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 • Health=Hospitals

3. 1970’s 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 Care:The 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 (con’t) • 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 nat’l/intern’l 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 dev’tal 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 pop’n 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 mechanisms—a 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.