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


How does health improve: An overview and history of global health policy Susan B. Rifkin London School of Economics Colorado School of Public Health – PowerPoint PPT presentation

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

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

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

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
  • 1976-Ideas advocated by the International Labour
    Organization (ILO) in the basic needs approach
  • Recognition development is not merely the concern
    of the economists

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

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

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

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)

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)

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

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

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

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

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
  • Pursuing Health System Reforms

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

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
  • Quantifiable, time bound targets to reduce
    poverty, disease an deprivation
  • 8 goals and 18 targets
  • But equity is not addressed

  • 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

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

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

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

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
  • Safe, secure and fairly paid work year-round
    opportunities work-life balance
  • Reduce exposure to material hazards, work-related
    stress, health-damaging behaviours

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

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

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.

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
  • Role of health sector in reducing inequities
    focus on universal coverage and defining and
    addressing inequities
  • Seeking intersectoral collaboration

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
  • Measuring progress and informing policies with

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

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

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
  • 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.