Improving Governance for Global Health
Albert Weale
School of Public Policy
University College London
UCL Institute for Global Health – Five Years On
Grand Symposium
Contemporary Debates in Global Health: the UCL perspective
Wednesday, 3rd October, 2012, Kennedy Lecture Theatre,
Institute of Child Health, 30 Guilford Street, London WC1N 1EH
Outline
1.
2.
3.
4.
5.
6.
The Setting of the Governance Challenge
Two Particular Challenges
Price-Worthy Health Care
A Right to Health Approach?
Effective Public Health
Global Governance and Its History
All according to the principle that it is more thoughtprovoking to be clearly wrong than vaguely right.
1. The Setting of the Governance Challenge
There is widespread consensus on three goals for a modern
health care system:
1. That is should be of high quality.
2. That is should be comprehensive.
3. That it should be without financial barriers to access.
Although not the only goals, they are important. But they are
intrinsically hard to combine.
Also, the extent to which they can be combined depends
upon the level of economic development of the country.
International Comparison of Spending on Health, 1980–2008
Average spending on health
per capita ($US PPP)
16
6000
5000
4000
United States
Norway
Switzerland
Canada
Netherlands
Germany
France
Denmark
Australia
Sweden
United Kingdom
New Zealand
14
12
10
8
2000
4
1000
2
0
0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
3000
6
Source: OECD Health Data 2010 (June 2010).
United States
France
Switzerland
Germany
Canada
Netherlands
New Zealand
Denmark
Sweden
United Kingdom
Norway
Australia
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
8000
7000
Total expenditures on health
as percent of GDP
Increases in Income and Improvements in
Health
1. Classification of Countries by Income (2007)
Low Income
(53)
Middle
Income (55)
Upper-Middle High Income
Income (41)
(60)
2006 GNI per
capita
≥$905
$906 - $3,595
$3,596 $11,115
$11,116 ≤
Examples
Afghanistan
India, Rwanda,
Haiti,
Zimbabwe,
Nigeria
Albania, El
Salvador
Namibia,
China, Cuba
Argentina,
Costa Rica,
South Africa,
Thailand,
Turkey
Canada,
France,
Germany, UK,
USA
Source:http://web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,,contentMDK:20420458~menuPK:6
4133156~pagePK:64133150~piPK:64133175~theSitePK:239419,00.html
Life expectancy in WHO regions
Source: The global burden of disease: 2004 update (2008)
Per cent distribution of age at death by region,
2004
Source: The global burden of disease: 2004 update (2008)
1. Emerging Institutional Characteristics
Health System Financing
2. Two Particular Challenges of Governance
• The Design and Implementation of Health Care
Reimbursement Systems
• The Implementation of Effective Public Health
Measures
3. Price-Worthy Health Care
Thailand (HITAP) as an Example
• Introduction of tax-based health care system in 2002 to
complement government and private sector schemes.
• Covers 75% of population
• Also covers public health
• Well developed system of health technology assessment:
participatory system of nominating items for health
technology assessment; attempt to prioritise; assessment
of cost-effectiveness.
• ‘High cost’ interventions assessed, e.g, allogenic
haematopoietic cell transplantation for sever thalassemia.
• But also able to deal with issues of social values, such as
absorbent materials for adult incontinents.
3. Price-Worthy Health Care
Thailand (HITAP) as an Example
• Well-trained public service.
• Design of open and participatory institutions for examining
interventions (to get away from insider group influence).
• Well-developed policy paradigm, using QALYs.
• Willingness to draw upon comparative experience from
other health technology appraisal systems.
See: S. Tantivess et al. ‘Efficiency or Equity’, Journal of
Health Organization and Management, 26: 3 (2012), pp.
331-42.
3. Price-Worthy Health Care
The International Movement
• We should give credit to the health economists fro putting this question
on the agenda.
• Institutionalised in national health technology assessment agencies, or
which NICE is the UK example.
• Cross-national commitment to spreading capacity for HTA, of which
NICE International is a leader.
• Also international scientific network in HTAi, which holds regular
meetings.
• Note: This is not uncontroversial politically.
• The UCL/King’s initiative on a catalogue of cases and decisions.
4. A Right to Health Approach?
• Some people advocate a right to health approach.
• This captures an important truth, but there are problems
with implementation, particularly if the right to health is
made a constitutional right.
• Experience in Latin America is that the ability to use legal
remedies for breach of constitutional rights is very
unequal, and so the right to health reinforces social
inequalities.
See: L. Cubillos et al. ‘Universal Health Coverage and
Litigation in Latin America’, Journal of Health Organization
and Management, 26: 3 (2012), pp. 390-406, at p. 398.
5. Effective Public Health: Not technical but
political
A list of desirable interventions:
–
–
–
–
–
–
–
–
Clean water
Sanitation
Adequate food supplies
Literacy and education generally
Good urban public transport
Good housing
Good maternity and early childhood services
Preventive interventions on tobacco and sexually transmitted diseases
By and large these are outside the medical care system.
The political conditions producing these public policies are rare and
depend on a system of political representation that produces ‘a
coalition of the whole’.
That depends on taking ‘windows of opportunity’.
6. Global Governance: Remember the History
• ‘What internationalism offered in
particular was the possibility of
carving out a politics-free zone where
men of science could meet… treating
the world and its peoples as the
whole they really were.’ Mazower, pp.
95-6.
• International organisations for the
movement of ideas: ITU; UPU and
ISO.
• But the failures of international action,
despite attempts by First International
Sanitary Conference, to deal with the
fourth, fifth and sixth cholera
pandemics.
6. Global Governance: A Conclusion
Global governance is great, but national politics will
keep breaking in.
So, improving global governance means working
with the grain of those national governmental
institutions that contribute to effective and priceworthy health care.