3.1 Overview of policies and strategies
Oxford Textbook of Public Health
Overview of policies and strategies
Walter W. Holland
Organization and financing
Health commissioning (administration)
Role of public health
Assurance of appropriateness
Criteria, access, and utilization
International trends in health care
Provider–purchaser model for both public health and personal health services
The role of public health in the determination of priorities
The prime aim of health policies worldwide has been the maintenance and improvement of the health status of populations. This implies an understanding of human health and disease in order to determine the major biological, political, social, environmental, and lifestyle factors influencing health status and the burden of disease. The risk factors which influence health differ between countries, and the examples in this book illustrate their investigation, influence on health, and methods of control. Thus policies for health will be influenced by different factors in each country and region. Although it may appear that the problems addressed in this chapter are mainly concerned with developed countries, it is important to emphasize that the issues are the same in all countries at all stages of development. Public health problems in the developing world may appear different and greater, but the principles and methods for solution are the same.
The health of most of the populations of the developed world has never been better. Powles (1992) has dealt comprehensively with the changes in disease pattern and related social trends. He has shown changes in disease patterns that have occurred and are occurring in different parts of the world and has attempted to relate these to changes in social and other environmental factors. Both this study and others have shown a great increase in non-communicable diseases in the developing world together with the abatement of the mortality from infectious diseases. At the same time, in the developed world, we have seen a diminution in the frequency of infectious diseases and a great extension of the length of life with consequent increase in the diseases that are associated with old age, cancer, stroke, heart disease, arthritis, and others. These have serious implications in terms of the measures employed for the prevention of disease and improvement in the quality of life.
There is a major argument as to whether the extension of life is merely associated with an extension of time of disability or whether it is an extension of good quality of life. That argument still rages (Fries 1980; Davies 1985) and a definitive answer is not available although it is suggested that major disability, at least, has not increased with increasing longevity (Fries 1998).
Of more worrying concern have been the changes in disease pattern and recurrence of conditions, virtually unknown in recent times in the developed world, in Eastern Europe. An example is the enormous increase in the incidence of diphtheria in Russia (Public Health Laboratory Service 1994).
With the reduction of common infectious diseases in the developed world new hazards have arisen, for example HIV and AIDS.
In all countries there has been an extension of life, but this has been particularly evident in developed areas. This has important implications for health policies; the problems are mainly concerned with the elderly, rather than children. In the elderly quality of life is more important than extension of life; thus policies will be concerned with such matters as mobility, social contacts, and relief of pain, rather than with acute treatments.
As the health of most of the populations of the developed world has improved, complaints and concerns with the health services have risen. All health systems face the challenges of demographic change (ageing of the population), increasing population mobility, growing social exclusion, costly new therapeutic techniques, and rising public demands and expectations. While all these place mounting pressure on service provision at a time that public spending is under tight constraints, there are new opportunities for prevention and treatment, there is growing interest in prevention and health promotion, and the quality, as well as quantity, of life is generally improving.
The public has widely different views on the quality of health services, ranging from 95 per cent considering that health services are good in France to only 25 per cent in Greece (Ferrara 1993). All countries face similar problems as follows:
inequalities in both health status and health service provision between different geographic areas and social groups;
variations in the utilization of services for similar conditions (for example hysterectomy);
difficulties in the apportionment of limited resources to different strategies (for example prevention versus cure, or cure versus care) or between services (for example cardiac services versus renal services);
many of the problems are related to lifestyle behaviour and political/economic issues (for example cigarette smoking).
These issues have recently been described in detail for the countries of the European Union (Abel-Smith et al. 1995; Holland and Mossialos 1999).
The following chapters all illustrate the approaches adopted in individual countries to cope with these dilemmas. Most people accept that difficult choices need to be made. Most concentrate on the provision of health services, but health services in themselves do relatively little to bring about an improvement in the health status of populations. Environmental factors, such as housing, traffic, and employment, and behavioural factors, such as smoking, diet, and alcohol consumption, probably make greater contributions. Nonetheless, health services have an essential role in improving quality of life and can produce specific valuable improvements in other aspects of health status.
