Health Policy – Theory and Basic Concepts

Dr. Rizwan S A, M.D.,

Health Policy - Definition

• A set of decisions or commitments to pursue courses of action aimed at achieving defined goals for improving health.

• Policies usually state or infer the values that underpin the policy position.

• They may also specify the source of funding that can be applied to the action, the planning and management arrangements to be adopted for implementation of the policy, and the relevant institutions to be involved.

-WHO Glossary of terms used in the Health for All Series, nos.1-8. Geneva: WHO, 1984; -Barr, N. Economic theory and the welfare state: A survey and interpretation, Journal of Economic Literature. XXX: 741-803, 1992; -WHO Health for All targets. The health policy for Europe, Copenhagen: WHO Regional Office for Europe, 1993.

Aim of health policies

• The prime aim - maintenance and improvement of the health status of populations

• The risk factors which influence health differ between countries

• Thus policies for health will be influenced by different factors in each country and region

Essential Concepts

• Health status• Health services• Organization and financing• Health commissioning (administration)• Role of public health• Assurance of appropriateness• Criteria, access, and utilization

Health status

• Increase in non-communicable diseases in the developing world together with the abatement of the mortality from infectious diseases

• In developed world the problems are mainly concerned with the elderly, rather than children

• This has important implications for health policies

Health servicesProblems faced• Inequalities between different geographic areas and social

groups

• variations in the utilization of services for similar conditions

• difficulties in the apportionment of limited resources

• lifestyle behaviour and political/economic issues

Health services have an essential role in improving quality of life and can produce specific valuable improvements in other aspects of health status

Organization and financing

The state is involved in all health systems in varying degrees:• as legal regulator of the arrangements for patients to receive

medical care and doctors to receive remuneration• as a contributor to health-care financing, taxes or compulsory

social insurance• as a guardian to ensure that the correct balance of resources

is used to achieve optimum population health

Health care may be conceived in an economic framework as an exchange of goods. Patients seeking medical care are making demands while doctors are supplying services

Health commissioning (administration)

Health commissioning needs to take into account the following factors:• improvement in health status

• risk reduction

• services and protection

• data needs for monitoring the achievement of the tasks identified

• The best model for this is that developed in The Netherlands

• 'the possibility for every member of society to function normally and to participate in social life'

• Thus the need for health care is ‘to enable an individual to share, maintain and if possible improve his or her life together with other members of the community’

• This societal perspective is a little different from the individual perspective and professional approach

Role of public health

• Chief responsibilities are – the surveillance of the health of the population, – the identification of its health needs, – the fostering of policies which promote health – the evaluation of health services

• Study of the nature and extent of disease and disability in the population and how this varies with age, sex, economic and social circumstances, occupation, and environment

• Thus the problems for which public health action is required include:• outbreaks of disease• problems arising from social and environmental issues• behavioural concerns such as smoking• health service issues - assessment of health-care needs and

outcomes, and the effectiveness and efficiency of particular services

• Public health, as a discipline, should not become involved in the direct management of clinical services in the community or within institutions—it lacks the expertise essential for these tasks

Assurance of appropriateness

• As the Dutch Report on Choices in Health Care emphasizes, responsibility for others, the ideal of equality, and the social benefits of good public health have encouraged the belief that people are responsible for their own health, and are free to choose how to use health care and which risks they are willing to take

• There are three points of departure: – the fundamental equality of people, – the fundamental need for the protection of human life,– the principle of solidarity.

Criteria, access, and utilization

• The first criterion that needs to be established is whether care is necessary or not

• The second criterion is the effectiveness of the services provided, the efficiency with which they are provided, and whether the individual could take responsibility for providing them

International trends in health care

• Every citizen in a country has the same rights to health care

• There has not been much of a decline in public financing of health care quantitatively, whether by compulsory insurance contribution or taxation.

• There is some trend towards consumers making a contribution in the forms of co-payments, for example prescription charges

• Some countries are encouraging people to take out private insurance or even to contract out of the public system.

