Health policy and planning

Health Policy – Theory and Basic Concepts

Dr. Rizwan S A, M.D.,

Health Policy - Definition
• A set of decisions or commitments to pursue courses of action
aimed at achieving defined goals for improving health.
• Policies usually state or infer the values that underpin the
policy position.
• They may also specify the source of funding that can be
applied to the action, the planning and management
arrangements to be adopted for implementation of the policy,
and the relevant institutions to be involved.
-WHO Glossary of terms used in the Health for All Series, nos.1-8. Geneva: WHO, 1984;
-Barr, N. Economic theory and the welfare state: A survey and interpretation, Journal of Economic Literature.
XXX: 741-803, 1992;
-WHO Health for All targets. The health policy for Europe, Copenhagen: WHO Regional Office for Europe, 1993.

Aim of health policies
• The prime aim - maintenance and
improvement of the health status of
populations

• The risk factors which influence health differ
between countries
• Thus policies for health will be influenced by
different factors in each country and region

Essential Concepts
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Health status
Health services
Organization and financing
Health commissioning (administration)
Role of public health
Assurance of appropriateness
Criteria, access, and utilization

Health status
• Increase in non-communicable diseases in the
developing world together with the
abatement of the mortality from infectious
diseases
• In developed world the problems are mainly
concerned with the elderly, rather than
children
• This has important implications for health
policies

Health services
Problems faced
• Inequalities between different geographic areas and
social groups
• variations in the utilization of services for similar
conditions
• difficulties in the apportionment of limited resources
• lifestyle behaviour and political/economic issues
Health services have an essential role in improving quality
of life and can produce specific valuable improvements in
other aspects of health status

Organization and financing
The state is involved in all health systems in varying degrees:
• as legal regulator of the arrangements for patients to receive
medical care and doctors to receive remuneration
• as a contributor to health-care financing, taxes or compulsory
social insurance
• as a guardian to ensure that the correct balance of resources
is used to achieve optimum population health
Health care may be conceived in an economic framework as an
exchange of goods. Patients seeking medical care are making
demands while doctors are supplying services

Health commissioning (administration)
Health commissioning needs to take into account the following
factors:
• improvement in health status
• risk reduction
• services and protection
• data needs for monitoring the achievement of the tasks
identified

• The best model for this is that developed in
The Netherlands
• 'the possibility for every member of society to
function normally and to participate in social
life'
• Thus the need for health care is ‘to enable an
individual to share, maintain and if possible
improve his or her life together with other
members of the community’

• This societal perspective is a little different
from the individual perspective and
professional approach

Role of public health
• Chief responsibilities are
– the surveillance of the health of the population,
– the identification of its health needs,
– the fostering of policies which promote health
– the evaluation of health services

• Study of the nature and extent of disease and
disability in the population and how this varies
with age, sex, economic and social
circumstances, occupation, and environment

• Thus the problems for which public health action is
required include:
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outbreaks of disease
problems arising from social and environmental issues
behavioural concerns such as smoking
health service issues - assessment of health-care needs
and outcomes, and the effectiveness and efficiency of
particular services

• Public health, as a discipline, should not become
involved in the direct management of clinical services
in the community or within institutions—it lacks the
expertise essential for these tasks

Assurance of appropriateness
• As the Dutch Report on Choices in Health Care
emphasizes, responsibility for others, the ideal of
equality, and the social benefits of good public health
have encouraged the belief that people are responsible
for their own health, and are free to choose how to use
health care and which risks they are willing to take
• There are three points of departure:
– the fundamental equality of people,
– the fundamental need for the protection of human life,
– the principle of solidarity.

Criteria, access, and utilization
• The first criterion that needs to be established
is whether care is necessary or not
• The second criterion is the effectiveness of the
services provided, the efficiency with which
they are provided, and whether the individual
could take responsibility for providing them

International trends in health care
• Every citizen in a country has the same rights to health
care
• There has not been much of a decline in public
financing of health care quantitatively, whether by
compulsory insurance contribution or taxation.
• There is some trend towards consumers making a
contribution in the forms of co-payments, for example
prescription charges
• Some countries are encouraging people to take out
private insurance or even to contract out of the public
system.