Organization and financing
The promotion of services to improve health by those working in public health and the influence that can be brought to bear on the management and administration of all services are important contributions to health service planning. Most health systems in developed countries have well-developed mechanisms for funding and provision. The problems in developing and developed countries may differ widely. In the former, health services are usually well organized in the urban areas, with deficits in the rural areas. But there are also problems in the former. In many developing countries most doctors are paid by the state, and are not well paid. However, opportunities usually exist for doctors in urban areas to supplement their income by private practice, which leads to great difficulties and disparities both between different groups of practitioners as well as between different areas in a country. There are also problems relating to the distribution of health workers caused by migration to developed countries. This may have grave implications for the supply and quality of health services. Different solutions are being developed; one suggestion is that all doctors who provide clinical services should be in private practice, and only those in public health and/or health planning should be employed by the state at a reasonable salary.
Although this problem also exists in developed countries, it does not have such an impact on the delivery of basic health services. Countries differ, however, in their ability to use these structures to initiate broad policies to maximize the population’s health. All health systems operate within a framework of national law. In some countries, such as the United Kingdom, the state is clearly visible as a regulator and provider of services. In others, legislation creates an environment in which doctors, hospitals, and insurance agencies operate with less visible state intervention. The ability of health services to co-operate with other agencies varies but it is less where there is little formal control beyond legislation of the health system itself. Most countries have endorsed the World Health Organization (WHO) Health for All charter but there is great variation in implementation in national and local policies. The state is involved in all health systems in varying degrees:
as legal regulator of the arrangements for patients to receive medical care and doctors to receive remuneration;
as a contributor to health-care financing, either through formal taxes or through quasi-taxes such as compulsory social insurance;
as a guardian to ensure that the correct balance of resources is used to achieve optimum population health.
Health care may be conceived in an economic framework as an exchange of goods. Patients seeking medical care are making demands while doctors are supplying services. However, there are ways other than medical treatment of using resources to improve population health and the priorities of medical practice emphasizing technical over social models of care do not always provide optimal health benefits. There is a role in all health-care systems for an overview of resource allocation, health policy, and population health outcomes; this is the task of health commissioning.
Health commissioning (administration)
Health commissioning needs to take into account the following factors:
improvement in health status (for example targeting smokers to reduce smoking should result in fewer cases of ischaemic heart disease);
risk reduction (for example, as above, reducing the number of smokers in a population);
services and protection needed to achieve improvements in health and reduction of risks (for example product labelling);
data needs for monitoring the achievement of the tasks identified (discussed in detail by Holland (1995)).
The prerequisites for achieving these goals need to be clear. The best model for this is that developed in The Netherlands (Ministry of Health, Welfare and Cultural Affairs 1993) which considers that health is seen as ‘the possibility for every member of society to function normally and to participate in social life’. Thus the need for health care is ‘to enable an individual to share, maintain and if possible improve his or her life together with other members of the community.’ This implies that necessary health care is that which allows the individual to be a full participant in society. This societal perspective is a little different from the individual perspective, where health is seen as the balance between what the individual wants to do and what the individual can do, or the professional approach, where health is the absence of disease. The Dutch model is the best one to follow in the arena of public health choices. Within that framework it is necessary to consider the place of public health. For that the current British definition is helpful as discussed below.
Role of public health
Public Health is the science and art of preventing disease, prolonging life, promoting health through the organised efforts of society. Public Health Medicine is that branch of medicine which specialises in public health. Its chief responsibilities are the surveillance of the health of the population, the identification of its health needs, the fostering of policies which promote health and the evaluation of health services. (Acheson 1988)
For the proper application of these principles it is essential to appreciate the methods to be used. Epidemiology, which is the science fundamental to the study and practice of public health, increases the understanding of the determinants of health and disease and the knowledge of their occurrence in populations and groups. Such information indicates the action that can be taken to prevent disease and promote health by health education or social policies which aim to modify behaviour, prophylactic procedures like immunization, screening for identification of those at special risk or in need of special care, and protection against specific environmental hazards. Preventive programmes also need to be monitored to determine whether they are achieving their objectives, at what cost, and how they may need to be modified.
