa h s

Ras h sas

Sa mss sra

n par ps

Bas Susa Prps

Maa prsp

Ha 3 5 asrs

Ha a

nr h s r

nr qu


33/90


ns:


34/90


Aa Pas Whrdss Ar Ma3Health policy decisions are made in many places by many individuals

and institutions. Tey are made by elected and appointed ocials who

serve in local, state and ederal governments. Tey are made by the

courts and by people themselves through the ballot box. Tey are also

made by private sector organizations such as health plans, hospitals

and corporations. You must identiy which decision maker can best

address the problem you have identied.

cHAnging tHe lAW

A primary means o bringing about change is to try to persuade the

state or ederal legislature, local city council or county board o super-

visors either to pass a new law or to change existing laws. For example,

in 2001, consumer groups in Caliornia sponsored a law that required

reporting on the outcome o coronary arterial bypass gra surgery and

other procedures done in the state by naming the hospital and sur-

geon or each procedure. Te coalition was inspired by a similar rule

in New York that had resulted in saving lives. Te medical proession

and others joined consumer groups, and the governor signed the bill in

September o 2001. Tis new law will result in better quality health care

and the better practice o medicine.

csras

Legislation must be carried by a politician trusted by the coalition to

work in partnership to pass a new law that will really meet the com-

munitys health needs and not someones political agenda. Te elected

ocial who agrees to carry your legislation must be a person with

the credibility, time, energy and sta to actually get the bill passed

and signed into law. Te coalition members must be careul to avoidbecoming viewed as working with one political party or the other.

Te elected ocial

who agrees to carry

your legislation must

be a person with the

credibility, time, energy

and sta to actually

get the bill passed and

signed into law.


35/90


cHAnging tHe lAW

+ Puss - Muss

Legislators and local legislative

ofcials are elected and, at least

theoretically, accountable tovoters.

Drafting and passing legisla-

tion is a highly political process.

Elected ofcials will weigh howtheir actions might help or

hurt their standing with voters,

campaign contributors and

supporters.

In smaller communities, elected

ofcials may be very accessible

to members of the public.

The state legislature is in session

for only part of the year. There

are also deadlines for introduc-

ing bills and for proposed bills

to make their way through the

legislative process.

Unlike the courts, the legislature

can look beyond the law and

broadly examine public policy.

Legislative rules typically make

it easier to stop proposed laws or

ordinances than to pass them.

A law enacted by the state leg-

islature can address a problem in

communities statewide.

Elected ofcials like to please

everyone, which makes it more

difcult to pass controversial

legislation.

An ordinance adopted in onecommunity can be a model for

other communities. A new law

enacted by the California Legis-

lature can be a model for other

states.

Sacramento (or Washington, D.C.)may be far enough from your

community that it is difcult for

community leaders and support-

ers to meet with legislators and

attend hearings in the capital.

Information on Changing the Law can be found on p. 53 in

Reerences.

Aa Pas Whr dss Ar Ma


36/90


In trying to get a

government agency

to solve or prevent a

health problem, you are

relying on that agency

to be willing to support

your coalitions analy-

sis o the problem and

what needs to be done.

WoRking WitH goveRnMent AgencieS

At the ederal, state and local levels, there are government admin-

istrative agencies (departments, commissions, boards, etc.) that are

responsible or various aspects o the health care system. Te details

o a public policy are oen determined by the regulations issued by ahealth agency aer a law has passed.

Federal, state, regional and local agencies have the power to adopt,

amend or repeal rules governing health care, saety and the environ-

ment. Tey can also bring enorcement proceedings to stop actions

that violate the law or agency rules and can even ne and revoke the

licenses o violators. Agencies also have the power to investigate prob-

lems and advise the executive branch (president, governor or mayor)

and the legislature regarding the need or new laws, programs and oth-

er governmental actions that would improve our health care system.

Tere are several ways to try to impact how an agency serves the health

o your community. You may want to ask an elected representative

to write or call an agency director and schedule a meeting, inviting

the community coalition leaders to join, or the coalition may ask or

a meeting directly. Te coalition or an elected ocial may arrange a

town hall meeting and invite the agency director to attend and partici-

pate. You may also encourage a reporter to investigate and write a story

on the problem your community has identied. A more ormal way to

encourage change is to le an administrative petition.