Provider–purchaser model

• For both public health and personal health services • The separation of commissioning and providing services

theoretically enables better decisions to be made over which services to provide within a limited budget

• Theoretically, it should also be possible to balance preventive, curative, and rehabilitative services

• Managed care, now so popular in the United States, is an example of this type of separation

The role of public health in the determination of priorities

• It has the necessary tools to describe the problems and to devise appropriate mechanisms for their solution

• In all the systems, however, the ability for public health to influence health policy is limited

• Decisions on priorities have become more explicit and democratic. Most countries have begun to debate how and what should be done

• Most have developed mechanisms for beginning to address the problem of inequalities and deprivation, with one notable exception (the United States)

• Most are facing the problem of increasing costs of medical care by rational deliberations

• Increased investment in public health research, in order to be able to introduce appropriate and effective preventive strategies

Health Policy in Developing Countries

• Central issue - making the best use of limited resources in environments in which there is a wide gap between needs and resources, expectations and performance.

• There are three main issues– diversity– Complexity– change

Diversity

• Ecological and geographical factors account for some of the variation in the pattern of distribution of health and disease but economic, social, and cultural determinants also contribute to the diversity

Complexity

• The explosion of new knowledge and innovative health technologies have markedly increased the complexity of health care

• it is necessary to mobilize inter-sectoral action because of the important influence of non-medical factors on health, such as:

• Agriculture• Education• Waterworks and sanitation• Labour and industry

Change

• Policy-making in developing countries has to be fluid and dynamic to adapt strategies and programmes to the many changes that are occurring in the environment– Epidemiological transition– Epidemics and other emergencies– Socio-economic variables

Epidemiological transition

• Traditional health problems, such as childhood diseases and communicable diseases, are declining, whilst chronic diseases, such as cancers, cardiovascular diseases, diabetes, are becoming increasingly prominent

Epidemics and other emergencies

• Epidemics and other acute problems, for example natural disasters

Socio-economic variables

• Changes in the economic and social situation in the country may have a profound effect on the health sector

• Health policies have had to be modified in the light of rapid development in some countries and economic recession in others

• In recent decades, national policies are increasingly favouring free-market economy in place of welfare programmes and central control

Major challenges and issues

• health reform with special emphasis on structural reform and decentralization

• tools for policy-making—assessment of burden of disease, cost-effectiveness, and health accounts

• financing health care—cost recovery schemes, user fees, and private insurance

• public–private partnerships • health research• donor agencies• equity in health

Health Reform

• Health reform has been defined as 'sustained purposeful change to improve efficiency, equity and effectiveness of the health sector' (Berman 1995)

• The decentralization of planning and management

• Delegate responsibility of management to peripheral authorities — provincial, state, municipal, and local governments

Models of decentralization

• Primary health care through community level services and local referral hospitals

• Provincial or state level co-ordinating services in defined geographical parts of the country

• Setting up a ministry of health at central government level

• Decentralization involves allocating functions to provincial and local governments as well as defining their relationships with each other and with the central government

Primary Health Care - Functions

• immunization • education on prevailing health conditions • food supply and proper nutrition • safe water and basic sanitation • MCH including family planning • treatment of common diseases and injuries • prevention and control of locally endemic

diseases • essential drugs

Provincial or state level provision

• intermediate role between the central government and the local health authorities

• they develop regional policies and programmes in the context of the overall national policy and plans

Central government provision

• setting national goals and targets• establishment of standards• accreditation of training programmes• registration of drugs• national disease surveillance• highly specialized services including research• emergency response to natural disasters and

major epidemics• international relations.

Making decentralization work

Certain important issues need to be addressed as follows • autonomy• financial resources• professional and technical capacity• information system• health-related sectors• relationship with other health-care providers

Tools for policy-making

• measurement of burden of disease• assessment of cost-effectiveness of

interventions• analysis of national health accounts

Burden of disease

The DALY is used to• Rank diseases and conditions by the burden of

disease• Estimate the cost-effectiveness of

interventions by comparing the cost of averting a DALY

National health accounts

• These analyses attempt to obtain an overview of health spending from all sources — public and private, corporate and personal — into comprehensive health accounts.

