Background: Like many urban areas, the Perinatal Periods of Risk Approach (PPOR) analyses conducted by Columbus Public Health indicated that addressing women's health is key to improving reproductive health outcomes. ( PPOR is a comprehensive approach to improving perinatal health outcomes at the community level. It includes a simple, systematic process for analyzing existing vital records and other data sources which enables communities to better understand and address local feto-infant mortality problems. Many urban health departments have used the PPOR approach to engage community stakeholders and create change in programs, policies and outcomes.)

The CDC report, Recommendations to Improve Preconception Health and Health Care - United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care provides a broad framework for how to go about improving preconception health. One of the report's recommendations is to assure health insurance coverage for women with low incomes. Family Planning (FP) Waivers granted by Centers for Medicare and Medicaid Services (CMS) are a viable strategy to fund some health care services for non-pregnant, low-income women; however, the State of Ohio does not have a CMS Family Planning (FP) Waiver.

Policy Solution: Implement a Family Planning Waiver in Ohio to address Preconception Health.

Policy Development Process: Work on this issue began in late Fall 2004 and continues today. Many toolkits define steps or approaches to creating a group to work on the issue, and while specific tools to guide the work were not employed, principles and ideas from some of the tools mentioned above were utilized (see The Healthy Start Guide to Effective Community Involvement or visit the American Public Health Association Website for specific tools to guide you in the process).

Some alliances can be very formal, collaborative partnerships, who develop their own vision and mission. This alliance, for most of the work to date, has been a "work group." The process began with convening the right people to start the work (see community assessment efforts discussed in the Community Action Toolkit and the Strategic Tobacco Retail Effort (STORE) Campaign). The work reflected steps and products similar to those found in the issue-specific ACOG toolkit.

The core group consisted of three organizations (all of whom were independently thinking about the steps needed to develop an Ohio Family Planning Waiver):

• Local Health Department (LHD) - Columbus Public Health
• State Health Department (SHD) - Ohio Department of Health
• The Center for Community Solutions (a non-profit agency)

Action steps taken:

1. Initial work was exploratory and background information and data were gathered.
2. The effort was expanded to include other working partners, followed by the addition of key advocacy players.
3. It was determined that the Center for Community Solutions would take the lead.
4. The LHD used Federal Healthy Start dollars to fund staff support through the Center for Community Solutions. The SHD was initially a quiet public partner due to the politically sensitive nature of this issue. The "work group's" efforts progressed with the three main partners and have now involved others.
5. The initial Work Group focused on shared learning.
6. Many states were consulted to see how they developed their own waivers. These states indicated that impetus came from the Medicaid Program, the Governor's Office or the Legislature. In Ohio, these entities were not the catalyst for developing the waiver.
7. Efforts were focused on the legislative process - broadly defined as including the Executive branch of government - state agencies.
8. Facts were gathered.
9. Budget numbers were run - After many analyses, it was decided that the initial approach would be through the Medicaid Office.
10. A concept paper was developed and shared with the Medicaid Office.

Lessons Learned:

1. Some of the work was delayed as a result of the election of a new Governor and accompanying changes that occurred in the State agencies. The new administration was subsumed in the transition process which included developing a new budget.
2. The Work Group worked with high level stakeholders who had the "ears" of the new Administration and an FP Waiver is now on the horizon. However, it was decided that this would most likely be pursued outside of the budget process after the State budget was passed.
3. Building partnerships and developing information sources (for example, concept papers) are key components of policy development. Working to develop the concept paper focused the partners and provided them with a tool to share with many audiences. The partnership component was critical for getting the work done. Building relationships with the right partners assisted in identifying the best channels through which to navigate.
4. This process is not over yet, but the signs are encouraging.