Te Caliornia Government Code gives any person the right to le

an administrative petition to a state agency requesting the adoption,

amendment or repeal o a rule. Te U.S. Constitution also gives people

the right to petition any government agency or the redress o griev-

ances. Advocates have used these rights to bring about important

reorms in Caliornia. For example, Consumers Union and 24 other

community organizations successully petitioned the Department

o Corporations to adopt rules regarding the conversion o nonprot

health maintenance organizations into or-prot entities, therebyestablishing procedures to protect the interests o the public. (See the

sidebar on p. 12 or more on this coalitions success story.)

csras

In trying to get a government agency to solve or prevent a health

problem, you are relying on that agency to be willing to support your

coalitions analysis o the problem and what needs to be done. In some


37/90


cases, the community members may view the agency itsel as the

problem. Nonetheless, it is almost always a good idea to get your in-

ormation and analysis, gather your support, and talk to the decision

makers in the agency. I you are not successul, you can then make the

point that, We tried to work with the agency, but they reused to pro-

tect our communitys health needs. Tat is why we have come to thecity council or action.

WoRking WitH goveRnMent AgencieS

+ Puss - Muss

Since agencies typically have

broad authority to act in the

public interest, they can address

actions that are harmful but not

necessarily illegal.

Since agency heads are

appointed by the executive

branch and subject to oversight

by the legislature, they are still

subject to political pressure.

You can request agency action at

any time, request immediate action

in emergency situations, and address

problems on a statewide basis.

In some instances, the legisla-

tive branch may have expressly

limited an agencys power over a

specic practice or type of entity.

Agencies can act relatively

quickly (months, rather than the

years sometimes required for a

lawsuit or legislation).

Because of their backgrounds

and experience, agency heads

and staff members may be

sympathetic with the industry or

profession they are responsiblefor regulating.Depending on the issue, going di-

rectly to the decision maker may

be less political than the legisla-

tive or legal process. (In most

cases, friendly legislators can still

help your cause before the agency

by voicing their support.)

Filing an administrative petition

is a formal action that is taken

seriously by agency ofcials andthe media.

Community leaders do not have

to be represented by lawyers.

Information on Working with Government Agencies can be

ound on pp. 42 and 53 in Reerences.



38/90


Health policy change

can take place in

hospitals or health

plans as well as in reg-

ulatory or accreditation

bodies or proessional

organizations.

WoRking WitH HeAltH cARe inStitUtionS

Health care institutions set policies and practices in response to laws

and regulations, but also independently. Tese policies can determine

how health care institutions operate, and can include, or example,

the quality and level o services provided or who has access to suchservices. Health policy change can take place in hospitals or health

plans as well as in regulatory or accreditation bodies or proessional

organizations. Health care institutions can be part o the government

(e.g., a county Department o Health Services) or they can be in the

private sector. Private sector health care institutions can be nonprot

organizationsincluding providers (e.g., Kaiser), medical associations

(e.g., Caliornia Medical Association), or regulatory bodies (e.g., Joint

Commission on the Accreditation o Healthcare Organizations)or

or-prot enterprises, such as a health plan or pharmacy.

A health care institutions goal is to improve health, primarily by pro-

viding services to consumers. It may also seek to prot or serve a social

or religious mission. I it is not serving the community, your job as an

advocate is to show that it is not doing its job and how it could improve.

Health care institutions are places where you can advocate or decision

makers to directly implement better health solutions.

Whether the decision maker is responsible or a government health care

provider or a private health institution, you need to take the same steps

to make change happen. With acts, support, planning and communi-cation, these institutions can be persuaded to change their systems and

improve your communitys health care. Because health care institutions

can be either governmental bodies or private companies, be sure to

read Working with Government Agencies and Working with Private

Companies in this chapter when planning your campaign.

csras

Decision makers or health care institutions can be held accountable

i they are not providing or improving health care consistent with

their goal and mission. Some will welcome community involvement

in identiying problems and working toward solutions. Others may be

unhappy about being called to task or alling short. From their per-

spective inside the institution they may eel that they are doing all they

can with the resources they have or without making less prot. It is

important to recognize the decision makers concerns, but advocates

must represent the communitys perspective on the quality or degree o

services being provided when advocating or change.