Provider–purchaser model
• For both public health and personal health services
• The separation of commissioning and providing services
theoretically enables better decisions to be made over
which services to provide within a limited budget

• Theoretically, it should also be possible to balance
preventive, curative, and rehabilitative services
• Managed care, now so popular in the United States, is an
example of this type of separation

The role of public health in the
determination of priorities
• It has the necessary tools to describe the
problems and to devise appropriate mechanisms
for their solution
• In all the systems, however, the ability for public
health to influence health policy is limited
• Decisions on priorities have become more explicit
and democratic. Most countries have begun to
debate how and what should be done

• Most have developed mechanisms for beginning
to address the problem of inequalities and
deprivation, with one notable exception (the
United States)
• Most are facing the problem of increasing costs
of medical care by rational deliberations
• Increased investment in public health research, in
order to be able to introduce appropriate and
effective preventive strategies

Health Policy in Developing Countries
• Central issue - making the best use of limited
resources in environments in which there is a
wide gap between needs and resources,
expectations and performance.
• There are three main issues
– diversity
– Complexity
– change

Diversity
• Ecological and geographical factors account
for some of the variation in the pattern of
distribution of health and disease but
economic, social, and cultural determinants
also contribute to the diversity

Complexity
• The explosion of new knowledge and innovative
health technologies have markedly increased the
complexity of health care
• it is necessary to mobilize inter-sectoral action
because of the important influence of nonmedical factors on health, such as:
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Agriculture
Education
Waterworks and sanitation
Labour and industry

Change
• Policy-making in developing countries has to
be fluid and dynamic to adapt strategies and
programmes to the many changes that are
occurring in the environment
– Epidemiological transition
– Epidemics and other emergencies
– Socio-economic variables

Epidemiological transition
• Traditional health problems, such as childhood
diseases and communicable diseases, are
declining, whilst chronic diseases, such as
cancers, cardiovascular diseases, diabetes, are
becoming increasingly prominent

Epidemics and other emergencies
• Epidemics and other acute problems, for
example natural disasters

Socio-economic variables
• Changes in the economic and social situation in
the country may have a profound effect on the
health sector
• Health policies have had to be modified in the
light of rapid development in some countries and
economic recession in others
• In recent decades, national policies are
increasingly favouring free-market economy in
place of welfare programmes and central control

Major challenges and issues
• health reform with special emphasis on structural
reform and decentralization
• tools for policy-making—assessment of burden of
disease, cost-effectiveness, and health accounts
• financing health care—cost recovery schemes,
user fees, and private insurance
• public–private partnerships
• health research
• donor agencies
• equity in health

Health Reform
• Health reform has been defined as 'sustained
purposeful change to improve efficiency,
equity and effectiveness of the health sector'
(Berman 1995)
• The decentralization of planning and
management
• Delegate responsibility of management to
peripheral authorities — provincial, state,
municipal, and local governments

Models of decentralization
• Primary health care through community level
services and local referral hospitals
• Provincial or state level co-ordinating services in
defined geographical parts of the country
• Setting up a ministry of health at central
government level
• Decentralization involves allocating functions to
provincial and local governments as well as
defining their relationships with each other and
with the central government

Primary Health Care - Functions
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immunization
education on prevailing health conditions
food supply and proper nutrition
safe water and basic sanitation
MCH including family planning
treatment of common diseases and injuries
prevention and control of locally endemic
diseases
• essential drugs

Provincial or state level provision
• intermediate role between the central
government and the local health authorities
• they
develop
regional
policies
and
programmes in the context of the overall
national policy and plans

Central government provision
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setting national goals and targets
establishment of standards
accreditation of training programmes
registration of drugs
national disease surveillance
highly specialized services including research
emergency response to natural disasters and
major epidemics
• international relations.

Making decentralization work
Certain important issues need to be addressed
as follows
• autonomy
• financial resources
• professional and technical capacity
• information system
• health-related sectors
• relationship with other health-care providers

Tools for policy-making
• measurement of burden of disease
• assessment
of
cost-effectiveness
interventions
• analysis of national health accounts

of

Burden of disease
The DALY is used to
• Rank diseases and conditions by the burden of
disease
• Estimate
the
cost-effectiveness
of
interventions by comparing the cost of
averting a DALY

National health accounts
• These analyses attempt to obtain an overview of
health spending from all sources — public and
private, corporate and personal — into
comprehensive health accounts.

