Dr. John Barry
Queen’s University Belfast
j.barry@qub.ac.uk
State
Market
Community/Civil Society
Shift from government to governance – dynamic relations between all
three of these spheres and actors in establishing rules. Regimes,
managing expectations, setting standards, making legislation,
implementation and review of policy
State ‘steers rather than rows’
A more inclusive style of politics and policy?
A flattening of policy but not necessarily one that leads to an equal
flattening...
A key issue in the study of governance is to analyse the dynamics,
actors, resources, power relations etc. between the state, market
and civil society
And within these spheres – in health area (overlap of all three
spheres) what is the power relations between for example,
hospital consultants, the HSE, Dept of Health, BUPA, IADNAM,
nursing unions?
A marked a major watershed in contemporary public
health governance. Heralded as a new approach,
PHC was focused on: promoting a preventive
approach to health: redressing the bias towards
curative health care and addressing the prevailing
inequities in health outcomes, between the rich
and poor and between urban and rural areas.
Citizenship defined in terms of rights and duties
were deemed to be a central tenet:
“The people have the right and the duty to participate
individually and collectively in the planning and
implementation of their health care.”
(WHO 1978: Alma-Ata Declaration IV)
Active citizenship;
Partnership working;
Equity focused policy;
Integration
Omnipresent features of government policy documents in
the UK and Ireland, but largely absent in practice.
Consequently income level continues to be a powerful
predictor of both infant mortality and life expectancy,
and over the past 30 years the non-random distribution
of health outcomes has continued and the gap between
the rich and poor increased.
REPUBLIC OF IRELAND
CUBA
Total population: 4,221,000
Total population: 11,267,000
Gross national income per capita (PPP
international $): 34,730
Gross national income per capita (PPP
international $): not available
Life expectancy at birth m/f (years): 77/82
Life expectancy at birth m/f (years): 76/80
Healthy life expectancy at birth m/f (years,
2003): 68/72
Healthy life expectancy at birth m/f (years,
2003): 67/70
Probability of dying under five (per 1 000 live
births): 4
Probability of dying under five (per 1 000 live
births): 7
Probability of dying between 15 and 60 years
m/f (per 1 000 population): 88/56
Probability of dying between 15 and 60 years
m/f (per 1 000 population): 127/82
Total expenditure on health per capita (Intl $,
2006): 3,082
Total expenditure on health per capita (Intl $,
2006): 363
Total expenditure on health as % of GDP
(2006): 7.5
Total expenditure on health as % of GDP
(2006): 7.1
Figures are for 2006 unless indicated. Source: World Health Statistics 2008
By placing public health as the driver for its health system,
Cuba has managed to turn the traditional disease paradigm
on its head and as result, has, despite severely limited
economic and material resources, achieved health outcomes
on a par with all of the high income countries.
That Cuba has a Ministry of Public Health as opposed to a
Ministry of Health is telling
Ensures that governance is focused on health and not on illness.
The Ministry of Public Health is one of the dominant ministries
in Cuba and plays a key role in determining the priorities
and activities of other Ministries.
The Cuban constitution (Articles 9 and 50) enshrines citizens’ right to
health care and their responsibility to be actively involved in
service planning and delivery (Articles 45 and 64).
This emphasis on active citizenship and participation is core to the
realisation of a system of public health governance.
Health is viewed as enabling people to achieve their full capacity,
irrespective of age or ability. Consequently there is cognisance of
the wider determinants of health, such as housing, education,
nutrition and exercise.
Prevention of ill health and promotion of health consequently permeates
all aspects of public health governance and practice, and is the
key.
Education is recognised as a weapon against disease and ill health.
The consultorio (clinic) is the basic primary health care unit, attached to a
geographical population of between 120 and 300 families. Groups of up to
15 consultorios come together to form Basic Work Groups, which
subsequently feed into a neighbourhood polyclinic.
Polyclinics, serve populations of between 10,000 and 20,000; by providing
treatment and emergency services, 24 hours a day, 365 days a year.
Local health committees bring together, on a regular basis, representatives
from the Cuban Women’s Federation and other community organisations
along with the medical and nursing staff, to evaluate current performance
and plan for future service delivery.
Cuba, despite limited economic resources the determinants of health are
prioritised. This is achieved through rationing and state controlled
allocation of resources according to need.
Cuban needs assessment model has been highlighted as one of the key elements in Cuba’s
internationally renowned disaster management system (Oxfam America, 2004).
Located in a dominant place on the wall of every consultorio, is a graphical depiction of the
area’s “health diagnosis.” This is a comprehensive annual profile of the area, which
informs the work programme and priorities for the incoming year. At a glance, a
demogram provides information on the age/sex profile of the community.
The locality profile also includes information on health supporting resources and potential
hazards. The transparency surrounding the demographic and epidemiological
information means that in Cuba both patients and staff are knowledgeable about the
needs of the local population, thereby generating greater accountability within the
system and promoting greater partnership working.