• The basic analysis consists of a matrix of elements as follows:

• the columns of the matrix list all sources of health spending • the rows of the matrix show the distribution of expenditure

for personal health care, public health and environmental sanitation services, and administration

Financing health care

• The wide margin between the public resources for health and the demands and expectations - common challenge

• Macroeconomic policies advocated by the International Monetary Fund and other funding agencies have forced many governments to trim public spending on health and to reassess the allocation of their limited resources

• policy-makers are exploring approaches to increase the resources available for health

• develop income-generating schemes• promote supplementary sources of finance

Income generation

• In the least developed countries, it is critically important to increase the financial resources if the health sector is to provide basic essential services

• In the more advanced middle-income countries, the main issue is how to organize and manage a prepay system that is efficient and fair

• In the high-income developing countries - using resources in the most cost-effective manner and promoting equity.

Mobilizing additional resources

• User fees generate resources that can be used to expand the quantity and improve the quality of health services

• Redistribution of resources• Community financing• Risk sharing through privately financed health insuranceIn summary, the policy direction for financing health care in many developing countries is to ensure that those who can afford to pay cover health costs from their own resources

This enables the public sector to focus resources on top priority health issues and to target selectively the needs of the poor

Public–private partnerships

• The WHO now strongly supports the promotion of public – private partnerships with the caveat that such partnerships should be mutually beneficial and must always benefit health– non-profit private sector—non-governmental

organizations and religious-based medical missions– employment-related health schemes– for-profit private services

Health research

• There is now increasing pressure to make decisions on the basis of sound scientific knowledge

• Evidence-based decision-making requires that relevant information be collected and analysed, and that essential research be conducted to elucidate issues

• Each country should adopt the principles of Essential National Health Research as a strategy for planning, prioritizing, and managing national health research

• The goal of Essential National Health Research is health development on the basis of social justice and equity; its content is the full range of biomedical and clinical research, as well as epidemiological, social, and economic studies

Equity

• Equity in health is intuitively understood to reflect a sense of fairness and justice

• But the term is used to refer to – health status of families, communities, and

population groups– allocation of resources– access to and utilization of services

Optimization of equity

Optimization of equity requires conscious attention to a number of important issues• political commitment• policy formulation• allocation of resources• inter-sectoral action• community involvement• information system• monitoring of equity• political commitment

Public health sciences and policy in developing countries

• Developing countries are those countries with a low average income as well as a low gross national product compared with the ‘developed countries’

• Problems• A shortage of resources - budget and

infrastructure• poverty, political instability, social unrest, and

security problems

• The major concern to alleviate suffering from the major diseases prevalent in the locality

• Thus, priorities are for hospitals to serve the immediate needs of sick patients instead of preventive services

• Limited knowledge and technologies to ascertain health problems often leads to inappropriate health decisions by leaders

Application of public health sciences and policy

• 1.Policies developed in response to immediate health problems - malaria, yaws, and rabies

• 2. Policies developed from existing knowledge, which are recommended by international organizations - poliomyelitis eradication programmes, EPI, ADD and ARI programmes

• 3. Policies for the control of specific diseases derived from national scientific research

• It is important for public health researchers and decision-makers to co-operate in the formulation of health policy

• To achieve this goal it is important to provide training for public health professionals, preferably in national schools of public health as well as abroad

Conclusion

• Not only must policy-making be knowledge based it must also be result oriented

• Careful planning and skilled management can achieve good results even where financial resources are limited

• Policy-makers must give high priority to strategies that will eliminate the major items of the unfinished agenda that still plague many developing countries

• Many lives can be saved and much disability prevented by simple measures like boosting immunization programmes, ensuring access to adequate supplies of safe water and good sanitation, providing effective treatment for common childhood ailments, and ensuring skilled care during childbirth including emergency obstetric care

Health policy in the developed world

• It is paradoxical that the greatest interest in public health policy now exists in developed countries where the benefits of public health activity may seem least apparent

• Three major impediments to relating overall mortality levels in rich countries to their public health endeavours– there are no readily available measures of the amount of

'organised effort' – adult mortality levels is strongly influenced two major overlapping

epidemics: (a) tobacco smoking, and (b) vascular diseases– lagged effects of changes in disease determinants over preceding

decades and these temporal relationships are not easy to specify or quantify

Examples of policies to improve health

1. Administrative means: fluoridation• Fluoridation introduces several themes pertinent to the

consideration of public health policy in rich countries– One is the power of research using quantitative methods, including

experiments on whole communities, to expand the repertoire of effective means for controlling disease and injury.

