HEALTH POLICY

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HEALTH POLICY

• CHANGE TO THE NEW UNIVERSALISM?

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Universalism Whats That?

• At present Brunei has a universal welfare health
  system run by government with services provided
  by government and funded through government.
• The new universalism sees government set
  strategic direction and heath targets and them
  partly uses the private sector and other sectors
  to fund and provide services
• Other countries have different systems but are
  challenged to establish the same effective mix

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Purpose

• To outline basic ideas in health policy worldwide
• To examine options for health system reforms over
  the next ten years
• To consider how we might know if health systems
  are improving peoples health overall

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Other Drivers

• Demographic profile and health service usage
  options for prevention and health promotion
• Technological advances
  Genetics/ diagnostics/ drugs
• Public expectations
  Information flows and access
• International health markets
  Health as right or commodity
• Denial of death
  The need for a new ethics
• Burden and double burden of disease
• cost to nations of chronic disease in
  populations

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Hegemonic Systems World Bank International
Monetary Fund (IMF) World Health Organisation
(WHO) Economic Unions (e.g., EU, WTO,
NAFTA) Bilateral Aid Programs Non-Governmental
Organisations (NGOs)

• National Systems
• History and Culture
• Health Problems
• Finance and Debt
• Welfare System
• Political System

• National Health Systems
• Public v. Private
• Generalist v. Specialist
• Prevention v. Treatment
• Cost and Financing
• Equity, Effectiveness, Efficiency

Reform Pressures, Plans and Programs Health
professionals Citizens Markets and /or government
managers
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Pre and post globalization descriptions of health
systems

• Based of bureaucratic styles of governance within
  a nation
• POST
• Refers to international market influences,
  declining welfare state and decentralization plus
  influence of world health organizations and
  international funders

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Reforms and changing direction

• From running services for patients to running
  systems to promote health and self reliance
• From professional control to consumer control
  the health smart card

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Twaddles two reform drivers

• Fiscal Crisis
• MPI greater than CPI
• Poor allocative efficiency
• Limited flexibility in choice
• Tech advance and prof/public expectations

• Alienation Crisis
• Clinical (Prof v lay knowledge)
• Organisational (Centre v home)
• Economic ( v Barter)
• Professional isolation

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Consequences for health systems

• Do international markets influence the way health
  is provided for?
• Are the key concerns more about efficiency than
  equity?
• Is effectiveness aligned with evidence' and what
  are the consequences?

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How Modern Health Systems Evolved 3 overlapping
stages

• National funding of health with forms of national
  insurance from the 1950s onwards.
• The introduction of Primary Health Care at local
  levels especially in developing countries
• New universalism responding to demand, managing
  health financing, reaching the poor, creating a
  mixed market that is fair to all

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The Three Key Area for Investment

• Achieving Good health outcomes for all citizens
  measuring goal attainment
• Being response to public demands for health
  services measuring responsiveness
• Ensuring health care financing is fair
  Measuring public and private costs and
  expenditure

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Health outcomes Which way forward?

• Four epidemiological transitions
• Pandemics of infectious disease
• Decline due to public health measures and poverty
  reduction
• Rise in life style diseases
• The new pandemic threats

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Responding to public demand how?

• Changing change by measuring
• Respect for Persons
• Respect for dignity
• Confidentiality
• Autonomy
• Client Orientation
• Prompt attention
• Quality of amenities
• Access to social support networks
• Choice of provider

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Innovations that create Citizen involvement

• Smart Health Cards
• Access to medical and health information via
  internet
• The rise in chronic illness and support groups
• Changing role of health professions

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Fair financing whats fair?
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Examples of Innovations in some country health
systems
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Strategic policy issues

• The public think differently to professional
  about health. It would help if both changed
• Health creation beyond health ministries
• Taking the burden of disease seriously through
  multi-strategies that address risk and protective
  factors

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Illness or Disease?

• Health
• Disease
• Symptoms all closely linked to the
  social norms and structures of society
• Normal functioning
• Illness
• A disease is diagnosed but an illness is
  experienced. -
• Disease as an objective scientific fact
  determined by a professional as expert illness
  has a moral, social, psychological basis defined
  within a cultural tradition subjectively
  experienced.

