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How does health improve: An overview and history of global health policy

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Title: How does health improve: An overview and history of global health policy


1
How does health improve An overview and history
of global health policy
  • Susan B. Rifkin
  • London School of Economics
  • Colorado School of Public Health

2
Introduction A personal experience
  • 1973 Zambia my first field experience
  • University Teaching Hospital commanded 70 of the
    total health budget
  • HealthHospitals

3
1970s Health links with Development
  • 1972-Nobel Prize economist Gunnar Myrdal
    publishes Asian Drama and argues development is
    based on human resources that demand health and
    eduation
  • 1976-Ideas advocated by the International Labour
    Organization (ILO) in the basic needs approach
  • Recognition development is not merely the concern
    of the economists

4
1970-1980 Welfare Concerns
  • Distribution high on the agenda
  • basic needs approach
  • distributive justice
  • Movement from community development to structural
    change (peoples participation)
  • Development defined in terms of human resources
    not merely economic growth

5
Primary Health CareThe Alma Ata Declaration, 1978
  • Jointly sponsored by WHO and UNICEF
  • Health sector leads the way to wider development
    goals
  • Themes and Values
  • Equity
  • Social justice
  • Community Participation
  • Prevention/Health Promotion
  • Intersectoral Collaboration
  • Appropriate Use of Resources
  • Sustainability

6
Economics in Command 1980-1990
  • Efficiency and effectiveness key elements for
    development programmes
  • Neo-liberal economics and reduce role for the
    state
  • Structural adjustment programmes
  • In health Selective/Comprehensive PHC debate and
    health system reforms

7
Selective vs. Comprehensive PHC-Definitions
  • Selective PHC focuses on Diseases that
  • have the highest prevalence and morbidity
  • have the highest risk of mortality
  • have the greatest possibility of control in terms
    of cost and effectiveness of the intervention
    (Walsh and Warren, 1979)

8
Definitions (cont)
  • Comprehensive PHC considers that health is not
    merely the absence of disease
  • Health is defined in the holistic sense
  • Health is concerned with equity
  • Multisectoral approaches are key to obtaining
    good health
  • Community involvement is critical (Rifkin and
    Walt, 1986)

9
Health System Reforms (HSR) Background
  • State interventions justified by market failures
  • Failures a result of
  • Brings into question the justification for a
    large state role in health care provision
  • Put forth arguments to support expansion of
    private sector

10
HSR The goals
  • Efficiency and quality
  • Equity
  • Increased resources for health
  • Consumer choice

11
Post-Modernism 1990-2000
  • The realisation that one size does not fit all.
  • Return to Poverty Reduction--Equity and
    Empowerment as key elements
  • Equity-addresses the differences in health among
    groups that reflects unfairness. These
    differences are avoidable and unnecessary.
  • Empowerment creates opportunities for knowledge,
    skills and confidence for those without those
    opportunities

12
Poverty Reduction
  • Poverty not just lack of resources but the
    inability to access these resources (contribution
    of A. Sen)
  • WB Poverty Reduction Strategy Papers
    (PRSP)-joint ownership between providers of
    external resources and country beneficiaries
  • Based on participatory assessment of needs with
    local government, civil society and the poor
  • Key is institutional strengthening and good
    governance

13
In Health A focus on health services
  • still seeking standarization--The World Bank
    Report 1993- Investing in Health (packages of
    services) and WHO 2000-Health Systems Improving
    Performance
  • Pursuing Health System Reforms

14
WHO Report 2000
  • Goal Attainment--goodness-best attainable
    average and fairness-smallest feasible
    differences among individuals and groups
  • Functions of Health System
  • service provision
  • resource generation
  • financing
  • stewardship

15
The Millennium Development Goals (MDGs)
Refocusing Health and Development
  • Presented by the Secretary-General of the UN,
    Sept. 2000
  • Reflecting experience of Alma Ata (Health for all
    by the year 2000), 1978
  • Attempt to integrate Selective and Comprehensive
    PHC
  • Quantifiable, time bound targets to reduce
    poverty, disease an deprivation
  • 8 goals and 18 targets
  • But equity is not addressed

16
MDGs
  • Eradication extreme poverty and hunger
  • Achieve universal education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/AIDS, malaria and other disease
  • Ensure environment sustainability
  • Develop a global partnership for develpment

