global health

Social Policy & Global Health Chapter 6

Key Ideas ○ A nation’s political and economic structures help

shape the way social services including health care are delivered

○ Nations commonly are grouped according to the way they pay for social services

○ Democracy plays an important role in health but some authoritarian governments also maintain good health among their people

Traditional Policy Making Cycle Problem

presented

Solution proposed

Proposal accepted

Policy implemented

Policy monitoring & modification

Policy Development Considerations ○ Policy environment: cultural, legal, and political

context in which policies are made ○ Solutions sometimes proposed before problem

is clearly defined ○ Even with accurate cost-effectiveness data

decisions may not be data-based ○ Window of opportunity often relevant ○ More similar to program evaluation

Defining the Problem ○ First step in policy making ○ Role of burden of disease analysis

○ May be challenging to quantify in marginalized or mobile populations (selection bias)

○ Making private issues public ○ Domestic violence ○ Media coverage, public attention

Program/Policy Evaluation ○ Program should be based on causal evidence ○ Cost-effectiveness analyses are helpful but usually

not stand alone ○ Politically powerful constituents can influence

decisions ○ Risk and risk perception are important, and prediction

is challenging ○ Balance of objective data and narrative

interpretations ○ Health may be secondary to other goals (e.g.,

economy) for decision-makers

Measurement Issues ○ Selection bias: people included in the study do not

represent the underlying population of interest ○ Randomized controlled trials: the exposure of

interest is assigned to participants at random ○ Reduces confounding

○ Sensitivity analysis: limiting the analysis to a specific group of people or definition of exposure/outcome to see if findings hold ○ Can be used to calculate upper and lower bounds

Political Economy & Health ○ Economies reflect the allocation of resources within

society ○ Political economy: how political and economic

institutions interact in a given environment ○ Market socialist countries tend to provide social

services directly through government agencies ○ Corporatist states typically provide social services in

collaboration with associations ○ Local politics and social norms influence how social

services are delivered

Political Economy & Health: Low & Middle Income Countries ○ Typically governments are challenged to provide

social protections and services ○ Low income, low tax revenue

○ Informal workers may get few or no services ○ Formal: government jobs

○ Colonial histories may have contributed to underdeveloped institutions ○ Services not for locals, civil wars

○ Clinton & Blair “third way”: markets exist but social programs are emphasized

Three Forms of Social Democracy in Low & Middle Income Countries

Feature Radical Social

Democratic Classical Social

Democratic “Third Way”

Unit of organization

Class Entire society Individual or

society

Social goals Equity Solidarity, growth Market-based

growth

Social policies

Universal entitlements, redistributive

policies

Universal policies, no

eligibility requirements

Means-tested benefits,

accessible education,

poverty reduction

Benefit levels Traditionally

high, now variable

Pretty high universally

Fairly low but with subsidies

Example countries

Kerala, West Bengal

Costa Rica, Mauritius

Chile, Uruguay

Health-Optimizing Social Policies ○ State understands the needs of the population ○ Well organized state with multilevel communication,

adequate resources, and strong infrastructure ○ A robust civil society to demand some distribution of

new wealth ○ A history of competition, compromise,

accountability, and feedback ○ A strong political party with health sector allies to

coordinate efforts and lead program development