Global and Public

Health Policy
Development
Shelbay G. Blanco, MD, MPH
Preventive and Social Medicine III
Department of Preventive and Social Medicine
Objectives

• By the end of this lecture, the learners should be able to:

1. Define "Policy" "Health Policy" "Global Health",
"Global Health Governance"
2. Identify the goals of health policy
3. Describe the policy process
4. Differentiate between health policies (Macro- vs.
Micro-policy)
5. Discuss Global Health major players and challenges
6. Discuss Sustainable Development Goals (SDGs)
Critical Question?

• Does the introduction of a health policy at the

national and international level imply corresponding
improvement in the quality of health of a
country/population?
•For effective health systems with efficient outcome:
Should health related policies be locally/nationally
or internationally motivated or initiated?
Critical Question?

•Should developing countries rely on the West

for changes in health of their population?
•What is the impact of health policies adopted
at the international scene on the health of
populations in developing countries?
Health?

•A state of complete physical, metal

and social well-being and not
merely the absence of disease or
infirmity

•WHO, 1948
 Health Systems?
H

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■ iiiiiiiiii

• Consists of organization, people and action whose primary intent is to promote,

restore or maintain health
• Includes effort, influence both determinants of health and direct improving activities
• Health systems of different countries depend significantly on many factors, including:
• Income distribution profile;
• Total health expenditure per capita
• Public health expenditure per capita
• Public and private expenditure
• Geophysical feature of the country and the relationship to logistical issues
• Availability and spatial distribution of medical and paramedical service providers and the degree of
public and private provision
• The priority given to the sector under the country social policy, particularly the degree of risk
pooling and social solidarity
• (WHO Health Systems, 2008)
What is Policy?

• A course of action adopted and pursued by a

government, ruler, political party;
• a principle to guide decisions and achieve rational
outcomes
• A statement of intent and is implemented as a
procedure or protocol
• Policy is a law, regulation, procedure, administrative
action, incentive, or voluntary practice of governments
and other institutions.
What is Public Policy?
Co
• A course of government action or inaction in response to
public problems (Kraft and Furlong)
• Whatever governments choose to do or not to do (Dye,
1987)
• The relationship of governmental units to its
environment (Eyestone, 1971)
• Purposive course of action or inaction undertaken by an
actor or set of actors in dealing with a problem or matter
of concern (James Anderson, 1994)
What is Health Policy?

• Health policy refers to decisions, plans, and actions that are

undertaken to achieve specific health care goals within a
society
• 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, planning and management
arrangements to be adopted for implementation of the policy
and the relevant institutions to be involved.
Why Health Policy?

• Scarce resources are used inefficiently

• People cannot access health care
• Service does not respond to what people want
• High disease burden
• Grossly inefficient and inequitable resource allocation
• Declining quality
• Demoralized workforces

• (Berman & Bossert, A Decade of Health Sector Reform in Developing

Countries: What Have We Learned? DDM Symposium, 2000)
Goals of Health Policy

Why health policies are needed?

• A health policy can achieve several things:
• It defines a vision for the future which in turn helps to
establish targets and points of reference for the short and
medium term.
• It outlines priorities and the expected roles of different
groups; and
• It builds consensus and informs people.
 Aims of Health Policy

•The Prime aim: Maintenance and improvement of the

health status of populations
•The risk factors which influence health difference
between countries
•Thus policies for health will be influenced by different
factors in each country and region
Health Policy in Developing Countries

• Central issue: making the best use of limited resources

in the environment in which there is a wide gap
between needs and resources, expectations and
performance
•There are 3 main issues:
• Diversity, complexity, change
What is Global Health?

• An area of study, research and practice that places a

priority on improving health and achieving equity in
health for all people worldwide
• Emphasizes trans-national health issues,
determinants and solutions
Inter- and multi-disciplinary collaboration within
and beyond health sciences
A synthesis of population-based prevention and
individual-level clinical care
Global Health Players and Challenges

International organizations (e.g. WHO, UNICEF, World

Bank)
Multilateral entities (e.g. G8, G20)
Multilateral initiatives (e.g. GAVI)
Bilateral initiatives (e.g. PEPFAR)
Philanthropies (e.g. Gates Foundation)
Global public-private partnerships
Private sector-industry
Civil society
 The World Health Organization (WHO) is a specialized non-political
health agency of the United Nations with headquarters in Geneva.