39/90


For example, community health care advocates in Oregon prepared a

report on the bill-collection practices o a local hospital, which included

home oreclosure. Teir report then compared the harassment o pa-

tients who were too poor to pay their bills with the hospitals claims o

providing ree and uncompensated care to the community. When the

hospitals decision makers were shown a copy o the report they agreedto change their policies, to provide real ree and uncompensated care,

and to cease harassing those too poor to pay or needed services.

Agreeing on and describing the health care problem, explaining how

it is aecting community members, and then comparing the problem

to the goal and mission o a health care institution can be an eective

strategy or a campaign.

WoRking WitH HeAltH cARe inStitUtionS

+ Puss - Muss

Health care institutions stated

goal of providing quality health

services for a community pro-

vides a lever to encourage policy

change to better those services.

Decision makers can be very

defensive and closed minded

when told that their institution

is failing to meet the communi-

tys needs.

Documenting problems threatens

to damage a health care insti-

tutions reputation, which can

impel its decision makers to

work with the community to

reach solutions.

Community members may not

be affected by the same prob-

lems or they may be reluctant

to challenge their local health

care institution.

Many health care institutions

want to maintain good commu-

nity relations and are open to at

least discussing problems experi-

enced by community members.

Raising a serious problem may

cause outside critics to suggest

shutting down a facility rather

than working to solve the

problem.

Working with decision makers in

health care institutions can leadto more open and continuing dis-

cussions and better community

health in the future.

Many local providers are part of

a larger state or national chain,which may make them harder to

inuence.

Improving practices in one

health care institution can lead

other institutions to change.



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WoRking WitH PRivAte coMPAnieS

Private businesses have an enormous stake in improving the delivery o

health care in Caliornia. Many businesses either provide or would like

to provide health insurance coverage or employees and their amilies.

Other businesses, such as pharmaceutical manuacturers, managedcare companies, hospitals and nursing home chains, provide the prod-

ucts and services that make up our health care system. How they go

about doing business is infuenced by each companys private policy

decisions.

Working with private businesses to bring about change in their poli-

cies may involve meeting one-on-one with executives or departments

to help solve a particular problem (or example, making certain pre-

scription drugs available at no charge to pediatricians in low-income

neighborhoods). It may also involve urging businesses to be part oa larger alliance to reorm the system itsel through new laws, rules,

structural changes or incentives.

Te Environmental Deense Fund (EDF) worked with McDonalds to

reduce the use o antibiotics to enhance the growth o bee and chicken.

Aer lengthy discussions and negotiations, McDonalds entered into

an agreement with EDF to not purchase chicken or bee produced

with growth enhancing antibiotics. Tat decision has meant the arm-

ers have had to change how they raise animals i they want to sell to

McDonalds. By working with business, EDF brought about a policychange that could benet the health o millions o people.

csras

Working with business will almost always result in less than what the

community thinks is the best way to solve its health problem. Keep in

mind that a solution proposed by a company may not be ideal rom the

community point o view, but it must be at least a good part o what is

needed to improve or maintain health or the coalition will challenge

the company to do better. Some groups and individuals may still be un-

comortable working with corporations they view as the bad guy, and

they may criticize the coalition. But with sucient outside pressure,

including pressure rom critics o the coalitions eorts, private com-

panies can be convinced that it is in their business interest to change

their policies.

Working with private

businesses to bring

about change in their

policies may involve

meeting one-on-one

with executives or

departments to help

solve a particular

problem.


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WoRking WitH PRivAte coMPAnieS

+ Puss - Muss

Since its public image is a very

valuable asset, a business may be

especially willing to help address

a specic problem if it enhances

its image among consumers,

shareholders, employees, govern-

ment ofcials and/or the media.

