The political context of health policy

Health Policy

The issue of healthcare policy has garnered a great deal of interest over the past decade. In recent months the debate over the development and implementation of a healthcare policy that will serve the purpose of assisting the masses. The purpose of this discussion is to define the relationship between the political, economic and social forces that affect health policy. The research will attempt to conceptualize this relationship. The research will also seek to define the political context of health. The research will also investigate how public health and healthcare are affected by the political context. Let us begin this discussion by defining health policy.

Defining Health Policy

Health policy can have different meanings depending on the source of the definition. Some definitions define health policy strictly in terms of the delivery of care. However, according to Navarro a National Health Policy is defined as

"the main components of a national health policy should be, including (1) the political, economic, social, and cultural determinants of health, the most important determinants of health in any country; (2) the lifestyle determinants, which have been the most visible types of public interventions; and (3) the socializing and empowering determinants, which link the first and second components of a national health policy: the individual interventions and the collective interventions (Navarro,2007).

Navarro explains that a national health policy has three determinants. These determinants work together to guarantee that the health policy that is adopted is efficient and beneficial to the whole of society. Now that we have defined health policy let us focus on determining the relationship between the political, economic and social forces that affect health policy.

Relationship between the political, economic and social forces that affect health policy

The issues of politics, economics and social forces all have a relationship to the manner in which health policy is addressed in society. This relationship exist because all of the aforementioned spheres have stakeholders who are affected in some way by the type of health policy that this adopted (Banerji 2006) . As such all of these factions have a say in the type of health of policy that is adopted.

As it pertains to the realm of politics, different political factions are stakeholders in the development and implementation of health policy. As it pertains to the development of health policy, the position that many politicians hold is based on their constituency they serve and their party allegiances. Politicians are only in office because people vote for them to be there or because they are appointed based on their position within a particular party. When a politician is beholden to their constituency the decisions they make concerning health policy legislation is often reflective of the needs of their constituency. If the constituency desires to have a health policy that is affordable and offers certain standard benefits, the type of health policy that the politician sponsors or encourages will be reflective of the needs of their constituency. Additionally, politicians are also influenced by party affiliation. If a party's platform involves a health policy that is universal, the politician associated with that party will quite often support the type of health policy that their party supports.

In either case the politician is often beholden to their constituency or to their party or to both depending on the type of political structure that governs the country. If politicians fail to encourage health policies that are consistent with the needs and desires of the constituency or the party they are affiliated with they may not be reelected,

As a result of this dependency politicians are stakeholders as it pertains to the development and implementation of health policy.

In addition to the aforementioned relationship between health policy and politics, there are other issues that make health policy political. According to a report entitled "Towards a New Politics of Health" there are five factors that make health policy political. These five factors include: unequal distribution, health determinants, organization, citizenship and globalization. These factors are explained as follows

Unequal distribution- Some groups within society also have more access to healthcare and other services than others. As such many health policies are governed or propelled by the unequal distribution of healthcare and other services related to health (Bambra et al., 2003).

Health Determinants- social determinants such as income and income can be altered by political interventions. As a result these determinants depend on political action.

Organization: any concerted effort designed to meet the health needs of the populace is determined by 'the organized efforts of society' (Secretary of State for Social Services, 1988) or the engagement of 'the social machinery' (Winslow, 1920; Bambra et al., 2003)."

Citizenship: access to 'a standard of living adequate for health and well-being' (UN, 1948) is, or should be, an aspect of citizenship and of human rights (Bambra et al., 2003)." That is every human being should have access to healthcare simply because they are human. This solidifies the idea that healthcare is a human right and not a privilege for the rich few (Bambra et al., 2003).

Globalization: the increased rate at which the world is connected via technology and transportation has created a complex global crises that is social, economic, ecological and ethical (Bambra et al., 2003). The authors explain that this crises will likely lead to bad health and premature deaths (Bambra et al., 2003).

The author explains that ultimately health policy is

"political because power is exercised over it. The health of a population is

not entirely under the control of an individual citizen, nor of a doctor

(especially not of a doctor, except in some instances of individual disease), but is substantially under the control of the social relations of the capitalist system. Changing this system and these relations are only achievable through politics and political struggle (Bambra et al., 2003).."

Indeed health policy is political because political action or inaction impacts the manner in which health policies develop and are implemented. Political forces can change the nature of the healthcare that is delivered.

In addition to the political nature of health policy, it is also economic. Healthcare can be extremely expensive. In addition healthcare is an economic sector unto itself. It is inclusive of doctors nurses, pharmaceutical companies and other sectors involved with providing healthcare. Because all of the aforementioned people and industries are effected by the health policy, the economy is also a stakeholder in the type of health policy that is developed.

