Monthly Policy Blog

A primary focus of CCUIH is to advocate for policies that improve the health of American Indian and Alaska Natives. In posting these monthly policy blogs, we aim to bring you current policy priorities and advocacy. 

A Policy Story in 6 Steps

A primary focus of CCUIH is to advocate for policies that improve the health of American Indians and Alaska Natives. Through our blog, we will bring you current policy priorities and advocacy. This year’s first blog will explore the six primary policy elements.

Policy tells a story; like all stories, there is a problem to solve or overcome and a solution. To better understand the 6 primary policy elements, I will take you through a story that has impacted my life and maybe yours. At the age of 3, my mother contracted wild polio. At this time, in the 1950s, polio paralyzed more than an estimated 15,000 people each year, and at its peak in 1952, the U.S. reported 57,628 cases, 3,145 deaths, and 21,269 people struggling with mild and disabling paralysis

In 1952, right before polio’s peak, my mother spent three months in the hospital, strapped to a board and isolated. Once she returned home, she required physical therapy three times a day. She graduated from casts to braces to walking unassisted but with a limp and permanent paralysis diagonally across her body. Her story didn’t end there. We have learned that this disease returns. She now has post-polio syndrome and is back to braces and a walker for mobility, as well as requiring constant care. 

Fortunately, years later, widespread vaccination campaigns have helped to eliminate many debilitating diseases, including polio, all facilitated through the policy process. Let’s dig deeper into the policy elements that helped eradicate wild polio.

Policies are not necessarily laws but can take the form of laws, regulations, and bills. I like to think of policy as the how-to to get where we want to go, like a road map to address an issue. And, like any roadmap, there are different turns we can take along the way to get to the same destination, and sometimes these are shortcuts and other times detours. Below, under each policy element, will be an example that led to polio eradication in the United States.

Six Policy Elements

1. Define the Problem

In this first step, we must define the problem. Perhaps a situation has emerged suddenly, or a problem has grown, so it must be addressed. Sometimes, an issue has been present for decades, and then a group or individual brings the problem to the forefront.  A problem may be a foreshadowing so that the definition could be built on the expectation of a future crisis and the policy is preventative. Regardless of how the problem emerges, we must define the issue to start working toward a solution. 

Example: Cases of polio continued to rise, becoming a public health issue with several epidemics occurring between 1948 and 1955

2. Set the Agenda. 

In this second step, we can assemble evidence and put the problem on a policy agenda to get decision-makers’ attention. Setting the agenda is essential to ensure the problem will be examined and, hopefully, a solution will be proposed and implemented. This step is also where we assemble evidence for the issue to highlight its importance and impact. 

In this step, I ask myself the 5 Whys to understand the situation’s root and ensure I ask the right question to solve the problem.

Example: Before a vaccine was readily available, and with case counts so high that included death and mild to severe paralysis, parents were fearful of letting their children out of the house and even playing with others. Children stopped going to school, and communities were distraught. Case counts continued to rise, and it was clear a polio vaccine needed to be a priority to protect the country’s health, economics, and social structures. This priority agenda-setting quickly led to the first polio vaccine being licensed and ready for distribution in 1955

Furthermore, when we ask ourselves the Whys regarding high cases of polio, this is what we find:

Why are polio rates so high?

Increased cases are because polio spreads very quickly and easily through person-to-person transmission.

Why is polio spreading so quickly?

Children have the highest case rate due to their lack of sanitation and proximity to one another, increasing transmission.

Why is lack of sanitation and proximity more likely with children?

Children are more likely to put items in their mouths, including their fingers, after touching random surfaces. Also, children congregate together in schools, pools, and daycare centers.

Why do children congregate?

We need children to be socialized and learn in a group setting as part of their healthy development.

Why do we need children to be part of a group and societal system?

Children grow up to be adults.

We do not always need to ask additional Why questions if a root appears in any previous questions. I often ask one more why, in case there are multiple roots. The final root is evident in this case, and the pertinent details are in the prior Why responses.

