Public health policy development in developing countries

PUBLIC HEALTH POLICY
DEVELOPMENT IN DEVELOPING
COUNTRIES
Dr.Shoeb Ahmed / Dr. Shoeb Ahmed Ilyas
Giang Nguyen
Kinley Zam Dorji
Manfred Egbe
07 May 201 Corvinus University of Budapest

REFLECTION
 Does the introduction of a health policy at national,
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 (initiated)?
 Should developing countries rely on the West for changes in the
health of their population?
 What is the impact of health policies adopted at the
international scene on the health of populations in developing
countries?
2
Dr.Shoeb Ahmed Ilyas

Outline
 INTRODUCTION:
 Health
 Health policy
 Health reform
 Health systems
 Are all health systems the same?
 WHY HEALTH POLICIES?
 POLICY DEVELOPMENT
 Alma Ata Declaration 1978
 World Bank / IMF SAP 1987
 WHO Bamako Initiative 1987
 UN Millennium
Declaration/Development Goals
(MDGs) 2000
 Paris Declaration
 CONCLUSIONS
 REFERENCES
3

Introduction
 Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity
(WHO, 1948)
 Policy is a plan of action developed to deal with a problem or matter of
concern in a public or private sector: authoritative guideline that directs human
behaviour towards a set of specific goal and provide the structure to that
action.
(Health reform, 8th edition)
 Policy development therefore is the process by which society makes decisions,
selects goals and the best means for reaching them, handles conflicting views
about what should be done and allocates resources to address needs
(Center for Health Improvement: Health Policy Guide)
4

Introduction (cont’)
 What then is health policy?
 Health related decisions made by legislators codified in law;
 Rules/regulations designed to implement legislation or to operate
government and its various health related programs;
 Judicial decisions related to health.
 Health reform
 Reform means positive change. Berman 1995 defines health
reforms as ‘sustained’, ‘purposeful’ & ‘fundamental’ change of
health systems.
 Attempt to improve efficiency, equity and effectiveness of the
health sector;
(ILO sector activity program, 1998)
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Introduction (cont’)
 Health system:
 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 health 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)
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Why Health Policy
 Scarce resources are used inefficiently;
 People cannot access the health care;
 Service does not respond to what people want
 High disease burden
 Grossly inefficient and inequitable resource allocation
 Declining quality
 Demoralized workforces
(Berman A., & Bossert J., A Decade of Health Sector Reform In Developing Countries:
What Have We Learned? DDM Symposium March 2000)
7

Policy development:
ALMA-ATA declaration 1978
 One of the most influential international
declaration on health;
 Birth of PHC, (comprehensive, universal, equitable
& affordable healthcare services); integral part
of a country’s health system;
1st level of contact;
 Governments, WHO UNICEF, funding agencies
etc:
 Protect & promote health of all people;
 Support national & international commitment
to PHC;
 Channel increased technical & financial
support to PHC;
 Restructuring of government to bring health closer
the people (decentralization);
 Despite all these efforts, PHC has not achieved
health for all by 2000;
8

PHC in Bhutan
PHC approach was adopted in its health care system ever since
becoming the signatory to Alma Ata Declaration.
 Challenges
Indicators 2000 2007
Infant mortality ratio (per 1000 live births) 60 40
Proportion of children covered under immunization
program
85% 90%
Maternal mortality ratio (per 100,000 live births) 560
(1990)
255
(2000)
Births attended by skilled health personnel 24% 55.9%
PHC coverage >90%
9

Why PHC has not been successful in
some developing countries
 Non respect of pyramidal levels of the healthcare system (many considered it
cheap and not good enough for them and so by passed to secondary and
tertiary levels)
 Weakening of PHC’s ability to maintain quality comprehensive services
(especially in Sub – Saharan countries) due to outbreak of civil wars, natural
disasters 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, marked the end of WHO’s use of
PHC as the means for the delivery of HC services in resource-poor countries)
10

