Big P, Little P – A Guide to Policy Engagement at All Levels
April 2019

​Stacy Collins
Associate Director, Health System Transformation
The Association of Maternal & Child Health Programs


As a maternal and child health (MCH) strategy, policy change can have a significant impact at all levels, often providing the greatest return on investment. “Big P – Little P” is convenient shorthand to distinguish between large and small policy decisions: Comparing “Big P” and “Little P” policies can help MCH professionals better understand where their efforts can have the most impact across the broad spectrum of MCH issues and how to best allocate time and resources.

Big P refers to state or national policy change. Legislation and executive actions, both of which require elected officials’ approval, are Big P policies. Increasing the appropriation for the Title V Block Grant is a Big P example. A court decision, such as the Supreme Court’s ruling on the Affordable Care Act, can result in a Big P policy change.

Big P policymaking is labor- and time-intensive and, due to the number of stakeholders and gatekeepers involved, is often difficult to influence. However, when Big P policies are implemented, the implications for change at a systems level can be far-reaching, affecting a much larger population than just one agency or jurisdiction. For example:

Big P/Little P in Action: Promoting Access to Healthy Food 

Little P:

  • A public health organization passes a healthy snack policy for all meetings and events
  • A county school board institutes an incentive policy for vendors to supply nutritious and affordable food for school lunch programs
  • A local food pantry institutes a policy mandating that fresh produce constitute 25 percent of the food distributed to clients

 Big P:

  • Congress and the executive branch revise federal SNAP (Supplemental Nutrition Assistance Program) income eligibility limits, allowing more families to purchase nutritious food

Little P policies are typically at the department or agency level and generally address organizational practices, agency priorities, internal and external distribution of resources, and regulations. These types of policy changes can create quick wins and sometimes lead to larger changes that typically are not as labor- or time-intensive as Big P policy changes.

There are many examples of impactful change resulting from Little P policymaking. Implementing policies to screen all pregnant women for substance use, offering free, long-acting reversible contraception to all eligible women, raising foster care reimbursement rates, and prioritizing medication-assisted treatment for pregnant women with opioid addiction are all examples of Little P policy changes that can have a significant (and sometimes immediate)  impact on the health of women and children.

Whether Big P or Little P, policymaking requires vision, leadership, and partnership to be effective. Policy change at all levels – local, state, or national – is the most effective way to improve the health of populations, and MCH professionals play an important role in this process.

Title V Small P Examples

​North DakotaThe state Title V program is requiring grantees to ensure compliance with the North Dakota Child Care Physical Activity ordinance, which requires all licensed child care facilities in the state to implement and follow the Centers for Disease Control and Prevention best practices for preventing childhood obesity in early care and education programs.

The state Title V program partners with the state Office of Tobacco Control, the Mississippi Municipal League, and the Mississippi Tobacco-Free Coalition to promote adoption of local smoke-free ordinances. To date, 148 Mississippi municipalities have passed comprehensive smoke-free ordinances. The partners educate local elected officials on the health and economic benefits of implementing smoke-free ordinances. Through this initiative, 34 percent of Mississippi’s population is now protected by a comprehensive smoke-free policy.


Through its Health Disparities Committee, the Pennsylvania Title V program is instituting a policy that requires vendors and grantees to have an internal health equity workplan. As a condition of funding, Title V vendors and grantees must develop strategies to identify and address health disparities and demonstrate that their work is sensitive and responsive to the needs of the communities served by the funding.

“PRISM” – Promoting Innovation in state MCH Policymaking

Discussion of Big P – Little P policy action was a primary focus at the kick-off meeting of PRISM (Promoting Innovation in State MCH Policymaking) during the AMCHP Annual Conference in March. PRISM is a five-year joint project of AMCHP and the Association of State and Territorial Health Officials, funded by the U.S. Health Resources and Services Administration.  The goal of PRISM is to build the capacity of state MCH programs and their state partners to implement policy change that improves outcomes for women with mental health and substance use disorders. For more information on PRISM, contact Stacy Collins at