Marc J. Roberts

Ethical analysis in public health

Public-health regularly encounters serious ethical dilemmas, such as rationing scarce resources, influencing individuals to change their behaviour, and limiting freedom to diminish disease transmission. Yet unlike medical ethics, there is no agreed-upon framework for analysing these difficulties. We offer such a framework. It distinguishes three philosophical views, often invoked in public-health discourse: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (liberalism), and views that emphasise character and virtue (communitarianism). We explore critical variations within each approach, and identify practical problems that arise in addressing the ethical dimensions of health policy. We conclude by examining challenges posed by the feminist argument of ethics-of-care and by postmodern views about the nature of ethics. Health professionals need enhanced skills in applied philosophy to improve the coherence, transparency, and quality of public deliberations over ethical issues inherent in health policy.

Global action on health systems: a proposal for the Toyako G8 summit

The G8 summit in Toyako off ers Japan, as the host government, a special opportunity to infl uence collective action on global health. At the last G8 summit held in Japan, the Japanese government launched an eff ort to address critical infectious diseases, from which a series of disease-specifi c programmes emerged. This year’s summit provides another chance to catalyse global action on health, this time with a focus on health systems. Global eff orts to improve health conditions in poor countries have embraced two diff erent strategies in recent decades, one focusing on health systems, the other on specifi c diseases. The interactions of these two strategies have shaped where we stand today. The fi rst strategy has emphasised systemic approaches to health improvement. In the late 1970s, the world embarked on a major eff ort to strengthen health systems from the bottom up, through the primary health-care movement. WHO and UNICEF launched this movement at the Alma Ata conference in 1978, which was attended by nearly all their member countries. The movement used an integrated multisectoral approach to health development, with special attention to disadvantaged populations in each country. This became known as a horizontal approach. This approach confronted many challenges. The problems were particularly severe in sub-Saharan Africa, because of “low fi nancing of health systems, bad governance, the human resources for health crisis, the high level of poverty of the people, the debt burden, the emergence of new diseases and the deterioration of the social system in many countries.” Today, with the 30th anniversary of the Alma Ata Declaration in 2008, calls have arisen for renewed attention to primary health care. Indeed, WHO’s annual report in 2008 focuses on primary health care and its role in strengthening health systems. The second strategy emphasised disease-specifi c approaches to health improvement. The last decade of the 20th century witnessed a rise in many diff erent single-disease control programmes. The Okinawa Infectious Disease Initiative, announced by Japan at the G8 summit in 2000, led to strengthened global eff orts on several diseases, in particular HIV/AIDS, tuberculosis, and malaria, but also poliomyelitis, parasitic diseases, and other neglected tropical diseases. These eff orts contributed to the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as other single-disease control programmes, ushering in a new era in global health cooperation. These programmes represent the vertical approach to health improvement. The disease-specifi c strategy has attracted substantial support in recent years and produced major results. Donors believe that this approach creates tangible products that can yield measurable improvements in health status. Development assistance for health is estimated to have grown from about