A further function is the study of the nature and extent of disease and disability in the population and how this varies with age, sex, economic and social circumstances, occupation, and environment. Information on the patterns of disease is essential in defining health needs and tasks for health services and in setting priorities. It also allows the review of the services as they now are and the identification of those who do and do not use them so that the need for new services or the modification of the present ones can be judged. In addition, it is necessary to evaluate how effective the services are in helping the community in cure and care, in the relief of suffering, the maintenance of working capacity, rehabilitation of the disabled, and lowering of death rates. It also needs to assess how efficient the services are in using the community’s resources. Both aspects are critical in assuring value for money and are an integral part of health service management and resource planning—the more so since technology is always offering expensive new options.
Thus the problems for which public health action is required include:
outbreaks of disease caused by infectious or toxic agents, for example smallpox, typhoid, food poisoning, bovine spongiform encephalopathy, radiation, and so on;
problems arising from social and environmental issues such as inadequate housing, unemployment, poverty, abortion, fluoridation of water, and global environmental and population issues (McMichael and Powles 1999; Raleigh 1999);
behavioural concerns such as smoking, excessive consumption of alcohol, drug abuse, and insufficient exercise;
health service issues including assessment of health-care needs and outcomes, and the effectiveness and efficiency of particular services.
Public health, as a discipline, should not become involved in the direct management of clinical services in the community or within institutions—it lacks the expertise essential for these tasks. Its prime responsibilities are to promote health and to prevent and control disease. It thus has responsibility for surveillance and for the planning and co-ordination of measures that promote and maintain health. It must be involved in the planning and distribution of clinical services in accordance with measures of need and demands and the assessment of effectiveness.
Assurance of appropriateness
Few countries, at present, appear to have developed an organizational framework whereby these principles and methods are systematically applied.
In considering the provision of services for health it is important to be clear about what is to be achieved. In most countries it is now accepted that everyone who needs health care must be able to obtain it. However, that is not always the rule, as is shown in the following chapters.
The form and content of the right to health care are the result of a series of political and social compromises. As the Dutch Report on Choices in Health Care emphasizes, responsibility for others, the ideal of equality, and the social benefits of good public health have encouraged the belief that people are responsible for their own health, and are free to choose how to use health care and which risks they are willing to take (Ministry of Welfare, Welfare and Cultural Affairs 1993). The fusion of such different starting points has always brought strain to the design of health-care systems. That these strains are limited in the determination of rights is partly due to a pragmatic coupling between equality and freedom of choice so that, in principle, everyone has equal rights to virtually all of the facilities of health care. People do not need everything they want and not all needs for health care are equally important. There is a need for health-care services to maintain or restore health, for care and nursing of impaired health, or to relieve suffering. The concept of health is therefore the most appropriate standard to determine as to when there is a need for health care.
A definition of ‘health’ is the ability to function normally. In this definition there will be a need for health care when people are restricted in their normal functioning or when there is a threat of such restriction. Such a need is more essential when the restriction is greater or threatens to be greater. From a community-oriented view of health this is an incomplete statement. Health has a value in itself because it allows a people to participate in social life and to develop themselves. The more health problems restrict a person’s possibilities in society the more the need for health care and the more necessary the health care.
As stated above there are a variety of approaches to health. From the perspective of the individual, health is linked to self-determination or autonomy. To be healthy is to be able, as an individual, to achieve in society what one has chosen to aim for. Whether that is possible depends on one’s physical, material, and psychological resources but also on what one wishes to achieve. Health can be described as a balance between what people want and what they can achieve. Thus there will be differences in how individuals express a desire for health care.
From the medical professional perspective, health is the absence of disease and is seen as a deviation from normal biological function. In this definition there is a clear distinction between health care for the sick and social services for people who are not sick, where health care must be seen as professionally given care provided on the basis of indications defined objectively by the provider.