Every business is a for-prot

entity. Typically, businesses will

oppose proposals that might

harm their economic interests,

support proposals that further

their economic interests, and be

indifferent to proposals that do

not affect those interests.

Large corporations have consid-

erable resources that could be

enormously helpful in bringing

about change (money of course,

but also media and public rela-

tions resources, lobbying and

governmental affairs staffs, and

high level contacts with other

large businesses, foundations

and government).

Businesses will want public

credit for working with com-

munity groups, sometimes even

when they are doing little or

nothing to address community

concerns. (Simply meeting

with community groups, for

instance, could be inated by

a corporate public relations

department into working

closely with [your organization]

to attack [your problem] in

[your neighborhood].)

Support from businesses (both

large corporations and small

companies) may increase the

credibility of your proposal and

lead to wider political support.

Many businesses have little or

no experience working with

community groups and may

initially be hostile, suspicious

or slow to understand how their

interests overlap with those of

the community.Change by a large corporation

can have an effect on its many

suppliers by forcing them to

provide better products.

Getting one corporation to

change can set standards forothers to meet.

Information on Working with Private Companies can be

ound on p. 53 in Reerences.



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USing tHe BAllot Box:tHe initiAtive And ReeRendUM PRoceSS

Te Caliornia Constitution gives voters the power to adopt new laws

by initiative and repeal existing laws by reerendum. Te charters o

many local governments also provide or direct lawmaking by votersthrough the initiative and reerendum process.

Health care and consumer activists have used the initiative process to

pass measures that have been blocked in the regular legislative pro-

cess. For example, health advocates in Caliornia successully passed a

tobacco tax proposal that repeatedly ailed in the state legislature.

Like any proposed law, an initiative measure needs to be careully dra-

ed to achieve the result you are seeking and, i possible, avoid problems

or opponents to attack. In most cases, sponsors o an initiative need tocollect a minimum number o signatures to have the proposal put on

the ballot, and at least 51 percent o the voters who show up to the polls

must vote Yes or it to pass.

csras

Passing a ballot measure requires signicant time and energy. For

the last six weeks o a campaign its a fat-out eort that can eel over-

whelming, as well as exhilarating. Working on an initiative is a very

public process where everything and every group are subject to scru-

tiny by the media and the public. Te leadership and the members othe coalition must be prepared to have their actions subject to intense

public review.

Health care and

consumer activists

have used the initiative

process to pass mea-

sures that have been

blocked in the regular

legislative process.


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USing tHe BAllot Box

+ Puss - Muss

The initiative process can

circumvent the regular legisla-

tive process and tap into public

outrage about a problem.

Huge amounts of time and money

can be expended to qualify and

pass an initiative.

Some initiatives (typically on

social issues) do not draw any

opposition or require a huge

expenditure of money.

Often voters are not sympathetic

to complicated measures, spend-

ing additional tax dollars or

passing new laws.

If passed, an initiative can have

lasting impact (e.g., Proposition

13 on property taxes, Proposition

98 on school funding, Proposition103 on insurance regulation).

If a proposal could harm a major

economic interest, expect strong,

well-nanced opposition.

Information on Using the Ballot Box can be found on p. 54 in

Reerences.

USing tHe coURtS

One method o bringing about change is to le a lawsuit. When legisla-

tive and administrative actions were blocked by the powerul tobacco

industry, lawsuits nally helped to bring about important reorms.

In a lawsuit, the plainti must do more than simply argue that what the

deendant is doing is wrong or harmul. A lawsuit contends that the

deendant is violating constitutional, statutory or common law.

ypically, lawsuits are brought either to stop actions that violate exist-

ing law(s) or to require actions that are mandated by existing law(s).

On occasion, when an appellate court interprets existing law in a new

way, a lawsuit can result in changing how the law is applied.

csras

Keep in mind that there are situations when community members

may eel that taking the matter to court is necessary to show that the

community is strong and orceully pursuing its rights. Tere are also

situations when the decision maker may agree, but because o political

considerations wants the courts to orce her or him to take the right

A lawsuit contends

that the deendant

is violating constitu-

tional, statutory or

common law.