17
PHC 2008
  • WH0 celebrates 30 anniversary with 2008 World
    Health Report
  • Confirms the commitment to equity and
    participation as key principles
  • Thus, confirms the link between good health and
    development policies including economics,
    education, social development

18
PHC in 2008
  • Topic of the World Health Report
  • Expansions of principles
  • Peoples health needs
  • Quality orientation
  • Government accountability
  • Social justice
  • Sustainability
  • Participation
  • Intersectorality

19
The World Health Report 2008 on PHC The Four
Sets of Reforms
Released October 14th, 2008
20
The Report of the Commission on the Social
Determinants of Health, 2008
  • Social injustice is killing people on a grand
    scale.
  • - Commission on Social Determinants of Health,
    WHO, 2008

21
1- Improve daily living conditions
  • Equity from the start
  • Comprehensive approach to early life (ECD)
  • Expand scope of education to include ECD
  • Fair employment and decent work
  • Make it a central goal of natl/internl
    policy-making
  • Safe, secure and fairly paid work year-round
    opportunities work-life balance
  • Reduce exposure to material hazards, work-related
    stress, health-damaging behaviours

22
2- Tackle the inequitable distribution of power,
money, and resources
  • Political empowerment inclusion and voice
  • Representation in decision-making, socially
    inclusive policy-making
  • Civil society promotes and realizes political
    social rights affecting health equity
  • Good global governance
  • Make health equity a global devtal goal
  • WHO leadership in global action on the SDH SDH
    as guiding principle

23
3- Measure and understand the problem, and assess
the impact of action
  • Routine monitoring systems for health equity
    across all levels
  • Invest in generating and sharing new evidence on
    influence of SD on popn health and equity, and
    effectiveness of measures
  • Provide training on SDH to policy actors,
    stakeholders, practitioners invest in raising
    public awareness

24
Importance of the CSDH Report (2008)
  • It provides evidence for the PHC policy of 1978.
  • It promotes action to tackle major barriers to
    health improvement.
  • Universal health care coverage (equity)
  • Health as a human right (participation/empowerment
    )
  • Intersectoral collaboration as a means to
    achieve equity
  • It provides firm recommendations about local,
    national and global institutions to insure the
    recommendations move forward.

25
2008-Present Defining health beyond the hospital
  • Emerging themes based on Draft paper for the
    International Conference on the Social
    Determinants of Health, Brazil Autumn, 2011
  • Governance to tackle root cause of health
    inequities-need to tackle mechanism that produce
    barriers to resources and opportunities view
    health as an indicator of fairness and a just
    society
  • Role of health sector in reducing inequities
    focus on universal coverage and defining and
    addressing inequities
  • Seeking intersectoral collaboration

26
Themes continued
  • Promoting participation-a role for communities in
    policy making to ensure their rights and
    responsibilities in matters that affect their
    daily lives addressing power relationships
  • Global action on the social determinants-aligning
    policies to address common concerns with global
    governance mechanismsa focus on foreign
    assistance
  • Measuring progress and informing policies with
    data

27
Policy Framework for addressing Governance Issues
(UNDP,2003)
  • Legitimacy by providing a Voice for all concerned
    parties
  • Direction and strategic vision
  • Performance through agreed indicators and
    assessment
  • Accountability in all sectors with transparency
    through joint decision making and common benefits
  • Fairness in decision making processes and access
    to resources

28
Role of the health sector improving health in a
social determinant analysis
  • Advocacy to promote a social determinants
    approach to development-why this approach must be
    integrated and intersectoral to reap benefits
  • Using it expertise to monitor impact of the
    approach on health status
  • Using evidence to bring sectors together to act
    on poor health
  • Using its influence with sectors to develop
    capacities for work on social determinants

29
In Conclusion
  • There is a growing consensus that health is not
    only hospitals, doctors and services.
  • In terms of health of populations, social
    determinants play a critical role on individual
    circumstances.
  • Social determinants that create inequities can be
    challenged and changed through mechanisms that
    have been defined and agreed to by all those
    affected by difficult circumstances.
  • In terms of health and health equity, governance
    is a foundation to ensure inequities reflected by
    all sectors can be adequately addressed.
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