• WHO is unique among the specialized UN agencies as it:

• has its own constitution: came into force on April 7th, 1948
which is celebrated every year as "World Health Day" with a
different theme each year to focus attention on a specific public
health issue.
• own governing bodies
• own membership
• own budget
World Health
• Two major policy developments influenced WHO:
Organization
1. The Alma-Ata Declaration of 1978 that identified primarv
health care as the key to the attainment of the goal of Health
for All.
2. Global strategy for Health for all by 2000, followed by MDGs,
and recently SDGs 2030.
WHO Scope of Work:
• Prevention and control of disease
• Development of comprehensive
health services
• Family Health
• Environmental Health World Health Assembly
• Health Statistics
• Health Research ^■Executive BoardBn:
• Health Literature and Information
• Coordination with other agencies
Secretariat

Regions

WPROi EURO I PAHO ■ AFRO ■ SERO ■ EMRO

International Health Organizations:
Intergovernmental (cont.’ d)

•UNICEF (UN •World Bank & USAID

Children’s Fund): (U.S. Agency for
• Maternal/Child Health International
•CPC (Centers for Development):
Disease Control and
Prevention):
• Disease prevention &
control
International Health Organizations:
Voluntary

♦Voluntary (Nongovernment organizations):

•Religious groups: Services
•Global Health Council (GHC): Health &
development
 Health Disparities in Developing
Countries

• Unequal levels of health

of
• Poorer countries: Higher rates of death,
disease, & disability
• Life expectancy is shorter
•Children suffer from malnutrition &
premature death
Primary Health Care Should Include:

•Immunizations
•Education
•Prevention & control of
•Improved food supplies
& nutrition diseases

•Safe water & sanitation •Treatment of diseases &

injuries
•Maternal & child health
•Adequate drug supplies
care
(WHO, 1978)
 Why PHC has not
been successful in
some developing
countries?
Why PHC has not been successful in
some developing countries?

• Non-respect of pyramidal levels of health care system

• Weakening of PHC's ability to maintain quality comprehensive
services, due to outbreak of civil wars, natural calamities and HIV
• Unsustained political commitment after the initial euphoria of
Alma Ata
• Issues of governance and corruption in the use of resources

• (World Health Report 2000- Health Systems: Improving Performances)

Epidemiological Transition

• Disparity in health status

• Higher death rates from communicable diseases in
developing countries
• Sanitation & immunization
• Relationship with health & poverty: HIV and infant
mortality
• Global burden Of disease due to infectious disease
being replaced by chronic diseases and lifestyle
diseases : heart disease, depression, tobacco use,
injury, violence
Problems Common to Developing
Countries
• Unsafe water
• Malnutrition & obesity
• Diarrheal diseases
• HIV/AIDS & malaria
•Tuberculosis
•Vaccine-preventable diseases
and Integrated Management of
Childhood Illness (IMCI)
Other Serious Health Concerns in
Developing Countries

•Maternal mortality
•Reproductive health
• Refugees from famine and war
•Viral hepatitis B
•Human trafficking
 Health Delivery Systems

• Entrepreneurial: Free-market approach

• Minimal government involvement (U.S.) Prior to
Affordable Care Act
Bismarck Model: Welfare-oriented
• Government regulation; taxes & personal
money (Germany)
Beveridge Model: Comprehensive
• Taxes & total government control;
comprehensive (United Kingdom)
Old & New Emerging Health Issues

• E. coli 0104.H4 outbreak in Europe

• Dengue fever
• Severe Acute Respiratory Syndrome (SARS)
• Cholera
• HIV/AIDS
• Hantavirus
• Influenza & avian flu
• EBOLA BIOLOGICAL
HAZARD
Environment

•Global pollution
• Depletion of ozone layer
•Greenhouse gases
• Biodiversity of plants & animals
•Chemical pollution
Tobacco-Related Illnesses

• Markets shifting from developed to developing

countries
•Tobacco-free initiative to ban advertising and
promote smoking cessation
• Using graphic pictures on cigarette packaging
Macro- vs. Micro
Health Policy
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Macro Health Policy
• Broad and expansive health policies that are
developed at the national level
• Affect a large portion of the population (region
or country)
• Define the country's vision priorities,
budgetary decisions, course of action to
sustain health
• Developed based on population-health needs
• For example, MOH policies; Vision 2030 health
transformation initiatives
Micro Health Policy

• More specific to level of by organization (from

organization or individuals, hospital to another)
examples: • Policies that apply to:
• Hospital administrative • Employees
policy and procedures • Operations
• Departmental/lnternal • Ethics
policy and procedures • Safety
• Clinical practice guidelines • Research
• Based on the operational
needs of the facility; differ
Inter-relationship between micro- and macro­
polic ies________

• Micro-policies at organizations are developed in line

with macro-policies put in place by the MOH
• The development and implementation of such
policies require a multi-disciplinary approach
• For example:
• Many ministries work together on development
of some macro-policies; MOH + MOMRA + MOE
etc (HiAP)
• Different departments of the hospital collaborate
for putting in place micro-policies
What is Sustainable Development?