The effectiveness of care is also defined objectively with the most important criteria being danger to life and the extent of normal biological function. Biological functions seem ultimately to be directed at survival and reproduction. From that perspective demands can be sorted according to gravity and it is possible to distinguish necessary from less necessary care.
From the community-oriented approach health is seen as the possibility of every member of the society to function normally. The choices are made at the level of society because individual health is linked to the possibility of participation in social life. Care is thus necessary when it enables an individual to share, maintain, and if possible improve his or her life together with other members of the community. Individual preferences in needs are not given priority here. The central question is which care is necessary from the point of view of the community. Of course this question is not answered in the same way by all communities. There are three points of departure: the fundamental equality of people, the fundamental need for the protection of human life, and the principle of solidarity. Thus the major aim of any such system is the improvement of health and the ability to participate within society. If one accepts this Dutch model, then it is possible to define the different types of care that need to be provided in a variety of ways.
The WHO (Europe) has recently (WHO 1999) discussed the key areas specifically for public health. These can be summarized as understanding health and disease, measuring health status, appropriate disease surveillance and control, promoting health and well being, evaluating and improving health outcomes, intersectoral and collaborative working, and advocacy and communications. These define the role of public health within a health system which includes health care and ensures that appropriate decisions are made.
Criteria, access, and utilization
The first criterion that needs to be established is whether care is necessary or not. The second criterion is the effectiveness of the services provided, the efficiency with which they are provided, and whether the individual could take responsibility for providing them.
These principles are established in some way or another in most health systems. They are thus concerned with improvement of health status, risk factor reduction, and improvement of services and protection.
In most developed countries there is now a split between provision and purchasing for health care. The relative role of those who purchase health care varies between countries. In most private insurance systems, what is insured constitutes what is bought; however, in those that have managed care, or purchasing authorities, these institutes decide what care should be purchased and where it should be obtained. It is thus feasible to introduce health-care systems that consider the improvement of health on a societal basis. The characteristic that prevents medical care becoming an ordinary market, from an economic viewpoint, is that the receivers of services are often unable to make informed choices about care. Patients make many of the key choices over health care, whether their feelings and symptoms indicate that they are ill, and whether to consult a doctor.
There are wide variations between the different methods of organization and responses of individuals to health care. Similarly, doctors do not perform uniformly. Individual doctors vary in their action when faced with similar patients and make different decisions for patients with similar conditions. In both the National Health Service and social insurance systems, doctors are gate-keepers to resources. They legitimize a patient’s claim for services. Health systems seek to influence doctors’ decisions broadly, for example in the level of remuneration given to a particular service.
As indicated, in all systems it is crucial that there is interaction between the different sectors of society. Health can only be improved through changes in the environment, through occupation, including agriculture as well as health services and education, and unless there is some degree of co-ordination between these activities the optimal distribution of resource will be lacking. This also has an important impact on the improvement of health which is the aim of most national health systems. Most systems have now come to terms with the fact that they cannot only treat established disease but also have to be concerned with the improvement of health and the prevention of disease.
International trends in health care
Abel-Smith et al. (1995) have reviewed trends in health care. They note that there is a worldwide trend towards giving every citizen in a country the same rights to health care. If President Clinton had followed through recent health proposals made in the United States, this would also have been the case in America. There has not been much of a decline in public financing of health care quantitatively, whether by compulsory insurance contribution or taxation. There is some trend towards consumers making a contribution in the forms of copayments, for example prescription charges. Some countries are following the trend set by the United Kingdom in 1978 (Department of Health and Social Security 1976) of distributing resources on a geographical per head of population basis.
Some countries are encouraging people to take out private insurance or even to contract out of the public system.
Most countries are attempting to improve efficiency and effectiveness by introducing charters for waiting times. These indicate the right to be treated within a given time and reduce travel times by locating services in individual practices or locations rather than concentrated in a few large centres; however, some specialist services (for example, cancer) are only provided in a limited number of institutions. All countries and political regions have become concerned with quality and effectiveness and a few, for example the European Union, have developed indices of outcome (Holland 1997).
