Political Economy of Health

The Politics of Universal Health Coverage

Presentation by

Dr Speciosa Wandira-Kazibwe Senior Presidential Advisor Population & Health,

Ministry of Health, Uganda at the

GIC Forum on Health and Social Protection, August 26–27, 2013

Gustav-Stresemann-Institute, Bonn, Germany

Organization of the Presentation

• Define health concepts: Health; PHC; Health System; UHC

• Determinants of health • Health system objectives • Defining Political Economy • Politics of Health • Political Strategies to Achieve UHC • Uganda

Health

• A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO, 1948

Primary Health Care (PHC)

• Primary Health Care (PHC): essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally acceptable to individuals and families in the community through their full participation and at a cost that the community and the country can afford to sustain at every stage of their development in the spirit of self-reliance and self-determination. Alma-Ata 1978

Universal Health Coverage

• Ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services. WHO

Health System

• All the organizations, institutions, and resources that are devoted to producing health actions; all activities whose primary purpose is to promote, restore, and maintain health. WHO 2002 - “purpose” includes the prevention of household poverty due to illness.

Determinants of Health • Biological • Social

• Political – includes public policy

(power/politics/ideology)

• Economic • Cultural

Health System Goals

• Goals: Improve health – average level & its distribution

(defining goal) Responsiveness to legitimate concerns – average

& distribution Fairness in financing Contributing to other social goals

Health System Functions

Stewardship Resource Mobilization

Provision of services Resource Development (Human, Infrastructure,

Technology)

Political Economy

• Locates economic analyses within a political environment and seeks to understand the interplay between politics and economics.

• Political Economy of Health: a perspective on

health policy which seeks to understand the conditions which shape population health and health service development within the wider macro economic and political context.

Politics… who gets what Harrold Lasswell (1902-1978)

• Government: management; conflict resolution; power for social existence.

the art of government: the activities of governments, state agencies: caveat on who is political and who can engage in politics

the power for social existence: power-structured relationship; every issue is political and likewise anyone and everyone can engage in a political act… (Millett, 1969)

Politics and Health

• Health is an unequally distributed resource / commodity

• Determinants responsive to political interventions

• The right to ‘a standard of living adequate for health and well-being’ (UN 1948)

• Power is exercised over health action as part of a wider economic, social and political system

No to Politics in Health [Adopted from Bambra C et al. Health Promot. Int. 2005;20:187-193]

• Health Care dominant doctrine • Health & Political Science – dominated by

behavior, institutions & rational choice health care issues are political

• Responsibility for health and authority: captured from individuals & the public domain

• Health policy versus Health Policies

A Political Economy Approach for UHC

• Politics and Economics matter in resource

distribution

• The past influences and informs the future

• Past institutions impact current health

UHC: A Social Contract • Ideology, Politics & Context Matter: Germany;

UK; South Korea; Rwanda Long standing feudal traditions & arrangements Social needs created by industrial capitalism

Political aims – political insecurity Culture & Tradition – basis for worker protection

Organized workers – guilds War

SHI: Transition to UHC Country Phase 1-Initial Insurance Related Law

Phase 2 – Law Establishing Compulsory Coverage

Time Frame No. of Years

% Health Insurance Coverage Time Frame No. of Years

% Health Insurance Coverage

Austria 1890-1930 40 7-60% 1930-1965/67 35-37 96%

Germany 1883-1930 47 10-50% 1930-1988 58 88%

Costa Rica 1940 -1961 10 17% 1990 29 85.00%

Belgium 1851 1969 118 universal

Luxemborg 1901 1973 72 universal

Israel 1911 1995 84 96%

1835-1938

Lessons for UHC Today

• Who sets the policy agenda

• Managing the process of agenda setting

• Political Strategies

Agenda Setting What defines public issues?

• Policy Entrepreneurs: Local & International • Ideology & Professional Training: beliefs & values • Traditions / Culture

• Crises: natural / economic • Political Cycles – window of opportunity • Media CONVERGENCE OF 3 STREAMS: PROBLEM, POLICY, POLITICAL =

SUCCESSFUL POLICY CHANGE …John Kingdom (1995)

Manage the Process: Stakeholder Analysis

• Stakeholder Analysis – who are the key players?

• Assess Political Resources –Power

• Analysis of Player’s Position /underlying interests

• Perception of definition of the policy, proposed solution and, material and symbolic consequences by stakeholder

Political Strategies

• Bargain to change position of players

• Distribute power resources to strengthen friends and weaken enemies

• Change the number of players by creating new friends and discouraging the foes: MOBILIZATION

• Change the perception of the problem and the solution

• Acquire the necessary skills for managing the process

• Ensure transparency through public deliberation

Systemic Characteristics of Health Sector Reforms

• Technical Complexity: Organization, Finance, Payment, Regulation, Behavior

• Costly due to well organized groups

• Non-mobilized are the key beneficiaries but not organized

Success Factors for UHC: Uganda’s Case Success Factor

1) Political Will 2) Effective control of

territory 3) Tax collection capacity 4) Human resource capacity 5) Social welfare policy 6) Sustained stewardship 7) Cultural homogeneity

Uganda

1) Yes: premised on a conducive legal, political, social & economic environment

2) No national ID, porous borders due to regional insecurity

3) Improving but not adequate 4) Inadequate – Management /

actuarial / health policy analysis 5) In place - fragmented 6) No multi-sectoral commitment 7) None: tribes, religion

WAY FORWARD Issue

1) High level commitment 2) Multi-sectoral

Engagement 3) Conflict lines 4) How to weather political

cycles

Status Quo

• Legal & Political • Transparent multi-agent agenda

setting • Use political strategies • Social entrepreneurs – local &

international: individual & agencies • Effective Community engagement

& mobilize people to ‘own’ their health: recapture power & control over own health; bureaucratic competence

Health Reforms in Uganda

• ‘Health Financing is necessary but not sufficient to achieve desired health sector objectives’ Build institutions: Stewardship; referral system;

management capacity; coordinated donor involvement; management of information; STRENGTHEN COMMUNITY ENGAGEMENT

Social Health Protection Resource mobilization: tax collection; community

schemes; ear marked taxes HEALTH REFORM SECRETARIAT TO MANAGE THE PROCESS

PARTNERSHIPS MATTER

• Providing for Health (P4H Network) - GDC, ILO, SDC and WHO … since 2009

• WB • UNICEF • ALL development partners to the overall

Health Sector

ASANTE SANA : DANKE SCHӦN

FOR GOD AND MY COUNTRY