Examination of the policy-making process for TB elimination

Numerous studies of health programs have shown that somewhere along the path from policy initiative to program implementation, choices are made which prevent programs from reaching the original goal. It has been argued that these program failures happen because policy choices create problems in the implementation process. This conclusion is troubling because it implies that these program failures are not inevitable; they are the result of misunderstanding or misrepresentation of the problem that the program intends to address. Why or how do these choices get made? The national Elimination of TB campaign, specifically the goals of targeted testing and treatment of Latent Tuberculosis Infection (LTBI) among foreign born individuals, has many of the textbook ingredients for ineffective implementation. There are documented high rates of non-compliance in this population, and confusion among providers about protocols and the necessity of prophylactic treatment has led to vigorous debates over the priority of such programs and uneven implementation nationally. Additionally, the high cost/benefit ratio of prophylactic treatment may be unconvincing for many state and local Health Departments. This problem and target population may be “difficult” ones, but it can be argued that more important are the political, social and economic concerns which contribute to their negative construction by policy makers. To understand how and why choices are made, the goal of LTBI treatment in the foreign born population was examined through an interpretative policy analysis, an anthropological technique which describes policy making through the use of ethnography which follows the process and culture of the policy process, and focuses on the perceptions or constructions which underlie recommendations or implementation. Past and current Tuberculosis treatment policy was examined to help describe the context of decision-making and the way that perceptions of the problem have spurred and continue to spur action. Special attention was paid to policies and programs directed at immigrants, the construction of immigrants as “high risk” and the revision of national policy to reflect emerging concerns. Additionally, CDC guidance documents were analyzed for changing prioritization, as well as recommendations and language directed at the problem of LTBI in the foreign born population. Additionally, 24 policy makers, TB program managers and health care providers were interviewed; these qualitative data were analyzed to understand how policy-making takes place, and how the different “levels” of actors view LTBI policies, the decision-making process regarding interventions aimed at LTBI and the target population of foreign born individuals.