Provider–purchaser model for both public health and personal health services
The separation of commissioning and providing services discussed above theoretically enables better decisions to be made over which services to provide within a limited budget. Theoretically, it should also be possible to balance preventive, curative, and rehabilitative services. For this to be effective an adequate knowledge of the epidemiology, including the natural history, of conditions is necessary. However, this is not possible for more than a small number of conditions, although a few, such as coronary heart disease, chronic obstructive lung disease, and lung cancer, may represent a large proportion of the disease burden in a particular population.
Coronary heart disease may be used as an example. The prevalence of the various stages of the disease can be ascertained in a defined population by appropriate epidemiological studies or estimated by extrapolation from studies in equivalent populations. Incidence figures for each stage of the condition are obtained in the same way. Many of the factors responsible for the development of coronary heart disease, for example smoking cigarettes, blood pressure, and poor diet, are known. Evidence of the effectiveness of various approaches to prevention, for example advice to school children not to start smoking, counselling adults who smoke to stop when they attend the doctor, banning cigarette advertising, and so on, is known (or required). Evidence of the effectiveness and procedures to be used for the treatment of the early stages of diseases such as angina is available. It is thus possible to devise an appropriate model of the requirement for different treatment strategies like the use of aspirin, thrombolytics, and anticoagulants, and the need for efficient ambulance services, coronary care beds, and so on. Finally, knowledge is available of the appropriate rehabilitative services that are effective after a myocardial infarction.
From this complex model it is thus possible to consider the balance of resources to be devoted to, or invested in, the development of effective methods to both reduce the burden of coronary heart disease as well as to improve the outcome of those who develop the condition.
Obviously this scheme is idealistic so far, but it remains the underlying rationale for the separation of purchasing and providing health services. Managed care, now so popular in the United States, is an example of this type of separation. All these models rely on the development of knowledge of the effective methods of treatment or prevention of a condition.
The problem in all countries is that, although the effectiveness of many procedures or treatments is known, understanding of many common ailments, for example arthritis, is still poor. Thus all countries are involved in a variety of schemes to identify cost-effective methods of investigation, prevention, treatment, and rehabilitation (Holland and Mossialos 1999).
The role of public health in the determination of priorities
The role of public health is in the determination of priorities among these possibilities for improving health. Theoretically, the role of public health is clear in almost all the systems described here. It has the necessary tools to describe the problems and to devise appropriate mechanisms for their solution. In all the systems, however, the ability for public health to influence health policy is limited. Few of the countries described have effective mechanisms to influence individual health behaviours (for example the smoking of cigarettes) or to consider investment in non-health activities (for example education or employment) which are known to have more profound effects on health status than the use of medical care services (Black 1980; Acheson 1998). Nonetheless, the framework and structures currently being devised, coupled with concerns about the environment and demography, as well as increasing fiscal constraints in all systems, is forcing all countries to begin to confront these issues.
Previously, decisions on expenditure and treatment were largely controlled by those who were providing services. The treatment or service delivered to an individual or community was rarely questioned. With improvements in educational attainments and rising costs of medical procedures all societies have begun to question health expenditure. Thus decisions on priorities have become more explicit and democratic. Most countries have begun to debate how and what should be done; for example, should preventive services be provided to all the population or should heart transplants be available on demand (dependent on a sufficient supply). As a result, most countries have also begun to spend resources more effectively and to examine ethical issues involved in the setting of priorities and supply of services. All these issues are raised in the following chapters, and common threads are beginning to emerge.
The chapters describing the policies and strategies of various countries demonstrate the progress that has been made not only in the control of disease but also in the delivery of services. Most countries demonstrate a willingness to consider a wider perspective in the provision of health services than purely concern with treatment activities. Most have developed mechanisms for beginning to address the problem of inequalities and deprivation, with one notable exception (the United States). Most are facing the problem of increasing costs of medical care by rational deliberations and are beginning to consider alternative approaches, including an increased investment in public health research, in order to be able to introduce appropriate and effective preventive strategies.
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