HEALTH POLICYHEALTH POLICY

CHANGE TO THE NEW CHANGE TO THE NEW UNIVERSALISM?UNIVERSALISM?

Universalism – What’s That?Universalism – What’s That?

• At present Brunei has a universal welfare At present Brunei has a universal welfare health system run by government with health system run by government with services provided by government and funded services provided by government and funded through government.through government.

• The The new universalismnew universalism sees government set sees government set strategic direction and heath targets and strategic direction and heath targets and them partly uses the private sector and other them partly uses the private sector and other sectors to fund and provide servicessectors to fund and provide services

• Other countries have different systems but Other countries have different systems but are challenged to establish the same are challenged to establish the same effective mixeffective mix

PurposePurpose

• To outline basic ideas in health policy To outline basic ideas in health policy worldwideworldwide

• To examine options for health To examine options for health system reforms over the next ten system reforms over the next ten yearsyears

• To consider how we might know if To consider how we might know if health systems are improving health systems are improving peoples health overallpeoples health overall

Other DriversOther Drivers

• Demographic profile and health service Demographic profile and health service usageusage options for prevention and health promotionoptions for prevention and health promotion

• Technological advances Technological advances Genetics/ diagnostics/ drugsGenetics/ diagnostics/ drugs

• Public expectationsPublic expectations Information flows and accessInformation flows and access

• International health markets International health markets Health as right or commodityHealth as right or commodity

• Denial of death Denial of death The need for a new ethicsThe need for a new ethics

• Burden and double burden of diseaseBurden and double burden of diseasecost to nations of chronic disease in populationscost to nations of chronic disease in populations

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

Pre and post globalization Pre and post globalization descriptions of health systemsdescriptions of health systems

• Based of bureaucratic styles of Based of bureaucratic styles of governance within a nationgovernance within a nation

• POST POST • Refers to international market Refers to international market

influences, declining welfare state influences, declining welfare state and decentralization plus influence of and decentralization plus influence of world health organizations and world health organizations and international fundersinternational funders

Reforms and changing Reforms and changing directiondirection

• From running services for patients to From running services for patients to running systems to promote health running systems to promote health and self reliance and self reliance

• From professional control to From professional control to consumer control – the health smart consumer control – the health smart cardcard

Twaddles two reform driversTwaddles two reform drivers

• Fiscal CrisisFiscal Crisis

• MPI greater than CPIMPI greater than CPI

• Poor allocative Poor allocative efficiencyefficiency

• Limited flexibility in Limited flexibility in choicechoice

• Tech advance and Tech advance and prof/public prof/public expectationsexpectations

• Alienation CrisisAlienation Crisis

• Clinical Clinical (Prof v lay (Prof v lay knowledge)knowledge)

• Organisational Organisational (Centre v home)(Centre v home)

• Economic Economic ($ v Barter)($ v Barter)

• Professional Professional isolation isolation

Consequences for health Consequences for health systemssystems

• Do international markets influence Do international markets influence the way health is provided for?the way health is provided for?

• Are the key concerns more about Are the key concerns more about efficiencyefficiency than than equityequity??

• Is Is effectivenesseffectiveness aligned with aligned with ‘evidence' and what are the ‘evidence' and what are the consequences?consequences?

How Modern Health Systems How Modern Health Systems Evolved – 3 overlapping stagesEvolved – 3 overlapping stages

• National funding of health with forms of National funding of health with forms of national insurance from the 1950s onwards.national insurance from the 1950s onwards.

• The introduction of Primary Health Care at The introduction of Primary Health Care at local levels especially in developing local levels especially in developing countriescountries

• New universalism – responding to demand, New universalism – responding to demand, managing health financing, reaching the managing health financing, reaching the poor, creating a mixed market that is fair to poor, creating a mixed market that is fair to allall

The Three Key Area for The Three Key Area for InvestmentInvestment

• Achieving Good health outcomes for Achieving Good health outcomes for all citizens – all citizens – measuring goal attainmentmeasuring goal attainment

• Being response to public demands Being response to public demands for health services – for health services – measuring responsivenessmeasuring responsiveness

• Ensuring health care financing is fair Ensuring health care financing is fair – – Measuring public and private costs and expenditureMeasuring public and private costs and expenditure

Health outcomes – Which way Health outcomes – Which way forward?forward?