• The basic analysis consists of a matrix of
elements as follows:
• the columns of the matrix list all sources of health spending
• the rows of the matrix show the distribution of expenditure
for personal health care, public health and environmental
sanitation services, and administration

Financing health care
• The wide margin between the public
resources for health and the demands and
expectations - common challenge
• Macroeconomic policies advocated by the
International Monetary Fund and other
funding agencies have forced many
governments to trim public spending on
health and to reassess the allocation of their
limited resources

• policy-makers are exploring approaches to
increase the resources available for health
• develop income-generating schemes
• promote supplementary sources of finance

Income generation
• In the least developed countries, it is critically
important to increase the financial resources if the
health sector is to provide basic essential services
• In the more advanced middle-income countries, the
main issue is how to organize and manage a prepay
system that is efficient and fair
• In the high-income developing countries - using
resources in the most cost-effective manner and
promoting equity.

Mobilizing additional resources
• User fees generate resources that can be used to expand the
quantity and improve the quality of health services
• Redistribution of resources
• Community financing
• Risk sharing through privately financed health insurance
In summary, the policy direction for financing health care in
many developing countries is to ensure that those who can
afford to pay cover health costs from their own resources

This enables the public sector to focus resources on top priority
health issues and to target selectively the needs of the poor

Public–private partnerships
• The WHO now strongly supports the
promotion of public – private partnerships
with the caveat that such partnerships should
be mutually beneficial and must always
benefit health
– non-profit private sector—non-governmental
organizations and religious-based medical
missions
– employment-related health schemes
– for-profit private services

Health research
• There is now increasing pressure to make
decisions on the basis of sound scientific
knowledge
• Evidence-based decision-making requires that
relevant information be collected and
analysed, and that essential research be
conducted to elucidate issues

• Each country should adopt the principles of
Essential National Health Research as a strategy
for planning, prioritizing, and managing national
health research

• The goal of Essential National Health Research is
health development on the basis of social justice
and equity; its content is the full range of
biomedical and clinical research, as well as
epidemiological, social, and economic studies

Equity
• Equity in health is intuitively understood to
reflect a sense of fairness and justice
• But the term is used to refer to
– health status of families, communities, and
population groups
– allocation of resources
– access to and utilization of services

Optimization of equity
Optimization of equity requires conscious attention
to a number of important issues
• political commitment
• policy formulation
• allocation of resources
• inter-sectoral action
• community involvement
• information system
• monitoring of equity
• political commitment

Public health sciences and policy in
developing countries
• Developing countries are those countries with
a low average income as well as a low gross
national product compared with the
‘developed countries’
• Problems
• A shortage of resources - budget and
infrastructure
• poverty, political instability, social unrest, and
security problems

• The major concern to alleviate suffering from
the major diseases prevalent in the locality
• Thus, priorities are for hospitals to serve the
immediate needs of sick patients instead of
preventive services
• Limited knowledge and technologies to
ascertain health problems often leads to
inappropriate health decisions by leaders

Application of public health sciences
and policy
• 1.Policies developed in response to immediate
health problems - malaria, yaws, and rabies
• 2. Policies developed from existing knowledge,
which are recommended by international
organizations - poliomyelitis eradication
programmes, EPI, ADD and ARI programmes
• 3. Policies for the control of specific diseases
derived from national scientific research

• It is important for public health researchers
and decision-makers to co-operate in the
formulation of health policy
• To achieve this goal it is important to provide
training for public health professionals,
preferably in national schools of public health
as well as abroad

Conclusion
• Not only must policy-making be knowledge based it must
also be result oriented
• Careful planning and skilled management can achieve good
results even where financial resources are limited
• Policy-makers must give high priority to strategies that will
eliminate the major items of the unfinished agenda that
still plague many developing countries
• Many lives can be saved and much disability prevented by
simple measures like boosting immunization programmes,
ensuring access to adequate supplies of safe water and
good sanitation, providing effective treatment for common
childhood ailments, and ensuring skilled care during
childbirth including emergency obstetric care

Health policy in the developed world
• It is paradoxical that the greatest interest in public health
policy now exists in developed countries where the benefits
of public health activity may seem least apparent
• Three major impediments to relating overall mortality
levels in rich countries to their public health endeavours
– there are no readily available measures of the amount of
'organised effort'
– adult mortality levels is strongly influenced two major
overlapping epidemics: (a) tobacco smoking, and (b) vascular
diseases
– lagged effects of changes in disease determinants over
preceding decades and these temporal relationships are not
easy to specify or quantify

Examples of policies to improve health
1. Administrative means: fluoridation
• Fluoridation introduces several themes pertinent to the
consideration of public health policy in rich countries
– One is the power of research using quantitative methods,
including experiments on whole communities, to expand the
repertoire of effective means for controlling disease and injury.
– Another is the possibility of massive disjunctions between the
cost-effectiveness of a preventive measure and the political
feasibility of its implementation.
– Perceptions of risks and benefits held by vocal minorities may
depart substantially from those of experts, and governments
may be more sensitive to their reputations in the eyes of the
press and other powerful bodies than they are to public opinion.

