Evolution of health systems: A global perspective :Evolution of health systems: A global perspective


The early health systems :The early health systems Traditional practices and medicine. e.g China, India Hospitals have a longer history than complete health systems Effect of industrial revolution, american civil war Workers health becoming a political issue- Germany Belgium (1894), Norway (1909), Britain (1911) Influence of the German model outside Europe-Japan WWII- British NHS (1948)- Beveridge report (1942) Bhore report India (1946)


A short history of health policy in developing countries: from people to performance :A short history of health policy in developing countries: from people to performance 1950-1960 Post War Reconstruction and Decolonisation-emphasis on increasing national income 1960-1970 Modernisation-recognition of need to reduce poverty 1970-1980 Welfare-Distribution of health and human resources 1980-1990 Economics in Command-neo-liberalism-market mechanisms and economic growth 1990-2000 Post Modernism-no “magic” bullets 2000- Millenium Goals-return to analysis of health as multi-dimensional 2008- Primary health care (WHO report)


Post War Reconstruction and Decolonization 1950-1960 :Post War Reconstruction and Decolonization 1950-1960 Development=economic growth Primacy for the contribution of technology and the trickle down effect Era marked by community development, equality/free welfare services and optimism Classical universalism- Concept of free access of health to all.


Modernisation 1960-1970 :Modernisation 1960-1970 Transfer of technology Questions about rapid improvements In health care Rising costs Return for investment not noticeable People who needed services most denied access Many existing services not used


1970-1980 Welfare Concerns :1970-1980 Welfare Concerns Distribution high on the agenda basic needs approach distributive justice Movement from community development to structural change (peoples’ participation) Development defined in terms of human resources not merely economic growth


Primary Health Care:The Alma Ata Declaration, 1978 :Primary Health Care:The Alma Ata Declaration, 1978 Jointly sponsored by WHO and UNICEF Health sector leads the way to wider development goals Held in the Soviet Union but influenced by the Chinese health care model Put prevention first Give priority to those most in need (equity) Unite traditional and modern medicine Integrate health campaigns with mass campaigns (seeds of community participation)


PHC Themes and Values :PHC Themes and Values Equity Social justice Community Participation Prevention/Health Promotion Intersectoral Collaboration Appropriate Use of Resources Sustainability


Activities/Components of PHC :Activities/Components of PHC Water and sanitation Food and nutrition Immunisation against 6 major diseases Mother and Child Care (MCH)/Family Planning (FP) Prevention and control of locally endemic diseases Treatment for common diseases and injuries Health education Provision of essential drugs


UNICEF’s Contribution: GOBI/FFF :UNICEF’s Contribution: GOBI/FFF G rowth Monitoring O ral rehydration B breast feeding I immunisation F family planning F female literacy F food technology


Economics in Command 1980-1990 :Economics in Command 1980-1990 Efficiency and effectiveness key elements for development programmes Neo-liberal economics and reduce role for the state Structural adjustment programmes In health Selective/Comprehensive PHC debate Health System reforms Emergence of the dominance of the World Bank over WHO


Selective vs. Comprehensive PHC-Definitions :Selective vs. Comprehensive PHC-Definitions Selective PHC focuses on Diseases that have the highest prevalence and morbidity have the highest risk of mortality have the greatest possibility of control in terms of cost and effectiveness of the intervention (Walsh and Warren, 1979)


Definitions (con’t) :Definitions (con’t) Comprehensive PHC considers that health is not merely the absence of disease Health is defined in the holistic sense Health is concerned with equity Multi-sectoral approaches are key to obtaining good health Community involvement is critical (Rifkin and Walt, 1986)


Post-Modernism 1990-2000 :Post-Modernism 1990-2000 The realisation that “one size does not fit all”. Return to Poverty Reduction--Equity and Empowerment as key elements In Health—still seeking standarization--The World Bank Report 1993- Investing in Health (packages of services) and WHO 2000-Health Systems: Improving Performance Pursuing Health System Reforms


The Millenium 2000-the legacy of PHC :The Millenium 2000-the legacy of PHC Principles of PHC shaping the policy dialogue today Equity (the role of poverty alleviation) Community Participation (Empowerment, human capacity building, rights based approaches) Sustainability (the question of financing and capacity building)


WHO Report 2000 :WHO Report 2000 Goal Attainment--”goodness”-best attainable average and “fairness”-smallest feasible differences among individuals and groups” Functions of Health System service provision resource generation financing stewardship


Poverty Reduction:An Overview :Poverty Reduction:An Overview Poverty not just lack of resources but the inability to access these resources (A. Sen) WB Poverty Reduction Strategy Papers (PRSP)-joint ownership between providers of external resources and country beneficiaries Based on participatory assessment of needs with local government, civil society and the poor Key is institutional strengthening and good governance


PRSPs :PRSPs World Bank strategy for poverty reduction Focused on donor aid negotiated with donors, governments and intended beneficiaries Commits all parties to supporting participation and anti-poverty strategies Concerns about turning rhetoric into reality because of length of time to implement and government capacity Highlights tensions between: WB funding agenda and country ownership Advocacy (need of resources) and planning frameworks (availability of resources)


Definitions of Key terms for poverty reduction :Definitions of Key terms for poverty reduction Equity-addresses the differences in health among groups that reflects unfairness. These differences are avoidable and unnecessary. Empowerment creates opportunities for knowledge, skills and confidence for those without those opportunities


World Development Report, 2001/02 :World Development Report, 2001/02 Attacking poverty Opportunity - encouraging effective private investment; expanding international markets; addressing inequalities Empowerment-addressing equity through strong institutions, community development, and destruction of social barriers Security addressing financial and personal risks


World Health Report 2003 :World Health Report 2003 PHC core principles universal access to care and coverage on the basis of need commitment to health equity as part of development oriented to social justice community participation in defining and implementing health agendas intersectoral approaches to health


MDGs :MDGs Presented by the Secretary-General of the UN, Sept. 2000 Reflecting experience of Alma Ata (Health for all by the year 2000), 1978 Attempt to integrate Selective and Comprehensive PHC Quantifiable, time bound targets to reduce poverty, disease an deprivation 8 goals and 18 targets


MDGs :MDGs Eradication extreme poverty and hunger Achieve universal education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other disease Ensure environment sustainability Develop a global partnership for development


Health is at the center of the Millennium Development Goals :Health is at the center of the Millennium Development Goals By 2015 Reduce the share of malnourished children by 1/2 Cut child death rate by 2/3 Lower maternal deaths by 3/4 Reverse the spread of HIV/AIDS, TB, and malaria


PHC in 2008 :PHC in 2008 Topic of the World Health Report Expansions of principles Peoples’ health needs Quality orientation Government accountability Social justice Sustainability Participation Intersectorality


Critical Health Policy Issues :Critical Health Policy Issues The analysis of which comes first—health or economic growth? The recognition of the major role of poverty alleviation—as both an economic and ethical obligation (equity) The need to address the role of people in health improvements—health staff, beneficiaries of health care and actors for changes of health patterns (empowerment) The critical question of how best to financially support health care and improvements in a rapidly changing, global environment (sustainability) And the Overarching question—What is the role of the State and how can this role be strengthened?


Debate :Debate Selective PHC v/s Comprehensive PHC