Four epidemiological transitionsFour epidemiological transitions

• Pandemics of infectious diseasePandemics of infectious disease

• Decline due to public health Decline due to public health measures and poverty reductionmeasures and poverty reduction

• Rise in life style diseasesRise in life style diseases

• The new pandemic threatsThe new pandemic threats

Responding to public demand – Responding to public demand – how?how?

• Changing change by measuringChanging change by measuring– Respect for PersonsRespect for Persons

Respect for dignityRespect for dignity ConfidentialityConfidentiality AutonomyAutonomy

– Client OrientationClient Orientation Prompt attentionPrompt attention Quality of amenitiesQuality of amenities Access to social support networksAccess to social support networks Choice of providerChoice of provider

Innovations that create Citizen Innovations that create Citizen involvementinvolvement

• Smart Health CardsSmart Health Cards

• Access to medical and health Access to medical and health information via internetinformation via internet

• The rise in chronic illness and The rise in chronic illness and support groupssupport groups

• Changing role of health professionsChanging role of health professions

Fair financing – what’s fair?Fair financing – what’s fair?

Examples of Innovations in Examples of Innovations in some country health systemssome country health systems

Strategic policy issuesStrategic policy issues

• The public think differently to The public think differently to professional about health. It would professional about health. It would help if both changedhelp if both changed

• Health creation beyond health Health creation beyond health ministriesministries

• Taking the burden of disease seriously Taking the burden of disease seriously through multi-strategies that address through multi-strategies that address risk and protective factorsrisk and protective factors

Illness or Disease?Illness or Disease?

• HealthHealth• DiseaseDisease• SymptomsSymptoms all closely linked to the all closely linked to the

social norms and structures social norms and structures of of societysociety

• Normal functioningNormal functioning• IllnessIllness

A disease is diagnosed but an illness is experienced. - A disease is diagnosed but an illness is experienced. - Disease as an objective scientific fact determined by Disease as an objective scientific fact determined by

a professional as expert – illness has a moral, a professional as expert – illness has a moral, social, psychological basis defined within a cultural social, psychological basis defined within a cultural tradition subjectively experienced.tradition subjectively experienced.

Challenging the Bio-medical Challenging the Bio-medical model dominancemodel dominance

• The focus on the individual, separate body The focus on the individual, separate body systems, the split between mind and body systems, the split between mind and body and the importance of measurable and the importance of measurable physiological conditions means the social, physiological conditions means the social, cultural, economic and environmental causes cultural, economic and environmental causes are downgradedare downgraded

• The social aspects of illness and experience The social aspects of illness and experience get ignoredget ignored

• It becomes difficult to define what is normal It becomes difficult to define what is normal healthhealth

The socio-ecological modelThe socio-ecological model

• The concept of holistic health - treat the The concept of holistic health - treat the whole person not just one part of the personwhole person not just one part of the person

• The rising voice of other health professions The rising voice of other health professions (nursing, other therapists and public demand (nursing, other therapists and public demand for complimentary health and medicine)for complimentary health and medicine)

• Increasing size of self-help movements ( see Increasing size of self-help movements ( see their websites)their websites)

• The availability of information once hidden The availability of information once hidden away in professional textbooks (even away in professional textbooks (even operations on TV)operations on TV)

ContinuedContinued

• Shifts in international bodies policies to Shifts in international bodies policies to embrace holistic views to some extendembrace holistic views to some extend

• The WHO recognizes the value of health The WHO recognizes the value of health approaches beyond medicineapproaches beyond medicine