3. Consider Options 

At this point, the policy agenda is set to include an identified problem. Now, we get to continue to use the roots we identified in the 5 Whys statement to develop considerations. In this step, decision-makers should consider the options when determining a solution. Consider including the potential opposing arguments to each proposed solution. 

Example: In this case, the vaccine was now available. However, the problem remained: how to prevent children from contracting polio and decrease the disease’s overall prevalence for years to come. Like many roadmaps, sometimes you may have a destination in mind. In this case, the destination or goal was to create high immunity (protection) within populations to slowly lead to eradicating the disease. We know that special consideration should include children and their socialization needs. 

        Potential Options:

A. Keep children home until cases decrease

B. Ensure all children are vaccinated

C .Provide vaccination guidance

D. Close all communal child gathering areas such as pools and daycares

E. Vaccinate annually

 

4. Selecting Criteria

When we make decisions, we do this based on criteria. In policy, we typically collaborate with others, and it is more effective when groups, stakeholders, and decision-makers agree on the criteria. Sometimes, these are all the same people or groups, and sometimes they differ. A shared criterion acts as an agreement on how considerations are weighed to arrive at a decision. To help guide these conversations, I use a Decision Matrix to find common ground. Think of this as how you decide where on your roadmap you want to take a turn or if you will include a detour or a shortcut. What will you gain, and what may you lose? What are the most important factors when deciding, such as time, money, number of people impacted, etc.? 

Example: In this example, the decision-making group selected the criteria to include children, decrease transmission, eliminate the disease, and have infrastructure already in place. The total scores clearly show that multiple options fit the requirements listed. Sometimes, the best solution may be the result of combining various options. 

5. Implementation

This fifth step is where programs are created or modified, or some action step occurs to implement the proposed solution. Picture the scene when the problem has a resolution (s) and what will be required to administer, such as what people or groups may need to be included, who will take ownership in implementation, evaluation, and other strategies. 

Example: Childhood immunization was proposed to help eradicate polio in the United States. This solution included guidance recommending that four doses of the polio vaccine be given to children before or by the first day they enter school. Over time, the cases declined sharply to less than 1000 cases in 1962 and remained below 100 cases after that year.

6. Monitoring and Evaluation

This last step is to identify the impact of the policy by asking many questions, such as: Did we solve what we were trying to solve? How many people were reached with this solution? Are there any groups of people that may still be affected by this initial problem (look at the equality and equity of the solution)? Is the problem still prevalent, and how much has it changed? Should anything be added or retracted from the implemented solution to be more equitable? Asking questions allows us to accurately account for the process and see where we may need to go back and make adjustments. Ensure that the evaluation metrics include more than quantitative analysis, such as qualitative information from the impacted community and other culturally applicable measures. A different team or group of leaders may guide the evaluation to ensure the policy implementation has efficacy and remains valid.

Example: Polio has since decreased globally by 99%, with only two countries reporting wild polio cases.. Monitoring and evaluation of polio continue today and include governmental and non-profit organizations often working together. Another part of this story is childhood immunizations, and there continue to be cases of diseases we once thought were eliminated that resurface in communities when children are not vaccinated. Continuous monitoring and evaluation of vaccination guidance is necessary to ensure the effectiveness of these strategies. The evaluation process also helps us uncover lessons learned.


Using the policy process can facilitate many phases of disease eradication. The examples above demonstrate six policy elements that can drive change. This work came too late to change my mother’s life. However, her perseverance and strength through this debilitating disease continue to inspire me to work toward using policy to make positive change, especially regarding health and our American Indian and Alaska Native communities. Remember that these policy elements are not always linear and often need to be repeated to ensure the problem does not reemerge. Specifically, the Monitoring and Evaluation steps for polio eradication continue to keep our communities safe and children healthy and are helping to eradicate polio worldwide.


CCUIH will be releasing a monthly blog throughout 2024. If you have policy topics or questions you’d like to see covered, please contact nanette@ccuih.org.