Pharmaceutical Reform : A Guide to Improving Performance and Equity

6 billion in 2000 to

Disaggregating the Universal Coverage Cube: Putting Equity in the Picture

14 billion in 2005. In addition to the Global Fund, collective eff orts to improve global health have included the GAVI Alliance, the Global Polio Eradication Initiative, the global health activities of the Bill & Melinda Gates Foundation and other private foundations, and various initiatives to develop new treatments for neglected tropical diseases. Various assessments suggest that these disease-specifi c partnerships have contributed to improvements in health conditions in poor countries around the world. However, the surge of disease-specifi c eff orts has also generated concerns about the unintended consequences of creating a fragmented array of uncoordinated programmes supported by multiple donors that recipient countries must struggle to manage. By focusing on specifi c performance measures, these programmes have sometimes not fully dealt with broader system failures. Yet such failures seem to lie behind the inadequate progress many countries have made on several key targets of the Millennium Development Goals (MDGs) for health—those related to child mortality (MDG 4), maternal mortality (MDG 5), and the prevention of HIV/ AIDS, malaria, and other diseases (MDG 6). Progress on these and other health improvements that depend on health system performance has been disappointing, especially when we consider the health status of poor and marginalised groups, for whom health status indicators (eg, infant mortality and maternal mortality rates) can be 50–100% higher than those of more advantaged population groups. The world is also facing the impending health threats of climate change. The potential consequences include enlargement of the geographical range of tropical diseases and massive fl ooding of low-lying inhabited areas, both of which would pose major challenges for health systems and disease control programmes in poor countries. Climate change could thus trigger negative interactions between poverty and health around the world, especially in poor countries. Addressing the health problems of poor countries can only move forward with a more balanced approach between specifi c-disease focus and system-based solutions; like weaving a piece of cloth, we need both the vertical and the horizontal threads to form strong fabric. Input-oriented approaches to health improvement (eg, Lancet 2008; 371: 865–69

Agenda Setting and Policy Adoption of India's National Health Insurance Scheme: Rashtriya Swasthya Bima Yojana

This publication, which is based on the unique methodology and tools developed for the World Bank Institute/Harvard School of Public Health Flagship Course on Health System Reform and Sustainable Financing, provides a powerful set of resources to help policy makers better navigate the complicated process of reforming pharmaceutical systems. Its problem solving approach complements technical resources and training curricula available on the discrete elements of a pharmaceutical sector. The application of the flagship approach to the pharmaceutical sector is both useful and timely. Ensuring the availability of medicines and the effective management of their procurement and distribution is central to the drive to achieve coverage and access to basic health care that is both universal and financially sustainable. Together, the methodology and case materials contained in this publication provide a rich resource from which policy makers in developing countries may draw to guide their efforts to meet these challenges. This book is designed to help participants gain a better understanding of all that goes on in the pharmaceutical sector. As noted above, it uses the flagship framework that we helped develop over the past decade. The essence of that approach is not to try to tell policy makers in detail what they should do. Rather it comprises a set of analytical tools that are combined into an overall, structured methodology for developing, adopting, and implementing reform proposals. The flagship framework also includes a comprehensive review of reform alternatives and a systematic review of their strengths and weaknesses in various situations. Throughout this book the authors have used the flagship framework to structure our analysis of pharmaceutical reform, continuously and explicitly applying its methods and concepts to the pharmaceutical sector. With a few minor exceptions, all the examples and all of the reform options come directly from pharmaceutical reform efforts around the world. The authors have also given specific attention to issues in pharmaceutical policy related to reproductive health.

How providers influence the implementation of provider-initiated HIV testing and counseling in Botswana: a qualitative study

Abstract—In recent years, the World Health Organizations “Cube Diagram” has been widely used to illustrate the policy options in moving toward Universal Health Coverage. The Cube has become a globally recognized visual representation of health system reform choices, with its axes defined by: (1) the services covered by pooled funds, (2) the population covered, and (3) the proportion of costs covered. The Cube shows the difference between the current national coverage situation in a country and the policy goal of universal health coverage, identifying where major gaps exist. The essential feature of the Cube diagram is that it shows a countrys coverage situation in terms of national averages. As a result, it does not present or call attention to significant disparities in coverage across population groups, which are characteristic of most low- and middle-income countries. This article recommends adding a new diagram that disaggregates the Cube. The new diagram, called the Step Pyramid, allows a policy maker to visualize specific choices in expanding the coverage status of different population groups. This new diagram can help policy makers focus explicitly on equity concerns as they set priorities in moving toward universal health coverage. The paper explains how to construct a Step Pyramid diagram, provides a hypothetical illustration, and then uses data from Mexico to create an example of a Step Pyramid diagram. The paper concludes with a discussion of the strengths, limits, and implications of both the Cube and the Step Pyramid.

