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HEALTH POLICY CHANGE TO THE NEW UNIVERSALISM?. Universalism – What’s That? At present Brunei has a universal welfare health system run by government with.

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Presentation on theme: "HEALTH POLICY CHANGE TO THE NEW UNIVERSALISM?. Universalism – What’s That? At present Brunei has a universal welfare health system run by government with."— Presentation transcript:

1 HEALTH POLICY CHANGE TO THE NEW UNIVERSALISM?

2 Universalism – What’s That? At present Brunei has a universal welfare health system run by government with services provided by government and funded through government. 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 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 Other countries have different systems but are challenged to establish the same effective mix

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

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

5 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

6 Pre and post globalization descriptions of health systems Based of bureaucratic styles of governance within a nation Based of bureaucratic styles of governance within a nation POST POST Refers to international market influences, declining welfare state and decentralization plus influence of world health organizations and international funders Refers to international market influences, declining welfare state and decentralization plus influence of world health organizations and international funders

7 Reforms and changing direction From running services for patients to running systems to promote health and self reliance From running services for patients to running systems to promote health and self reliance From professional control to consumer control – the health smart card From professional control to consumer control – the health smart card

8 Twaddles two reform drivers Fiscal Crisis Fiscal Crisis MPI greater than CPI MPI greater than CPI Poor allocative efficiency Poor allocative efficiency Limited flexibility in choice Limited flexibility in choice Tech advance and prof/public expectations Tech advance and prof/public expectations Alienation Crisis Alienation Crisis Clinical (Prof v lay knowledge) Clinical (Prof v lay knowledge) Organisational (Centre v home) Organisational (Centre v home) Economic ($ v Barter) Economic ($ v Barter) Professional isolation Professional isolation

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

10 How Modern Health Systems Evolved – 3 overlapping stages National funding of health with forms of national insurance from the 1950s onwards. 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 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 New universalism – responding to demand, managing health financing, reaching the poor, creating a mixed market that is fair to all

11 The Three Key Area for Investment Achieving Good health outcomes for all citizens – measuring goal attainment Achieving Good health outcomes for all citizens – measuring goal attainment Being response to public demands for health services – measuring responsiveness Being response to public demands for health services – measuring responsiveness Ensuring health care financing is fair – Measuring public and private costs and expenditure Ensuring health care financing is fair – Measuring public and private costs and expenditure

12 Health outcomes – Which way forward? Four epidemiological transitions Pandemics of infectious disease Pandemics of infectious disease Decline due to public health measures and poverty reduction Decline due to public health measures and poverty reduction Rise in life style diseases Rise in life style diseases The new pandemic threats The new pandemic threats

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16 Responding to public demand – how? Changing change by measuring 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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18 Innovations that create Citizen involvement Smart Health Cards Smart Health Cards Access to medical and health information via internet Access to medical and health information via internet The rise in chronic illness and support groups The rise in chronic illness and support groups Changing role of health professions Changing role of health professions

19 Fair financing – what’s fair?

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22 Examples of Innovations in some country health systems

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

26 Illness or Disease? Health Health Disease Disease Symptomsall closely linked to the social norms and structures of society Symptomsall closely linked to the social norms and structures of society Normal functioning Normal functioning Illness 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.

27 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 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 The social aspects of illness and experience get ignored It becomes difficult to define what is normal health It becomes difficult to define what is normal health

28 The socio-ecological model The concept of holistic health - treat the whole person not just one part of the person 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) 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) Increasing size of self-help movements ( see their websites) The availability of information once hidden away in professional textbooks (even operations on TV) The availability of information once hidden away in professional textbooks (even operations on TV)

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

30 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 (1978) The Declaration of Alma-Ata. WHO Regional Office for Europe WHO (1986) The Ottawa Charter for Health Promotion. WHO (1986) The Ottawa Charter for Health Promotion. WHO (1997) The Jakarta Declaration on leading Health Promotion into the 21 st Century. WHO Geneva WHO (1997) The Jakarta Declaration on leading Health Promotion into the 21 st Century. WHO Geneva

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

32 The Solid Facts To address ill, health policy and action needs to address the social determinants through government, business and individual actions. 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 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 WHO statement ‘Solid facts’ is an evidence based policy document that describes what action needs to be taken and why.

33 The Solid Facts Key Areas for Action The social gradient The social gradient Stress Stress Early life Early life Social exclusion Social exclusion Work Work Unemployment Unemployment Social support Social support Addiction Addiction Food Food Transport Transport

34 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

35 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. 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. 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. ?????) 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 longer you live in stressful conditions the greater the physiological wear and tear

36 The Social Gradient Policy Implications Address life’s transitions Address life’s transitions Early disadvantage is a risk factor for later in life 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 Reducing level of educational failure, job insecurity and income differences as will as those in poor housing

37 Stress Social and psychological conditions cause long- term 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. 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 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 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

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

39 Addressing the Burden of Disease What burden in Brunei? 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)

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

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

42 Institutions of Care Provision Hospitals Residential Care Doctors Rooms, etc. Micro-processes of Care Professional – Patient Interaction Socio-political environment Roles of Governments, intermediaries, individuals Class ethnicity, gender, race effects GOALS: equity, efficiency, quality FINANCEFINANCE Public Health Health protection Early 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)

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

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


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