Economics also has a relationship to health policy because of poverty and the unequal access to care that poor people have. Regardless of the country poor people usually have the most limited access to care. According to an article published by the World Bank entitled " cost recovery is a major economic issue as it pertains to helath policy. The article explains

"On the face of it, the issue of cost recovery is, from an ethical perspective, an open-and-shut case. User fees deter patients, especially poor ones. And where they do not, they end up absorbing a larger share of the income of a poor household than of a rich household (ie they are regressive)."If the aims are to improve the health of the poor and to prevent households from becoming impoverished through ill health, then clearly user fees are to be avoided (Wagstaff 2001)."

Although the idea of not having user fees may seem to ideal, particularly for the poor, is not a feasible solution. The authors explain that this is not a feasible solution because there are real costs associated with the delivery of health services. These costs are not just monetary. The authors further explain that free healthcare services often lead to extended periods in which to receive care. These waits can lead to a loss in income. In addition there are transport costs associated with the delivery of healthcare. With these costs understood, in theory user fees should reduce the waiting periods associated with free care. In addition such fees allow health care services to expand and increases the amount of overall healthcare available. This would mean that the cost associated with receiving healthcare would be reduced for the poor.

The author further explains that the quality of free healthcare services can also deter people from seeking free care, even poor people. The article asserts the poor often choose to forego free healthcare because of the quality of the service. For instance, in some cases, free clinics may not have access to the medicines that people need. As a result even those that have low incomes choose not to go to free clinics. Instead they will pay or travel to go to clinics that are not free. The authors further explain that "If user fees were introduced and the revenues could be used to improve quality, there might well be an improvement in the health of the poor with only a modest increase -- if any -- in the overall costs associated with ill health. It may well also be the case that user fees could improve accountability and give users a greater voice in the decision making process (Wagstaff, 2001)."

The relationship between healthcare and economics is a particular issue in poorer countries. The report explains that the economic impact in poor countries is seen in the form of grants and loans that the World Bank grants. The report explains that credit worthy countries that are extremely poor can qualify for long-term interest free credit. These credits are given under the International Development Assistance program. Although some countries qualify for these interest free credit, they often resort to borrowing funds because IDA funds are limited and based on a first come first serve basis.

Countries that have both IDA and loans for the purpose of healthcare for citizens are under what is referred to as an IDA blend. It is referred to in this manner because the terms under which the funds are borrowed is a mixture of the ID and those of the International Bank for Reconstruction and Development (IBRD) program. The author explains that the IBRD program carries an interest rate but is well below the rate that a private financial institution would carry. The author further explains that IBRD loans

"are available to creditworthy countries with a per capita income below $5,225.

When countries reach this threshold, the process of "graduating" from the IBRD

scheme is triggered. In its IBRD loans, the Bank borrows at preferential interest rates and then on-lends to the borrowing country at a rate that is somewhere between the rate the Bank borrows at and the market rate. International Development Assistance credits are financed in part through the income earned on IBRD loans, and in part through contributions from bank members (Wagstaff,

2001)."

Although borrowing money for health services solves one problem, it also creates a problem which is that of debt.. Debt is particularly problematic as it relates to poor countries and healthcare because it effects the ability of the country to get additional loans as the loans are based on creditworthiness. Having to pay back loans also impedes on the ability of the country to provide its citizens with other services. The overall economies of these countries are also affected by the debt because it prevents the government from invest in revenue creating Although there has been some effort to provide these countries with debt relief so that they can move forward and create economic opportunity for the country.

Obviously the economic condition of an entire country along with the economic conditions of the individual family unit affect access to healthcare. In addition, the cost of delivering healthcare to the masses is a real expense. Debates concerning whether or not healthcare should be free or consists of user fees. The research suggests that free healthcare is problematic because the quality of the care isn't as good as fee-based care. In addition, free care often leads to extended waiting periods that can cost people time. On the other hand, fee-based systems are costly for poor people and in many cases the cost associated with fee-based care places the burden on people in society that can least afford it. As such, economic issues affect the development and implementation of health policies.

In addition to the political and economic forces that govern health policy, social forces also exists. Health policy is a social issue because healthcare is a necessity for every human being. There is a time in every persons life when healthcare is needed. As a result of this need health policy is related to the society as it pertains to quality of life issues.

According to many scholars providing healthcare is an ethical issue. Many governments believe that being able to provide healthcare for everyone is necessary for social equity. Social equity guarantees that the resources that are available to some people are available to all people. This includes services such as education, and healthcare. When a society does not provide healthcare for the entire populous in a manner that is affordable and efficient, certain ethical questions arise. The main question that arises is whether or not healthcare is a right as opposed to a privilege. For many, access to healthcare is a privilege because they don't have access to affordable insurance and as such they can not receive the care that they need.

According to Navarro (2009), health policies are also affected by class alliances. Navarro asserts that there is "an alliance between the dominant classes of developed and developing countries -- a class alliance responsible for the promotion of its ideology, neoliberalism. This is the cause of the enormous health inequalities in the world today (Navarro, 2009)." The article also explains that the assumption that there have been significant reductions in interventions is false. Instead, the author argues, there has been a significant change in the nature and character of the interventions that are offered to citizens. These changes are a result of changes in class (and race and gender) relations in each nation (Navarro,2009).