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Challenging the Bio-medical model dominance

• The focus on the individual, separate body
  systems, the split between mind and body and the
  importance of measurable physiological conditions
  means the social, cultural, economic and
  environmental causes are downgraded
• The social aspects of illness and experience get
  ignored
• It becomes difficult to define what is normal
  health

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The socio-ecological model

• The concept of holistic health - treat the whole
  person not just one part of the person
• The rising voice of other health professions
  (nursing, other therapists and public demand for
  complimentary health and medicine)
• Increasing size of self-help movements ( see
  their websites)
• The availability of information once hidden away
  in professional textbooks (even operations on TV)

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Continued

• Shifts in international bodies policies to
  embrace holistic views to some extend
• The WHO recognizes the value of health approaches
  beyond medicine
• HEALTH IS A COMPLETE STATE OF PHYSICAL, MENTAL
  AND SOCIAL WELL-BEING NOT MERELY THE ADSENCE OF
  DISEASE (WHO 1988)

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Three Key WHO Policy Documents for the wider
view and action in health beyond the bio-medical
model

• WHO (1978) The Declaration of Alma-Ata. WHO
  Regional Office for Europe
• WHO (1986) The Ottawa Charter for Health
  Promotion.
• WHO (1997) The Jakarta Declaration on leading
  Health Promotion into the 21st Century. WHO
  Geneva

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Key Actions for health advancement

• Ottawa Charter and Jakarta Declaration
• Building better public policy
• Creating supportive communities
• Strengthening community action for health
• Development of person skills
• Reorientation of health services
• Addressing the burden of disease

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The Solid Facts

• To address ill, health policy and action needs to
  address the social determinants through
  government, business and individual actions.
• There is now very good scientific evidence for
  this policy direction
• The WHO statement Solid facts is an evidence
  based policy document that describes what action
  needs to be taken and why.

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The Solid FactsKey Areas for Action

• The social gradient
• Stress
• Early life
• Social exclusion
• Work
• Unemployment
• Social support
• Addiction
• Food
• Transport

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Solid Facts

• To address the social determinants has far
  reaching implications for the way a country makes
  decisions about its development
• This is because it requires different types of
  policy investment to the present
• In some cases these policies address vested
  interests

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The Social Gradient

• Within all countries and across all countries
  those who are richer live longer, have less
  illness and have a better quality of life than
  those who are poorer.
• There is a social gradient of health even among
  the well off.
• Disadvantages tend to concentrate around the same
  people and are cumulative (E.G. ?????)
• The longer you live in stressful conditions the
  greater the physiological wear and tear

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The Social GradientPolicy Implications

• Address lifes transitions
• Early disadvantage is a risk factor for later in
  life
• Reducing level of educational failure, job
  insecurity and income differences as will as
  those in poor housing

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Stress

• Social and psychological conditions cause
  long-term stress.
• Examples continuing anxiety, low self-esteem,
  social isolation, lack of control over work and
  home life powerfully effects your health.
• Some of these risks are cumulative
• Stress activates stress hormones that effect
  cardiovascular and immune systems. When this
  happens often this increases the risk of
  depression, infection, diabetes, harmful patterns
  of fats, high blood pressure, etc

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StressPolicy Implication

• Focus upstream beyond medical intervention
• The quality of the social environment in Schools
  and workplaces
• Ensure there are institutions that give people a
  sense of identity and belonging
• Government Policies that support families and
  reduce financial insecurity

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Addressing the Burden of Disease

• What burden in Brunei?
• Heart Disease (50.5 per 100,000)
• Cancer (49.9)
• Diabetes (26.7)
• Cerebrovascular (18.6)
• Transport crashes (16.0)
• Influenza/Pneumonia (9.6)

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Prevention

• 5kg reduction in all those overweight in a
  population of 15 million would reduce health care
  cost from Type 2 Diabetes buy 43.7 million
  (Marks et al. 2001)
• A decrease of 3g (50mmol sodium salt) per day,
  the average sytolic blood pressure of those over
  50 yrs would fall by 5mmhg. Stoke would decease
  by 16 ( Law et al. 2002)
• Diet is a key risk factor in 56 of all deaths (
  Crowley 1992)

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Prevention Strategies _examples

• Salt Intake
• Sugar intake and fatty foods
• Focus on the supply and demand of foods and
  improve nutrition
• Road safety
• Focus on the traffic environment, technical,
  vehicle, behavior and emergency systems
• Measure changes over time

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Interactive Model Example (Duckett, 2000)
Socio-political environment Roles of Governments,
intermediaries, individuals Class ethnicity,
gender, race effects GOALS equity, efficiency,
quality
Public Health Health protection Early
detection Health promotion
FINANCE

• Outputs of Health Services
• Number of Patients treated
• Days of Care

• Outcomes of Health Services
• Mortality
• Morbidity
• Quality of Life
• Perceptions

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Creating health markets

• Funder Purchaser Provider Splitting
• Funder Finance Ministry
• Purchaser Health Ministry
• Provider public and private heath organisations
• Requires shifts to block budgeting and
  up-skilling ministry as a purchaser organisation

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The New Universalism?

• A mixed market for health
• Government as creator of equity and fairness
• Market as provider
• Public as contributor beyond being the patient
• Evidence/ technology/ access for all
• Mixed funding models