Health impact assessment, health systems, health & wealth

Transcription

1 International Policy Dialogue on Implementing Health Impact Assessment on the regional and local level February 2008, Seville Health impact assessment, health systems, health & wealth Dr Antonio Durán Técnicas de Salud, Spain

2 Performance Health Systems Social Welfare Impact on the economy Health Economic growth Health Outcomes Wealth

3 OF COURSE, MORE THAN A SIMPLE TRIANGLE IS INVOLVED! How can well-functioning health systems contribute to health and welfare (workforce development, human capital formation, productive networks, alleviating the cost of illness, lowering the number of early retirements, etc.)?; How can productive investments in health and in health systems contribute to economic development (health clusters of innovation, technology transfers, citizen empowerment, increase choice, etc.)?

4 Globally, health is now a $3.5 trillion industry - 10% of the world's GDP WHO, 2007, Everybody s business; WHO's health system strengthening strategy, WHO Geneva There is a moral obligation to provide information about, and/or justification for the health-related actions to other actors!!

5 Sixty years ago at the launch of the World Health Organization, the world s governments declared health to be a fundamental human right without distinction of race, religion, political belief, economic or social condition. Thirty years ago in Alma Ata, the world s governments called for health for all by the year 2000, mainly through the expansion of access to primary health facilities and services. While the world missed that target by a long shot, we can still achieve it, at remarkably low cost. Ten key steps can bring us to health for all in the next few years Jeffrey D. Sachs, Primary Health for All, Ten key actions could globally ensure a basic human right at almost unnoticeable cost, Scientific American Magazine - January, 2008

6 Can Health Impact Assessment help avoid a seemingly never-ending list of magic bullet type of proposals which then amount to very little?

7 (in a context of changes in the world economy, the environment and the health systems ) Health situation in the European Region and in the world at large: improvement in main health indicators coexisting with interand intra-country inequalities

8 Malaria mortality annual rates since World minus sub-saharan Africa World Sub-Saharan Africa Source: The World Heath Report, 1999, WHO

9 Estimated number of people living with HIV/AIDS in CEE/CIS and in Western Europe (in 1000s). Source: UNAIDS webpage, Aids Epidemic Update (various years)

10 Age-standardized death rate, adult males, England and Wales, ,400 1,200 1,000 per 100, I II III IV V Source: European Observatory on Health Care Systems, 2002, UK, HIT series.

11 Need to re-analyze the reasons: - Part of the improvements have been due to economic development, improved education and nutrition, better housing and a number of factors not directly related to health care. But to a large extent we do not have robust, quantifiable evidence - Recent research has demonstrated an influence on health indicators of effective health care bigger than previously thought.

12 50/100,000 overall Regional TB incidence in European Region in / EU-15 countries 25/ EU countries 2004 enlargement 51/ BUL, CRO, ROM, MKD, TUR 103/ other countries bordering EU27

13 TB notification rates in WHO/EURO Notified cases per 100,000 population East Europe (18 countries) Europe (53 countries) European Union (with subsequent EU enlargements) 306,346 East Europe (18 countries) ,346 All EUR (53 countries) ,485 European Union (25 countries) Year

14 Effective health systems?? TB morbidity and mortality Poverty and social exclusion

15 Components of a health system? HEALTH CARE SYSTEM Medical Care and Prevention Services ENVIRONMENT - Physical - Social -Genetic Health Promotion IMPROVED HEALTH Health Promotion INDIVIDUAL BEHAVIOUR Better: -Housing -Water Supply -Education -Nutrition, etc. ECONOMIC DEVELOPMENT

16 HEALTH SYSTEM IS The ensemble of all organizations, institutions and resources that are devoted to producing health actions HEALTH ACTION IS Any effort, whether in personal health care, public health services or through inter-sectoral initiatives, whose primary purpose is to improve health Murray, CJ, Frenk, J, 2000, A framework for assessing the performance of health systems, Bulletin of the World Health Organization, 78 (6), 717

