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HEALTH POLICY

HEALTH POLICY. CHANGE TO THE NEW UNIVERSALISM?. 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.

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HEALTH POLICY

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  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. • 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

  3. 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

  4. Other Drivers • Demographic profile and health service usageoptions for prevention and health promotion • Technological advances Genetics/ diagnostics/ drugs • Public expectationsInformation 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

  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 • POST • 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 professional control to consumer control – the health smart card

  8. 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 Twaddles two reform drivers

  9. 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?

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. Fair financing – what’s fair?

  16. Examples of Innovations in some country health systems

  17. 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

  18. 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.

  19. 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

  20. 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)

  21. 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)

  22. 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

  23. 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

  24. 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.

  25. The Solid FactsKey Areas for Action • The social gradient • Stress • Early life • Social exclusion • Work • Unemployment • Social support • Addiction • Food • Transport

  26. 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

  27. 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

  28. The Social GradientPolicy 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

  29. 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

  30. 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

  31. 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)

  32. 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)

  33. 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

  34. Workforce • Numbers • Skill Mix • Capital • Buildings • Equipment • Institutions of Care Provision • Hospitals • Residential Care • Doctors Rooms, etc. • Supplies • Pharmaceuticals • Etc. Micro-processes of Care Professional – Patient Interaction 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

  35. 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

  36. 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

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