• ““HEALTH IS A COMPLETE STATE OF HEALTH IS A COMPLETE STATE OF PHYSICAL, MENTAL AND SOCIAL WELL-PHYSICAL, MENTAL AND SOCIAL WELL-BEING NOT MERELY THE ADSENCE OF BEING NOT MERELY THE ADSENCE OF DISEASE” (WHO 1988)DISEASE” (WHO 1988)

Three Key WHO Policy Three Key WHO Policy Documents Documents for the wider view and for the wider view and action in health beyond the bio-medical action in health beyond the bio-medical modelmodel• WHO (1978) The Declaration of Alma-WHO (1978) The Declaration of Alma-

Ata. WHO Regional Office for EuropeAta. WHO Regional Office for Europe

• WHO (1986) The Ottawa Charter for WHO (1986) The Ottawa Charter for Health Promotion.Health Promotion.

• WHO (1997) The Jakarta Declaration WHO (1997) The Jakarta Declaration on leading Health Promotion into the on leading Health Promotion into the 2121stst Century. WHO Geneva Century. WHO Geneva

Key Actions for health Key Actions for health advancement advancement

Ottawa Charter and Jakarta DeclarationOttawa Charter and Jakarta Declaration

• Building better public policyBuilding better public policy

• Creating supportive communitiesCreating supportive communities

• Strengthening community action for healthStrengthening community action for health

• Development of person skillsDevelopment of person skills

• Reorientation of health servicesReorientation of health services

• Addressing the burden of diseaseAddressing the burden of disease

The Solid FactsThe Solid Facts

• To address ill, health policy and action To address ill, health policy and action needs to address the social determinants needs to address the social determinants through government, business and through government, business and individual actions.individual actions.

• There is now very good scientific There is now very good scientific evidence for this policy directionevidence for this policy direction

• The WHO statement ‘Solid facts’ is an The WHO statement ‘Solid facts’ is an evidence based policy document that evidence based policy document that describes what action needs to be taken describes what action needs to be taken and why.and why.

The Solid FactsThe Solid FactsKey Areas for ActionKey Areas for Action

• The social gradientThe social gradient• StressStress• Early lifeEarly life• Social exclusionSocial exclusion• WorkWork• UnemploymentUnemployment• Social supportSocial support• AddictionAddiction• Food Food • TransportTransport

Solid FactsSolid Facts

To address the social determinants has far To address the social determinants has far reaching implications for the way a country reaching implications for the way a country makes decisions about its developmentmakes decisions about its development

This is because it requires different types of This is because it requires different types of policy investment to the presentpolicy investment to the present

In some cases these policies address vested In some cases these policies address vested interestsinterests

The Social GradientThe Social Gradient

• Within all countries and across all countries Within all countries and across all countries those who are richer live longer, have less those who are richer live longer, have less illness and have a better quality of life than illness and have a better quality of life than those who are poorer.those who are poorer.

• There is a social gradient of health even among There is a social gradient of health even among the well off.the well off.

• Disadvantages tend to concentrate around the Disadvantages tend to concentrate around the same people and are cumulative (E.G. ?????)same people and are cumulative (E.G. ?????)

• The longer you live in stressful conditions the The longer you live in stressful conditions the greater the physiological wear and teargreater the physiological wear and tear

The Social GradientThe Social GradientPolicy ImplicationsPolicy Implications

• Address life’s transitionsAddress life’s transitions

• Early disadvantage is a risk factor for Early disadvantage is a risk factor for later in lifelater in life

• Reducing level of educational failure, Reducing level of educational failure, job insecurity and income differences job insecurity and income differences as will as those in poor housingas will as those in poor housing

StressStress

• Social and psychological conditions cause Social and psychological conditions cause long-term stress.long-term stress.

• Examples: continuing anxiety, low self-Examples: continuing anxiety, low self-esteem, social isolation, lack of control over esteem, social isolation, lack of control over work and home life powerfully effects your work and home life powerfully effects your health.health.