The Structural Adjustment Program (SAP)
 World Bank’s strong ideological framework based on privatization, cost
recovery and big loans in the health sector;
 Emphasis on financial and macroeconomic goals rather than social sector issues
 Outcome of SAP:
 Less positive for healthcare delivery in resource challenged environments;
 Negative in terms of state of health, food security and access to care;
 Major impact on the ‘brain – drain’ of health workforce from developing
countries to the West;
 Weakened capacity of national governments to adequately fight HIV/AIDS
or significantly address other MDGs;
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The Bamako Initiative 1987
 Aimed at meeting the growing crisis of scarcity of drugs and reduced access
to quality healthcare and counter the negative impact of SAP
 Built on 8 principles
 Improve PHC services for all (equity)
 Decentralize management of PHC services to district levels
 Decentralize management of locally collected patient fees to community
level
 Ensure consisted fees are changed at all levels for health services
 High commitment from governments to maintain & expand PHC services
 National policy on essential drugs be complementary to PHC
 Ensure the poorest have access to PHC (pro-poor policy)
 Monitor clear objectives for curative health services
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Outcomes of Bamako Initiative
 Community pharmacies established (drug funds), innovation financing
mechanisms adopted in some countries (Lao People’s Republic), BI type
revolving drug funds in Myanmar, Vietnam, some districts in Cambodia,
Nepal (within the community Drug Program), Philippines at community or
barangay levels.
 Improved health indicators recorded in many countries
 Dependence on the sales of drugs, leading to irrational drug use (ex. Lao
people’s Republic)
 The initiative was highly donor driven with little coverage
 There were logistical, financial and quality control issues at operational
community levels;
 Donors and governments usually got involved in implementation rather than
focusing on policy matters
Quality of care improved and services were more efficient:
13

1993 World Bank Development Report
on Health Sector reform (UN MDGs)
 Search for alternatives to health policy making due to inability of PHC, BI
and other international initiatives to improve access and quality of HC in
developing regions/countries;
 WBDR 1993 changed orientation of how HC services in resource-poor
countries be delivered (HC sector activities to improve health);
 1993 WBDR became known as “health sector reform” emphasizing on using
the private sector to deliver HC services while reducing/removing
government services (introduction of user pay, private health insurance, cost
recovery, public-private partnership as focus of HC delivery) - NPM
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UN Millennium Declaration (MDGs)
 Rallying call to improve health in all parts of the globe in order to inject
political support, establish verifiable benchmarks & engender an
international solidarity of all nations;
 MDGs focused on broad multi-sectoral approach to development including
health – reduce child mortality; improve maternal health; combat HIV/AIDS,
malaria & other diseases;
 Development assistance & actions through funds and initiatives such as:
 Global fund against AIDS, TB, & Malaria (GFATM)
 US President’s Malaria Initiative (PMI)
 US President’s Emergency Fund for AIDS Relief (PEPFAR)
 Road map for accelerating the attainment of the MDGs related to
maternal & newborn health in Africa
 International Health Partnership (for the health MDGs)
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MDGs:
 New rounds of national health policies & strategic plans in the health
sector or revision of existing ones because of injection of much needed
resources in the sector through funds and initiatives
 Maternal health still remains a major problem in most developing
countries (especially Sub – Saharan Africa)
 Emerging problems between aid donors and recipients (countries) on aid
effectiveness;
Paris declaration on aid effectiveness 2005
 Laid down indicators (12) to provide measurable and evidence – based
way to track progress against aid effectiveness objectives and set targets
for 11 of the indicators for the year 2010
MDGs (cont’) and Paris declaration 2005
16

The challenge
WITH ALL THESE INTERNATIONAL/NATIONAL POLICIES & 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 a great challenge of moving forward
 Internally and not locally/nationally motivated and supported
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WAY FORWARD
 More action on policy: need of translating international/national policies into
measurable national plans:
 National plans focusing on essential intervention; integrated service
delivery strategy; correct skills-mix; health care facility; and supplies;
 Focus in strengthening health systems on health workforce, medicines,
supplies and equipments and progress measurement;
 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.
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Reference
 http://www.hsph.harvard.edu/ihsp/publications/pdf/closeout.pdf
 http://www.wpro.who.int/publications/Health+in+Asia+and+the+Paci
fic.htm
 http://www.worldpress.org/Africa/3251.cfm
 Doyin Oluwole, Health Policy Development, Washington D.C. September
18, 2008
 Andrew Cassels: Health Sector Reform; Key Issues in Less Developed
Countries. Journal of International Development Vol. 7, No. 3, (329 -
347) Canterbury Kent 1995
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Public health policy development in developing countries

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