2.Enhanced coverage with clinical procedures:
control of high blood pressure
• Rose coined the term 'prevention paradox' to
describe how, when risk is related monotonically
to a quantitative attribute such as blood pressure,
the interventions which offer most to the
individuals at high risk contribute less to reducing
the population burden of the disease than do
small downward shifts in the whole distribution
(Rose 1985).

3. Behaviour change: HIV and sudden infant
death
• In circumstances such as those surrounding
the early HIV epidemic, the ability of formal
public health programmes to contribute to
health improvement may be limited by the
need to await the building of a supporting
political consensus

• The main point to emerge from these
examples is that the 'organised efforts' that
have contributed most to reducing the burden
of these diseases have been the research
efforts.
• Thus, in developed countries, investment in
the development of public health science is
the most fundamental component of public
health policy

• medicine and public health should not be
understood just as domains of professional
practice; they are, more fundamentally,
cultural resources appropriated by all
members of society — lay as well as
professional

• Behaviour change: road traffic injuries - lessons
– large secular declines in traffic injury deaths are likely
to have occurred with a substantial degree of
independence from the specific policies and
programmes
– But important degree of variation seems attributable
to the intensity and nature of the control measures
taken
– It was possible to build support for the escalation of
control measures notwithstanding a political culture
that valued personal independence

• Behaviour change: smoking
– cigarette smoking remains the leading public
health problem in developed countries. It is
without rival in the disease burden it generates.
– If the course of the epidemic of nicotine addiction
is to be curtailed, intergenerational transmission
must also be minimized

Unsolved issues
• physical inactivity and obesity
• sustainability
• Global warming
• Use of materials and absorption of wastes
• Effects on ecosystems

Four interim conclusions
• Governments may be more concerned to
protect their reputations in the eyes of the
press than to implement measures with high
public support and dramatically favourable
cost–benefit ratios
• Enhanced coverage with preventive measures
applied to individuals appeals to doctors but
may, in many circumstances, offer only
modest gains in health

• Formal programmes to promote change to
healthier ways of life may have small effects
compared with the informal processes
promoting such changes
• Combinations of regulatory measures and
persuasion are likely to be more effective in
changing behaviour but these are only likely to
be politically feasible where there is
widespread public appreciation

'Social capital'
• Tangible substances in the daily lives of people, namely,
goodwill, fellowship, mutual sympathy and social
intercourse among a group of individuals and families who
make up a social unit
• If he may come into contact with his neighbour, and they
with other neighbours, there will be an accumulation of
social capital, which may immediately satisfy his social
needs and which may bear a social potentiality sufficient to
the substantial improvement of living conditions in the
whole community.
• The community as a whole will benefit by the cooperation
of all its parts, while the individual will find in his
associations the advantages of the help, the sympathy, and
the fellowship of his neighbours

• Inherited stocks of social capital are important
determinants of the good government and
economic well being of today's citizens
• Eg. government in Italy – north and south
Strong 'civic community‘ was responsible for the
success of the south: the empirical measures
used were voting behaviour (including turnout,
not preferences), newspaper readership, and
density of sports and cultural associations

The search for equality
• Recent favourable trends in overall adult
mortality have been accompanied by growing
inequalities in states such as the United
Kingdom, because mortality declines have
been much greater in more favoured strata
• 'materialist' interpretation of the cause marked increase in income inequalities

Making progress safe
• Material progress both favours and harms
health
• It has been one of the main responsibilities of
public health institutions to help resolve this
ambivalence
• This has enabled the net effect closely
towards its beneficial effect

• Public health endeavour will continue to be an
important determinant of what we are able to
mean by 'progress' and of whether we shall be
able to make it safe

Health policy and planning

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Health policy and planning