This book provides a multi-disciplinary framework for developing and analyzing health sector reforms, based on the authors' extensive international experience. It offers practical guidance—useful to policymakers, consultants, academics, and students alike—and stresses the need to take account of each country's economic, administrative, and political circumstances. The authors explain how to design effective government interventions in five areas—financing, payment, organization, regulation, and behavior—to improve the performance and equity of health systems around the world.
Public–health regularly encounters serious ethical dilemmas, such as rationing scarce resources, influencing individuals to change their behaviour, and limiting freedom to diminish disease transmission. Yet unlike medical ethics, there is no agreed–upon framework for analysing these difficulties. We offer such a framework. It distinguishes three philosophical views, often invoked in public–health discourse: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (liberalism), and views that emphasise character and virtue (communitarianism). We explore critical variations within each approach, and identify practical problems that arise in addressing the ethical dimensions of health policy. We conclude by examining challenges posed by the feminist argument of ethics–of–care and by postmodern views about the nature of ethics. Health professionals need enhanced skills in applied philosophy to improve the coherence, transparency, and quality of public deliberations over ethical issues inherent in health policy.
Three main questions were raised at the IUHPE conference in June 2002 on "new dimensions in promoting health," with a particular focus on the process of policy change:
? How should people with an interest in promoting health across sectors approach the policy change process?
? What skills are needed to engage in the policy change process?
? How do we build collaborations across the policy arenas?
In short,the answer to all three of these questions is "politics." First, the policy change process needs to be approached through politics. Second,engagement in policy change requires political skills. And third, collaboration across policy arenas requires management of the political process.
A decade ago, in his election campaign for President of the United States, Bill Clinton made famous the slogan, "It?s the economy, stupid!" He plastered those words on the wall of his campaign headquarters in Little Rock, Arkansas, to remind him and his supporters that winning the election required a focus on economic promises.
But the policy change process is driven itself by politics. Indeed, more attention by Bill and Hillary Clinton to the politics of health care — from "it?s the economy, stupid," to "it ?s the politics, stupid!" — might have improved their chances of passing health reform in the United States in 1994.
The failure of the Clinton reform plan highlights the importance of the political process for promoting policy change, and the risks of underestimating political challenges. This article first reviews three political themes about the policy reform process, and then presents a systematic approach to the development of political strategies for reform, using examples of health policy.
The modern state is being reshaped by multiple forces acting simultaneously. From above, the state is actively constrained by agreements promoted by international agencies and by the power of multinational corporations. From within, the state is being reshaped by increasing trends toward marketization and by problems of corruption. From below, the state's role is being diminished by the expansion of decentralization and by the rising influence of non–governmental organizations. This article explores these three sets of processes — from above, from within, and from below — and suggests some implications for public health. Public health professionals require an understanding of the changing nature of the state, because of the consequences for thinking about the metaphors, solutions, and strategies for public health.
Global inequities in access to pharmaceutical products exist between rich and poor countries because of market and government failures as well as huge income differences. Multiple policies are required to address this global drug gap for three categories of pharmaceutical products: essential drugs, new drugs, and yet–to–be–developed drugs. Policies should combine "push" approaches of financial subsidies to support targeted drug development, "pull" approaches of finnancial incentives such as market guarantees, and "process" approaches aimed at improved institutional capacity. Constructive solutions are needed that can both protect the incentives for research and development and reduce the inequities of access.
Global health problems require global solutions, and public–private partnerships are increasingly called on to provide these solutions. But although such partnerships may be able to produce the desired outcome, they also bring their own problems. A first–of–its kind workshop in April, hosted by the Harvard School of Public Health and the Global Health Council, examined the organizational and ethical challenges of partnerships, and ways to address them.