• defined as development that

meets the needs of the present
without compromising the
ability of future generations to
meet their own needs.
How are the SDGs different from the MDGs?

• The 17 Sustainable Development Goals with 169

targets are broader in scope and will go further than the MDGs by
addressing the root causes of poverty and the universal need for
development that works for all people. These goals will cover the three
dimensions of sustainable development: economic growth, social Inclusion
and environmental protection.
• The SDGs are universal and apply to all countries, whereas the MDGs were
intended for action in developing countries only.
 GOOD HEALTH
3 AND WELL-BEING
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce
neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live
births.
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water­
borne diseases and other communicable diseases.
3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment
and promote mental health and well-being.
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents.
3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning,
information and education, and the integration of reproductive health into national strategies and programmes.
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and
access to safe, effective, quality and affordable essential medicines and vaccines for all.
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3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil
pollution and contamination.
SDG3 - Good Health and Well-Being
Maternal mortality rate (per 100,000 live births) 12 • f
Neonatal mortality rate (per 1,000 live births) 3.9
Mortality rate, under-5 (per 1,000 live births) 7.4
Incidence of tuberculosis (per 100,000 population) 10.0
New HIV infections (per 1,000) * 0.0
Age-standardised death rate due to cardiovascular disease, cancer, ] 5.4
diabetes, and chronic respiratory disease in populations age 30-70 years
(per 100,000 population)
Age-standardised death rate attributable to household air pollution and 84
ambient air pollution (per 100,000 population)
Traffic deaths rate (per 100,000 population) 275
Life Expectancy at birth (years) 74.8
Adolescent fertility rate (births per 1,000 women ages 15-19) 83
Births attended by skilled health personnel (%) 98.0
Percentage of surviving infants who received 2 WHO-recommended vaccines (%) 96
Universal Health Coverage Tracer Index (0-100) 77.8
Subjective Wellbeing (average ladder score, 0-10) 63

Sustainable Development Report 2019 O Transformations to achieve the SDGs

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Universal Health Care by 2030

• Means that all people and communities

can use the promotive, preventive,
curative, rehabilitative and palliative
health services they need, of sufficient
quality to be effective, while also
ensuring that the use of these services
does not expose the user to financial
hardships (WHO)
Universal Health Care by 2030

Based on:
•WHO Constitution of 1948
declaring health as a
fundamental human right
•The "Health for All" Agenda
set by Alma Ata Declaration
in 1978
 UHC

• Cut across all of health-

related SDGs and bring hope
of better health and
protection for the world's
poorest
•At present, there has been a
surge for compliance of UHC
globally
Public Policy Analysis

• Public policy analysis is a rational,

systematic approach to making policy
choices in the public sector
• It is a process that generates information on
the consequences that would follow the
adoption of various policies
• It uses a variety of tools to develop this
information and to present it to the parties
involved in the policy making process in a
manner that helps them come to a decision.
 Approaches

• There are three approaches to policy analysis:

• Empirical
• Valuative
• Normative (value-critical)
I Approach Primary Question Type of In formation
Empirical Does it and will it exists? Descriptive and predictive
(facts)
Valuative Of what worth is it? (Values) Valuative
Normative What should be done? Prescriptive
(action)
Theoretical Approaches

Political Systems Theory

Group Theory
Elite Theory
Institutionalism
Rational Choice Theory
 Elite Theory

• The model shows that the top of political and economic

hierarchies set the institutional agenda (top-bottom style)
• Agenda setting is viewed as:
• Elites on their own randomly select issues they specialize in, or
observe hierarchies like congressional committee structure
• Society's elites may select issues that serve their own interest and
ignore the public interest
• The elitist model has following key assumptions:
• There exist a dominant class that monopolize political power
• Ordinary citizens have relatively little power over matters that are of
Institutional Theory

• Policy is a product, authoritatively determined,

implemented and evaluated by the government ?
institutions (congress, local and national)
• A policy does not become a public policy until it is ((
legitimized by government entity concerned.
Government policies provide legal powers that demand
obligations from and command loyalty of the citizens
• The Constitution serve as the highest kind of policy to
which all other policies must subscribe
• Laws passed by Congress, Executive orders and judicial
decisions come second in terms of relevance and priority
Rational Choice Theory

• Aka social-choice, public-choice or formula theory, originated

with economists and involves applying the principles of micro-
economic theory to the analysis and explanation of political
behavior
• One of its basic axioms is that political actors, like economic
actors, act rationally in pursuing their own self-interest
• "Because governments are made up of individuals and individuals
operate from self-interest when they are engaged in a system of
exchange, whether this is in the market economy or in politics"
• Individuals who are engaged in decision-making exchanges or
transactions like voting also have preferences that vary from
person to person
Rational Choice Theory