– Another is the possibility of massive disjunctions between the cost-effectiveness of a preventive measure and the political feasibility of its implementation.

– Perceptions of risks and benefits held by vocal minorities may depart substantially from those of experts, and governments may be more sensitive to their reputations in the eyes of the press and other powerful bodies than they are to public opinion.

2.Enhanced coverage with clinical procedures: control of high blood pressure• Rose coined the term 'prevention paradox' to

describe how, when risk is related monotonically to a quantitative attribute such as blood pressure, the interventions which offer most to the individuals at high risk contribute less to reducing the population burden of the disease than do small downward shifts in the whole distribution (Rose 1985).

3. Behaviour change: HIV and sudden infant death• In circumstances such as those surrounding

the early HIV epidemic, the ability of formal public health programmes to contribute to health improvement may be limited by the need to await the building of a supporting political consensus

• The main point to emerge from these examples is that the 'organised efforts' that have contributed most to reducing the burden of these diseases have been the research efforts.

• Thus, in developed countries, investment in the development of public health science is the most fundamental component of public health policy

• medicine and public health should not be understood just as domains of professional practice; they are, more fundamentally, cultural resources appropriated by all members of society — lay as well as professional

• Behaviour change: road traffic injuries - lessons– large secular declines in traffic injury deaths are likely

to have occurred with a substantial degree of independence from the specific policies and programmes

– But important degree of variation seems attributable to the intensity and nature of the control measures taken

– It was possible to build support for the escalation of control measures notwithstanding a political culture that valued personal independence

• Behaviour change: smoking– cigarette smoking remains the leading public

health problem in developed countries. It is without rival in the disease burden it generates.

– If the course of the epidemic of nicotine addiction is to be curtailed, intergenerational transmission must also be minimized

Unsolved issues

• physical inactivity and obesity• sustainability

• Global warming• Use of materials and absorption of wastes• Effects on ecosystems

Four interim conclusions

• Governments may be more concerned to protect their reputations in the eyes of the press than to implement measures with high public support and dramatically favourable cost–benefit ratios

• Enhanced coverage with preventive measures applied to individuals appeals to doctors but may, in many circumstances, offer only modest gains in health

• Formal programmes to promote change to healthier ways of life may have small effects compared with the informal processes promoting such changes

• Combinations of regulatory measures and persuasion are likely to be more effective in changing behaviour but these are only likely to be politically feasible where there is widespread public appreciation

'Social capital'• Tangible substances in the daily lives of people, namely, goodwill,

fellowship, mutual sympathy and social intercourse among a group of individuals and families who make up a social unit

• If he may come into contact with his neighbour, and they with other neighbours, there will be an accumulation of social capital, which may immediately satisfy his social needs and which may bear a social potentiality sufficient to the substantial improvement of living conditions in the whole community.

• The community as a whole will benefit by the cooperation of all its parts, while the individual will find in his associations the advantages of the help, the sympathy, and the fellowship of his neighbours

• Inherited stocks of social capital are important determinants of the good government and economic well being of today's citizens

• Eg. government in Italy – north and south Strong 'civic community‘ was responsible for the success of the south: the empirical measures used were voting behaviour (including turnout, not preferences), newspaper readership, and density of sports and cultural associations

The search for equality

• Recent favourable trends in overall adult mortality have been accompanied by growing inequalities in states such as the United Kingdom, because mortality declines have been much greater in more favoured strata

• 'materialist' interpretation of the cause - marked increase in income inequalities

Making progress safe

• Material progress both favours and harms health

• It has been one of the main responsibilities of public health institutions to help resolve this ambivalence

• This has enabled the net effect closely towards its beneficial effect

• Public health endeavour will continue to be an important determinant of what we are able to mean by 'progress' and of whether we shall be able to make it safe

Thank you