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action. When a government agency or private corporation is sued, it

generally eels that it has been attacked. Litigation can cause the people

you want to make decisions to become angry and reuse to talk to you.

It is wise to try other approaches beore going to court.

USing tHe coURtS

+ Puss - Muss

A lawsuit can be led on any

business day of the year.

It is difcult for courts to

address matters of pure policy

for example, nding the best way

to solve a health problem.

Plaintiffs can ask for emergency

orders or injunctions to prevent

irreparable harm.

Unless sufcient funding is avail-

able, going to court requires a

lawyer who is willing to work

pro bono or for a contingent or

reduced fee.

Courts may be less overtly politi-

cal than other venues. (However,

depending on the state, judges

may be elected or appointed by

elected ofcials.)

Once a suit is led, the focus

tends to shift to the court and

the lawyers, making it harder for

members of the community to be

involved.

A lawsuit can result in an impor-

tant legal precedent that leads

to reforms in other areas.

A well-funded defendant can use

tactics that drive up costs in an

effort to exhaust a plaintiffs

funds.

In some types of cases, there

is the potential for recovering

attorneys fees and litigation

costs.

Lawsuits can take quite a long

timesometimes yearsespe-

cially if appeals are involved.

Information on Using the Courts can be found on p. 54 in

Reerences.


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diRect gRoUP Action

In some cases it may be necessary to take direct group action to ocus

public attention on an issue. For example, i ling a lawsuit, going to

the legislature or ling an administrative petition is not easible, you

might explore whether a respected local institution (e.g., League oWomen Voters, PA, newspaper, community clinic, church or union)

would sponsor a public hearing on the issue. Ideally, the sponsoring

institution would work closely with community leaders to schedule the

hearing; invite speakers, elected ocials, policymakers and the media;

plan the agenda; and actually convene and chair the hearings.

csras

Te success o taking direct group action will oen be judged by the

number o people who turn out, the importance o the participants and

the general seriousness o the event. You are asking the media and the

public to pay attention to your event, so a good deal o planning and

organizing is essential to present your best possible case. Some may as-

sume that you are holding your own event because you have no other

support. You will need to ocus on the act that you are not relying on

others and have the strength and creativity to bring your communitys

health issues in ront o the public and decision makers.

diRect gRoUP Action

+ Puss - Muss

Community leaders will have

input into many aspects of the

event, including subject matter,

how issues will be presented and

who will be invited.

Scheduling a hearing and invit-

ing people to attend is easy.

Actually getting them to pre-

pare, attend and participate in

a manner that will result in an

effective event requires exten-

sive one-on-one effort.

A carefully planned and well-

orchestrated event can educate

government ofcials, local politi-

cians, reporters and the wider

public about your particular

problem.

Direct group action is not an

end in itself but sets the stage

for other actions to bring about

change, including legislation,

litigation, petitioning admin-

istrative agencies and working

with private businesses.

Te success o taking

direct group action

will ofen be judged

by the number o

people who turn out,

the importance o the

participants and the

general seriousness

o the event.



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diRect gRoUP Action cont.

+ Puss - Muss

Public ofcials can be called

on for their views. They may be

given the opportunity to tellthose attending the hearing or

other event what action (if any)

they plan to take to address the

problem.

The logistics can be daunting:

Community leaders and the

sponsoring institution will haveto decide where and when to

hold the hearing or other event;

whether the facility can safely

accommodate the number of

people expected; what the tone

should be; who should be invited

to attend and speak; who should

chair the event; how the event

should be opened; who should

speak, in what order and for how

long; how to control speakerswho try to dominate or divert

the hearing or other event.

Organizing a public event can

utilize community resources and

build the communitys capacity

to advocate for its health needs.

Information on Direct Group Action can be found under

Health Care Advocacy on p. 45 in Reerences.

No matter where you decide is the best place to advocate or which

decision maker you decide is the best to help solve the problem you

have identied, you will need to take certain ollow-up steps to ully

implement your strategy.

You can use the Worksheets starting withAfer You ake Action

on p. 76 to help organize your work and carry out your campaign

successully.


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Advocatingfor Change | Understanding How to Impact Health Polic