17 Boundaries of the health system PERSONAL ( MEDICAL ) SERVICES NON-PERSONAL HEALTH SERVICES INTERSECTORAL ACTION C O V E R A G E HEALTH GAIN OTHER CONTRIBUTING FACTORS WHO, 2000, World Health Report 2000, Geneva

18 HEALTH SERVICES 1 HEALTH SYSTEM 2 Machinery strictly related to the delivery of personal care and public health services 3 HEALTH FIELD Everything globally related to the social production of health and disease (from education to agriculture, to urban life, etc.) Broader machinery, including the Financing, Regulation,Resource Generation and Service Delivery, (i.e, planning, research, the links with Universities and the health industry, health technologies, subsidies to family carers, etc.)

19 HEALTH SYSTEMS FRAMEWORK FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM I Stewardship (oversight) Health (level and equity) N P U Creating resources (investment and training) Responsiveness (to people s non- HEALTH NEEDS medical expectations) T S Delivering services (provision)? Financial protection and fair distribution of burden of funding Financing (collecting, pooling and purchasing) Efficiency

20 Health systems are complex adaptive (as opposed to mechanical) systems Health outcomes are NOT merely a product of a set of physical inputs, human resources, organizational structure and managerial processes. Plsek P and Greenhalgh, 2001, Complexity science, The challenge of complexity in health care: BMJ 2001; 323: (15 September)

21 HEALTH SYSTEM PERFORMANCE ASSESSMENT (HSPA): - Did we attain our goals? - What health system and non-health system resources did we use for achieving those outcomes? - Were we efficient in using resources to attain those outcomes? - In which way do the health system functions influence the observed levels of attainment and efficiency? - What policies should be designed/ implemented in order to improve attainment and efficiency? Source: World Health Report 2000, proceedings, WHO, Geneva

22 A Framework for Policy Analysis Citizens Professionals Policy elites Interest groups CONTEXT ACTORS as individuals as members of a group CONTENT PROCESS Source: Walt G & Gilson L, 1994, Reforming the health sector in developing countries Health Policy and Planning; 9 (4):

23 THE IDEAL POLICY CYCLE Evaluation E T H I C S Problem Definition P O LI T I C S Diagnosis Implementation Policy Development Political Decision Roberts M, Hsiao W, Berman P and Reich M. 2004, Getting Health Reform Right, Oxford University Press, p. 22

24 The focus should be on actions by the Ministry of Health as the main health system steward. The MoH should provide leadership to inter-sectoral, cross-jurisdictional programmes

25 What Scope for Stewardship? Stewardship of broader, tertiary factors Stewardship of secondary, health-enhancing factors Stewardship of Health System (strategies etc) and of other h.s. functions Financing Service provision Resource generation Education, employment, trade etc. Wider economic and social factors such as corruption, reliability of global financial system, access to mass media, levels of social capital etc.

26 STEWARDSHIP; A FRAMEWORK Steering and Policy Making Regulating Intelligence for Accountability Personal Health Services Non personal Health Services Intersectoral actions

27 Member States and indeed the WHO European Office need to be better equipped to effectively cope with their responsibilities in intersectoral work.

28 Despite 30 years of research, we still lack a robust, generalisable, evidence base to inform decisions about strategies to promote the introduction of guidelines or other evidence-based measures into practice. Grimshaw et al. Effectiveness and efficiency of guideline dissemination and implementation strategies Health Tech Assess 2004; 8(6): 66

29 Tools and instruments required: 1. Revisited epidemiological analysis, strategic & operational planning for setting priorities/goals 2. High level information to communicate with stakeholders (providing leadership) 3. Effective advocacy & influence and negotiation tools and techniques to build alliances 4. Norms that protect the weakest members of society without interfering economic progress 5. Behavioral change and citizen empowering schemes through transparency & accountability 6. Effective monitoring and supervision tools 7. Normative instruments for enforcing rewards and sanctions as necessary.

30 It took 30 years for Cochrane s proposals to give birth to the Cochrane Collaborations. What would it take for Health Impact Assessment(s) to lead to more systematic decision making processes in relation to health?

31 Thanks