Health experts and professionals – ‘on tap but not on top’?
Working with rather than on fellow citizens
From ‘no taxation without representation’ to ‘no operation without representation and
participation’?
Very different set of governance arrangements within a more egalitarian, rights-based health
care system
Cuba has more than double the number of doctors
per head of population then the UK and contrary
to the UK and other high income countries
propensity to recruit medical and nursing
personnel from poorer countries, Cuban doctors
and nurses are working in over 60 countries.
In 2005, 1500 doctors from some of the poorest
communities in Latin America, Africa and the
USA, graduated as the first cohort of students from
the Latin American School of Medicine in Havana.
“Capability is primarily a reflection of the freedom to achieve valuable
functionings….In so far as functionings are constitutive of well-being,
capability represents a person’s freedom to achieve well being.” (Sen,
1992:49)
Wilkinson and Pickett’s The Spirit Level: What more equal societies almost
always do better (2009)
SCOTTISH EXECUTIVE
INFANT DEATHS PER 1000
OBESITY
“Our finding that measures of child wellbeing are related to income inequality
internationally among rich countries is supported by similar associations with
child outcomes among the 50 states of the US. While our results have the usual
limitations of cross sectional analyses, they cannot easily be attributed to
confounding. Improvements in child wellbeing in rich countries might depend
more on reductions in inequality than on further economic growth, and attempts
to reduce the proportion of children in relative poverty are urgently required.”
Kate E Pickett and Richard G Wilkinson (2007), ‘Child wellbeing and income
inequality in rich societies: ecological cross sectional study’, British Medical
Journal
UK 2010 Marmot Report into Health Inequalities
“In contrast to 1980 when the Black Report was published, we now…know much more
about the importance of psychosocial influences on population health. We also
know much more about the biology of chronic stress about how rank and status
harm health (Marmot, 2004). We know that children get the best start in life by
being brought up in more equitable societies, rather than in rich ones (Pickett &
Wilkinson, 2007). Why did the Marmot Review not make hard-hitting
recommendations to reduce the harm created by great differences in rank and
status? Crucial parts of the contemporary tale are missing in this latest review of
health inequalities.” Pickett, K and Dorling, D (2010), ‘Against the organization of
misery?: The Marmot Review of Health Inequalities, Social Science and Medicine,
71, p. 1233.
“Within countries, income disparity could be translated
directly into disparity in life expectancy. For instance, a
boy living in the deprived Glasgow suburb of Calton
will live on average 28 years less than a boy born in
nearby affluent Lenzie. Similarly, the average life
expectancy in London's wealthy Hampstead was 11
years longer than in nearby St Pancras”
WHO’s Commission on the Social Determinants of
Health, 2008, in Tam (2010), Against Power
Inequalities: Reflections on the struggle for inclusive
communities, p.112
Public Health Alliance (2007), Health Inequalities on the island of
Ireland
“Many studies in large numbers of first-world countries have shown
that the more disadvantaged people’s social and economic
circumstances are, the worse their health status is likely to be.”
Department of Health, Social Services and Public Safety (Northern
Ireland)
“Disparities in health status within the population lead to
consideration of the links between socioeconomic factors and
health’.
Department of Health and Children (Republic of Ireland)
So....shouldn’t we be tackling the causes (inequality chief among
them) of ill health and not just the effects ?
“Develop an equitable tax and welfare system to reduce the income gap;
End child poverty;
Ensure a decent minimum wage;
Provide a universal, appropriate and effective health service that provides care on the
basis of need rather than ability to pay;
End the accommodation/housing crisis;
Promote equality in education through increased investment in education in
disadvantaged areas and facilitation of increased uptake of secondary and third
level education in these areas;
Provide effective public services;
Invest in disadvantaged areas to end long-term unemployment and build social capital;
Develop healthy public policy which acts on the inter-related determinants of health;
Ensure that policies implemented across all sectors contribute to improving health and
reduce health inequalities;
Work against discrimination through respecting human rights and ‘rights’ proofing all
policies and practice;
Enable and empower the active participation of communities in decision making;
Improve data collection, research and knowledge on health inequalities and how they
can be overcome, including recognition of methodologies which give voice to those
experiencing inequalities.”
Funding is not the only issue ....equality and distribution
matter
Equality is more/as important as funding – strategy for
securing health outcomes in difficult financial times?
A equity based health care system is cheaper, delivers
better outcomes for more people…but
Requires a very different governance framework,
challenging vested and powerful interests such as
consultants, and the pressure for the commercialisation
of health, focusing on primary and public health and
being explicitly political (and focused on justice)
Addressing health injustice – where ethics, equality and
epidemiology meet....
What say the Irish Association of Directors of Nursing
and Midwifery?
“Rise up with me against the organization of
misery
But stand up,
you, stand up,
but stand up with me
and let us go off together
to fight face to face
against the devil’s webs,
against the system that distributes hunger,
against organized misery.
Pablo Neruda, (1972). The Captain’s Verses, p.99