• Being rational, they are able to comprehend and

rank their preferences from most to least
desired. In making decisions, they are guided by
these preferences and will seek to maximize the
benefits they gain
• Involves methodological individualism and the
individual decision maker is the primary unit of
analysis and theory
• Rational choice theory argues that actions of
groups can be explained by the behavior model.
The Policy Process
The key steps include:
Step 1: Identify the Problem or Issue
Step 2: Policy Analysis
2.1 Identify and Describe Policy
Options
2.2 Assess Policy Options
2.3 Prioritize Policy Options
Step 3: Develop a Strategy for Furthering Adoption
of the Policy Solution
Step 4: Policy Enactment
Step 5: Policy Implementation

Overarching activities: Stakeholder engagement &

education AND Evaluation
 What is a Problem?

• a gap between existing state and the desired

state (MacCrimon and Taylor, 1976)
•An unacceptable gap between normative
ideals and aspiration levels and present/future
conditions
• A gap must (Vesely, 2014):
• Be perceived as important
• Be difficult to overcome
• Be manageable
Two basic approaches

Traditional
sociology • A social problem exists when
there is a large gap between
society's ideals and actual
outcomes.
• A social problem exists
Modern when a s'gnificant number of
. . . people believe that a certain
constructivism condition is in fact a problem
(Kerbo, Coleman 2006, p. 363)
THREE ELEMENTS of POLICY
SYSTEM

Crime Policy analysts Law enforcement

Inflation Citizen's group Economic
U nemp loyment Labour unions Welfare
Discrimination Parties Personnel
Urban squalor Agencies Urban

Source: Adapted from Thomas R. Dye, Understanding Public Policy 3rd ed.

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 1
Agenda Public
Universe administration
actors,
political
Policy parties
Agenda

Government

t
Agenda

Private and
civic sector
Decision actors, media
Agenda

Figure adapted from Birkland 2006. Activate Windows

 Policy Reform

•Means positive change

•Fundamental, intended and enforced
change of the policy paradigm
and/or organizational structure of a
policy sector'
•Sustained, purposeful and
fundamental change of health
systems (Berman, 1995)
 Policy Reform

Attempt to improve efficiency, equity and

effectiveness of health sector (ILO Sector Activity
Program, 1998)
Reform characteristics:
• Fundamental: deviation from existing structure or
paradigm - a change in priorities
• Intended: involves a decision maker that intentionally
strives for change
• Enforced/Adopted: shows success of the reform I
proposal in all stages of policymaking except 3
implementation
Classification

By Peters and Hogwood

• Policy innovations
• Policy succession - replaces existing policy with another
one but no radical changes happens but just a
continuation
• Policy maintenance - adaptation of the policy to
maintain its orientation and functioning
• Policy termination - abolishment of all policy related
activities and public financing
Classification

•Capano and Hewlett

•Cyclical (change occurs but remains status quo)
• Dialectical (change occurs thru a process of
negation and synthesis)
• Linear (change occurs in evolutionary fashion
without any clear endpoint)
•Teleological (change occurs in direction of a final
identifiable goal)
Factors that affect health policy
decision making
• Advocacy coalitions,
values, beliefs and policy
learning
• Economic factors
• Cultural/religious factors
• Behavioral factors
• Physical environment
• Availability of medical
services
ffziB9
• Technology advances
• Epidemiological structure
(disease distribution and
disease prevention priorities)
• Public health evidence
• Political situation
The Challenge

With all these International and

National Policies and Strategies,
Why is there minimal change in
health in developing countries?

Most National Governments are stocked at the

level of policy, there is little or no action; there
is great challenge of moving forward
Internally and not locaIly/nationally
motivated/supported
Ways Forward

• More action on policy: need of

translating international/national
policies into measurable national plans:
• National Plans focusing on essential
interventions; integrated service delivery
strategy; correct skills-mix; health care
facility and supplies;
• Focus in strengthening health systems on
health workforce, medicines, supplies and
equipment and progress measurements
Ways Forward

• More action on policy: need of

translating international/national
policies into measurable national plans:
• National Plans focusing on essential
interventions; integrated service delivery
strategy; correct skills-mix; health care
facility and supplies;
• Focus in strengthening health systems on
health workforce, medicines, supplies and
equipment and progress measurements
Ways Forward

More action on policy: need of

translating international/national
policies into measurable national plans:
• Empowerment of the individual, family
and community to take care of their own
health and demand quality services;
• Providing essential services to most or all
of the population in a rapid, equitable
and sustainable way
Summary

• Health as a global priority

• Health disparities exist among countries
• Intergovernmental organizations provide
leadership, financing, & support
• Many voluntary agencies work in world
health
• Public health measures: Sanitation, safe
water & vaccination
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