Global Health Policy

I spent one week doing an intensive block course in Global Health Policy. It was interesting and rather thought provoking. Turns out one of the reasons I must take time to write things down is because I can forget and I don't want that to happen especially since the course is technically not over I need to remember the things that were stirred within me. Honestly, I don't know where to start.

According to Stuckler and McKee, there are 5 metaphors used to describe Global Health Policy:
1. Global health as public health: including issues such as tobacco control,  climate change and population growth. It is aimed at decreasing the overall global burden of disease hence the focus on risk for disease. With particular response to the control of tobacco smoking in Australia, there have been positive effects seen with bans of indoor smoking and creation of smoke zones. Also, plain packaging with putting visual aids of the possible side effects of smoking have registered benefit. Other policies include restrictions on tobacco growth locally, restricting advertising as well as selling cigarrettes. Efforts to produce 'safe' tobacco products have been unsuccessful. According to theWorld Health Organisation Framework Convention on Tobacco Control(WHO FCTC), countries that signed up are required to put strategies for demand and supply reduction for Tobacco as well as provide support for individuals in member states that require assistance quitting.

I guess changing the image of smoking means that when you see a cigarette you no longer think

But you think:

I admire the bravery it must have taken to enact this policy.

2. Global health as charity: Health is promoted as a key element in the fight against poverty. There are a number of actors here: philanthropists, faith-based organisations, professional associations(these are increasingly expected to engage in their 'cooperate social responsibility'), NGOs, foundations,community groups and labour unions. Thus the number of public-private partnerships are on the increase. Their role includes advocacy, implementation, innovation, lobbying and financing. The motivation includes: humanitarian purposes such as alleviation of human suffering, Rights based approaches and for social justice. They tend to be pro-poor, attempting to fill gaps for weak health systems, deliver heath in difficult settings, engage in policy and research.

Resulting concerns about these groups:
a) Regulation/ Coordination: there are a large body of organisations involved with no specified regulation. They are bound by their individual contracts, accountability to funders but none to the communities in which they serve.
b) Increased red tape e.g in PPPs paper work requirements for each 'group' involved in the partnership. Also, conflicts and claims for recognition underlie a lot of these agreements.
c) Some charities have evolved into businesses
d) It is no surprise that vicissitudes such as the Global financial crisis dampen philanthropy thus the sustainability of many of these programmes is questionable. This is further challenged by the change in vision following  new funding sources or board members.
e) There is also concern that their existence tends to undermine the existing health systems. This is also because they often have better work conditions as well as training/workshops which keep key staff away.
f) Questions as to whether they are able to represent aptly the communities in which they exist and whether they creator equity issues as the communities in which they operate tend to receive high quality services that may not be available for the greater population.

3. Global Health as security: The policies seek to protect the country's population. The focus is usually on communicable diseases such as epidemics like avian influenza, drug resistant TB. With globalization, disease knows no bounds given daily exchanges in travel, goods, services and products. A lot of advanced economies invest in this because when such epidemics break out, managing them is challenging and very costly. The other explanation is that there is fear of what is unknown and control over this is a form of power- a concept that was recurring throughout the week.

We also discussed the work of the International Red cross society which has a mandate for both neutrality and impartiality. They have unique role on the global scene with policy that protects them even from testifying against war criminals. Clearly, there is need for more diverse representation on the UN security council as they have a major role in interventions within countries to do with war as well as prosecution of international criminals.

4. Global health as foreign policy: According to the Stuckler and Mckee(2008), here countries use policy to create a positive image, exert affluence and establish strategic alliances. The underlying theme is power. Interesting rhetorical questions triggered include:

• Who sets the global policy agenda? Whose interests are served?
• When countries receive aid("free money"), what has that money actually bought from them?
• Are there conditions that enable the "sovereign" to solidify their position of affluence?

"... is it not the supreme and most insidious exercise of power to prevent people, to whatever degree, from having grievances by shaping their perceptions, cognitions and preferences in such a way that they accept their role in the existing order of things, either because they can see or imagine no alternative to it, or because they see it as natural and unchangeable, or because they value it as divinely ordained and beneficial" (Lukes 2005, p. 28)

5. Global health as investment:View of health as a means to attainment of development. This has a focus more on work force population as compared to say women and children. An important question to ask is: What is the best way to invest in health (vertical vs horizontal programmes) and for whom? These tend to be aimed at cost effective, measurable, outcome/output based interventions such as described in the millennium development goals.

Interesting to note is how at a global level power dynamics affect the changes in policy for example: In 2009, Global fund and GAVI allied together with the world bank to invest in health system strengthening. his partnership initially excluded the World Health Organisation who have had an increasingly diminishing voice on the global platform because of the emergence of many well financed players on the scene. This focus was eventually dropped following changes in leadership in the partner organisations and also the effects of the Global Financial crisis. There is still universal acknowledgement of the relevance of health system strengthening but currently nothing is being done.

I believe that there is a role both for vertical and horizontal programmes. However, during the course of this programme it became increasingly clear to me that governments need to take more responsibility for their populations. I do not expect foreign aid to be able to aptly target health system strengthening because it is very rigorous and expensive. It needs to be a priority for the developing nations to come up with systematic plans to improve this and not be swayed with implementation of vertical programmes. There is a role for primary health care but without supporting functional and strong health systems, mortality rates will persist to be higher than acceptable and countries will remain 'dependant' on foreign human and financial resources.

"Countries receiving foreign aid need not be naive that there are no strings attached to aid. Rather, they should aim at reducing the length and strength of the strings, eventually cutting them off." Me :-)