Economics and the Allocation of Resources to Improve Health

Abstract Abstract—Rashtriya Swasthya Bima Yojana (RSBY) is Indias largest health insurance scheme. Launched in 2007, it now covers over 37 million, mostly poor, families. This massive scheme represents a major departure from past approaches to government support for health care in India. In this article, we use data from key informant interviews, published and unpublished documents, and newspaper reports, applying Kingdons framework for agenda setting and policy adoption to explain how RSBY became national policy.  Indias government-operated health care delivery system had consistently failed to meet its most basic objectives—especially for the poor. A variety of previous reform efforts had been unsuccessful. Then, in 2004, the result of the national election was seen by the victors as representing a mandate to address deprivation among those in Indias vast unorganized sector. That election also brought to the fore a new set of policy makers who were willing to introduce subsidized health insurance that made extensive use of the private sector. Technological advancements offered the reformers both new options and new experiences on which to base their innovations. A group of policy entrepreneurs, including Congress Party leaders, technocrats, and senior government officials, collaborated with international agencies to develop the RSBY approach, place it on the agenda, and assure its adoption as national policy.  This analysis explores factors that made this significant equity-oriented health reform possible in India and provides lessons for health reformers in other countries who seek to learn from Indias experiences in moving toward universal health coverage. Finally, we suggest some adjustments in Kingdons framework to help apply his ideas in different contexts.

Equity in Health Reform

BackgroundUnderstanding the motivations and perspectives of providers in following guidance and evidence-based policies can contribute to the evidence on how to better implement and deliver care, particularly in resource-constrained settings. This study explored how providers’ attitudes and behaviors influenced the implementation of an intervention, provider-initiated HIV testing and counseling, in primary health care settings in Botswana.MethodsUsing a grounded-theory approach, we purposively selected and interviewed 45 providers in 15 facilities in 3 districts and inductively analyzed data for themes and patterns.ResultsWe found that nurses across facilities and districts were largely resistant to offering and delivering provider-initiated testing and counseling for HIV (PITC) for three reasons: (1) they felt they were overworked and had no time, (2) they felt it was not their job, and (3) they were afraid to counsel patients, particularly fearing a positive HIV test. These factors were largely related to health system constraints that affected the capacity of providers to do their job. An important underlying themes emerged: nurses and lay counselors were unsatisfied with pay and career prospects, which made them unmotivated to work in general. Variations were seen by urban and rural areas: nurses in urban areas felt generally overworked and PITC was seen as contributing to the workload. While nurses in rural areas did not feel overworked, they felt that PITC was not their job and they were unmotivated because of general unhappiness with their rural posts.ConclusionsThe attitudes and behaviors of providers and barriers they faced played a critical role in whether and how PITC was being implemented in Botswana. Provider factors should be considered in the improvement of existing PITC programs and design of new ones. Addressing constraints faced by providers can do more to improve supply of human resources than merely recruiting more providers.

Bureaucracy, Pluralism, and Governmental Conflict@@@The Environmental Protection Agency: Asking the Wrong Questions.@@@Public Lands Conflict and Resolution: Managing National Forest Disputes.

This paper provides a review and critique of various ways in which economists have looked at the problem of allocating resources to health care. Three different perspectives that various economists have used at various times are considered: the so-called human capital view, that version of utilitarianism which leads to willingness to pay as the basis for life valuing, and cost-effectiveness analysis. My purpose is two-fold. First, I want to show that although all these ideas have been advanced within the same disciplinary tradition, they have quite different philosophical roots and justifications. They rely on and/or imply quite different views of the relationship between individuals and the state, and of the objectives at which the state is directed.

Getting Health Reform Right

International sources of health statistics overwhelmingly report national average performance. And many international statements about health policy - including the Millennium Development Goals (MDGs) — are formulated in those terms (MDGR, 2013). Yet, in almost all nations there are subgroups who are noticeably less well-off both in their utilization of healthcare services and in their health status. And in recent years, those concerned with healthcare rights (Daniels, 2008) and the movement towards Universal Health Coverage (Rodin and de Ferranti, 2012) have called attention to such disparities and urged governments to act to decrease such differences.