Transcript HEALTH POLICY - BRUNEI RESOURCES

HEALTH POLICY
CHANGE TO THE NEW
UNIVERSALISM?
Universalism – What’s That?
• At present Brunei has a universal welfare health
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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
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
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
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
National Health Systems
•History and Culture
• Public v. Private
• Health Problems
• Generalist v. Specialist
• Finance and Debt
• Prevention v. Treatment
• Welfare System
• Cost and Financing
• Political System
• Equity, Effectiveness, Efficiency
Reform Pressures, Plans and Programs
Health professionals
Citizens
Markets and /or government managers
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
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
Twaddles two reform drivers
• Fiscal Crisis
• Alienation Crisis
• MPI greater than CPI
• Poor allocative efficiency
• Limited flexibility in
• Clinical (Prof v lay
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choice
Tech advance and
prof/public expectations
knowledge)
• Organisational (Centre v
home)
• Economic ($ v Barter)
• Professional isolation
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?
How Modern Health Systems
Evolved – 3 overlapping stages
• National funding of health with forms of national
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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
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
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
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
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
Fair financing – what’s fair?
Examples of Innovations in some
country health systems
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
Illness or Disease?
• Health
• Disease
• Symptoms
• Normal functioning
• Illness
all closely linked to the
social norms and structures of
society
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.
Challenging the Bio-medical model
dominance
• The focus on the individual, separate body
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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
The socio-ecological model
• The concept of holistic health - treat the whole
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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)
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 WELLBEING NOT MERELY THE ADSENCE OF
DISEASE” (WHO 1988)
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
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
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.
The Solid Facts
Key Areas for Action
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The social gradient
Stress
Early life
Social exclusion
Work
Unemployment
Social support
Addiction
Food
Transport
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
The Social Gradient
• Within all countries and across all countries
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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
The Social Gradient
Policy Implications
• Address life’s 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
Stress
• Social and psychological conditions cause long•
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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
Stress
Policy 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
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)
Prevention
• 5kg reduction in all those overweight in a
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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)
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
Interactive Model Example (Duckett, 2000)
Socio-political environment
Roles of Governments, intermediaries, individuals
Class ethnicity, gender, race effects
GOALS: equity, efficiency, quality
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Workforce
•Numbers
•Skill Mix
Capital
•Buildings
•Equipment
Supplies
•Pharmaceuti
cals
•Etc.
Public Health
Health protection
Early detection
Health promotion
Institutions of Care
Provision
•Hospitals
•Residential Care
•Doctors Rooms, etc.
Micro-processes of
Care
Professional – Patient
Interaction
Outputs of Health
Services
Outcomes of
Health Services
•Number of
Patients treated
•Days of Care
•Mortality
•Morbidity
•Quality of Life
•Perceptions
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
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