• Some of these risks are cumulativeSome of these risks are cumulative• Stress activates stress hormones that effect Stress activates stress hormones that effect

cardiovascular and immune systems. When cardiovascular and immune systems. When this happens often this increases the risk of this happens often this increases the risk of depression, infection, diabetes, harmful depression, infection, diabetes, harmful patterns of fats, high blood pressure, etcpatterns of fats, high blood pressure, etc

StressStressPolicy ImplicationPolicy Implication

• Focus upstream beyond medical Focus upstream beyond medical interventionintervention

• The quality of the social environment in The quality of the social environment in Schools and workplacesSchools and workplaces

• Ensure there are institutions that give Ensure there are institutions that give people a sense of identity and belongingpeople a sense of identity and belonging

• Government Policies that support Government Policies that support families and reduce financial insecurityfamilies and reduce financial insecurity

Addressing the Burden of Addressing the Burden of DiseaseDisease

• What burden in Brunei?What burden in Brunei?– Heart Disease (50.5 per 100,000)Heart Disease (50.5 per 100,000)– Cancer Cancer (49.9)(49.9)– DiabetesDiabetes (26.7)(26.7)– CerebrovascularCerebrovascular (18.6)(18.6)– Transport crashesTransport crashes (16.0)(16.0)– Influenza/PneumoniaInfluenza/Pneumonia (9.6)(9.6)

PreventionPrevention

• 5kg reduction in all those overweight in a 5kg reduction in all those overweight in a population of 15 million would reduce health population of 15 million would reduce health care cost from Type 2 Diabetes buy $43.7 care cost from Type 2 Diabetes buy $43.7 million (Marks et al. 2001)million (Marks et al. 2001)

• A decrease of 3g (50mmol sodium – salt) per A decrease of 3g (50mmol sodium – salt) per day, the average sytolic blood pressure of day, the average sytolic blood pressure of those over 50 yrs would fall by 5mmhg. those over 50 yrs would fall by 5mmhg. Stoke would decease by 16% ( Law et al. Stoke would decease by 16% ( Law et al. 2002)2002)

• Diet is a key risk factor in 56% of all deaths Diet is a key risk factor in 56% of all deaths ( Crowley 1992)( Crowley 1992)

Prevention Strategies Prevention Strategies _examples_examples• Salt IntakeSalt Intake

• Sugar intake and fatty foodsSugar intake and fatty foodsFocus on the supply and demand of foods Focus on the supply and demand of foods

and improve nutritionand improve nutrition• Road safetyRoad safetyFocus on the traffic environment, technical, Focus on the traffic environment, technical,

vehicle, behavior and emergency systemsvehicle, behavior and emergency systems• Measure changes over timeMeasure changes over time

Institutions of Care Provision•Hospitals

•Residential Care•Doctors Rooms, etc.

Micro-processes of Care

Professional – Patient Interaction

Socio-political environmentRoles of Governments, intermediaries, individuals

Class ethnicity, gender, race effectsGOALS: equity, efficiency, quality

FINANCE

Public HealthHealth protectionEarly detection

Health promotion

Workforce•Numbers•Skill Mix

Capital•Buildings

•Equipment

Supplies•Pharmaceuti

cals•Etc.

Outputs of Health Services

•Number of Patients treated•Days of Care

Outcomes of Health Services

•Mortality•Morbidity

•Quality of Life

•Perceptions

Interactive Model Example (Duckett, 2000)

Creating health marketsCreating health markets

• Funder Purchaser Provider SplittingFunder Purchaser Provider Splitting

• Funder Finance MinistryFunder Finance Ministry

• Purchaser Health MinistryPurchaser Health Ministry

• Provider public and private heath Provider public and private heath organisationsorganisations

Requires shifts to block budgeting and up-Requires shifts to block budgeting and up-skilling ministry as a purchaser organisationskilling ministry as a purchaser organisation

The New Universalism?The New Universalism?

• A mixed market for healthA mixed market for health• Government as creator of equity and Government as creator of equity and

fairnessfairness• Market as providerMarket as provider• Public as contributor beyond being Public as contributor beyond being

the patientthe patient• Evidence/ technology/ access for allEvidence/ technology/ access for all• Mixed funding modelsMixed funding models