Name of Lead Author: Tabitha Rono
Organization: Christian Health Association of Kenya
The 1978 Alma-Ata conference had developing countries make great strides in primary health care, however when there was a shift to selective primary healthcare the social dimension of health was overlooked. Infectious diseases pose great challenges to global communities especially developing countries and this is linked to social determinants of health inequalities. Governments in developing countries will have to consider identifying these social determinants of health inequalities, strengthen public private partnerships and invest in evidence based research. These actions will help increase ownership and line health to economic development. Developing countries will then be able to make evidence based decisions. Though viable there are a number of challenges from: disproportionate influence to global health of politically and economically powerful countries, lack of baseline data to inadequate government political capacity to address social determinants of health inequalities. In conclusion there will be need of increased collaboration, accountability and transparency by both developed and developing countries and commitment to global health. All these is aimed at getting local solutions to health and improving health care for all.
Globally health systems are struggling with a myriad of complex challenges with growing demand for health and need to contain costs to manage the health systems. This is pushing for more evidence based decision making to ensure equity. However, there is a need for rebalancing of policy away from downstream secondary care (Hunter, 2007) to upstream public health.
Since the recession experienced in 2008, there has been dwindling funds with increased demand of value for money. After the 1978 Alma-Ata Conference, developing countries made important steps in improving population statistics by involving action on main social determinants (WHO, 2005). When this approach was changed to selective primary health care based on a small proportion of cost –effective interventions the social dimension was overlooked. A point in case is the Ebola hemorrhagic fever that escalated due to neglect of understanding the cultural influences and this lead to a global problem. Infectious diseases like Ebola and HIV are social diseases and addressing their social determinants helps reduce the risk and it is time that health was looked at from a social perspective.
Achieving the highest attainable quality of life is faced with glaring health inequalities across nations. Addressing these health inequalities will require an in-depth look at the social determinants of health and how they relate to health outcomes. European countries reviewed their policies to address several health inequalities. These policies centered around: taxation and tax credits, sickness and rehabilitation benefits, old age pensions, maternity or child benefits, unemployment benefits, housing policies, labor markets, communities and care facilities (Marmot, 2005) .Developed countries have worked on incorporating these aspects in their policies but developing countries have lagged behind.
What actions can developing countries take in order to address health inequalities? Health inequalities in developing countries have been associated largely with poverty. The United Nations report on the world social situation points out a broader and more comprehensive approach to poverty reduction incorporating socio-political dimensions (United Nations, 2005). This includes improvement in education, health and increased political representation in making of laws. There are three actions that developing countries can adapt to reduce health inequalities:
1. Identify social determinants of Health and address systematically This aspect has not been critically looked at and appreciated. In health policy social determinants of health focus on societal conditions affecting health status of individuals and their ability to remain healthy and cope with illness and ill health (Lee, et al., 2007)). As much as this comprises of medical technologies, use and scope of public health intervention it does not strictly deal with public and health policies. This thus explains the reason most heath policies in developing countries have not incorporated this to address health inequalities.
Governments and communities need to participate actively in identifying the social disparities and prioritize activities to address them. An example is a training conducted by PEPFAR in Kenya through collaboration with one local and one international university on community asset mapping and faith health collaborative leadership programme. One high burden county was identified and selection of communities supported by government and other stakeholders in HIV care were involved in identifying the social determinants as relates to HIV. This training was an eye opener with participants appreciating themselves as important community assets and there were many local resources that had not been explored with conflict seen as a good thing in addressing problems. Funding was not given to the participants to carry out the activities but they used what was available to address the social determinants identified. Out of this training the participants formed collaborations in the community.
2. Strengthen Public Private Partnership Private public partnership has been defined as a long term contract between a private party and government agency aimed at providing public service where the risk and management is it’s responsibility (World Bank, 2012). A number of developing countries in Africa are implementing free or low cost health care service but there are challenges as relates to quality. The private sector in Sub-Saharan Africa has increasingly become an important source of healthcare and private providers are preferred because of the long opening hours, larger supply of pharmaceuticals and health care personnel, trust and courtesy of personnel (Konde-Lule, et al., 2010). In Kenya the government acknowledges the role that the private sector plays. One such partnership is the collaboration of government agencies with organizations like Medicines for essential drug supply (MEDS) a faith based supply chain system supplying county governments with drugs and supplies at subsidized costs. Another example is the support from the Clinton foundation and CDC to support government supply chain system where health facilities can get results of viral loads and PCR online. Health facilities can follow up online their submission of reports on consumption and receipt of lab commodities like test kits, viral load and PCR kits. The government has been able to engage the private health sector to provide health to government employed staff. The need to improve equity pushed for the formation of the Kenya Private sector alliance that actively engages the government on policy formulation and implementation.
3. Investment in evidence based research The healthcare market is one that is complex and this has made it a far reaching problem to attain universal access to health care. There are complex challenges facing health systems from increased demand for healthcare, constant flow of new interventions and treatment, rising public expectations to introduction of cost containment measures (Hunter, 2007). However there is a changing trend in disease pattern caused by various factors like global warming, terrorism and changed health lifestyle. It will be noted that there has been less research of new drugs with the already existing drugs becoming less potent against microorganisms and its irrational use leading to resistance and evolving of microorganism. Globally there is reduced funding and an increased move to value for the dollar meaning achieving more with less.
Developing countries however have not been able to link health and its role in the economy and this could be due to varied factors. Taking Kenya that is a developing country, its health policy document acknowledges not using disease burden and cost effectiveness in determining priority interventions (Ministry of Health, 2012). Increased use of economic analysis in the UK and other developed countries has assisted in informing on adoption of health technologies and reimbursement decisions in health care. The UK government for instance has the National Institute for Health and Clinical Excellence (NICE) that helps in decision making. The ability of this institution to conduct economic evaluations especially where there are uncertainties leverages policy makers (Andronis, Barton, & Bryan, 2009). However, developing countries lack such partnerships and investments are made based on donor interest. This leads to less commitment by the governments and introduction of several health technologies that are not harmonized and evaluated objectively. Developing countries stand to benefit greatly knowing that they have limited resources and work on minimizing wastage of those resources. Limitations in implementation of the actions The three actions require investment and support from the global health bodies and developed countries in partnerships with developing countries. However this is impeded by global health inequalities between developed and developing countries. International communities formed a world trade system that has been successful in enforcing norms that facilitate global economies, however human health has been given least attention. International health regulations are limited in scope and rooted by power structures (Gostin, 2005). The rapid spread of infectious diseases like Ebola hemorrhagic fever and now Zika will require nations to re think and incorporate international health laws for the best interest of its population. Economically and politically powerful countries have had disproportionate influence on global health agenda furthering their economic interest through creation and protection of intellectual property rights for pharmaceutical companies making it unaffordable in developing countries. This imbalance thus means developing countries will continue experiencing health inequalities and will not be able to effectively address these challenges if their capacity for disease surveillance and response to emerging infections are not addressed. Data is very important as it informs on progress in health care. Developing countries face the challenge of having accurate data and utilization of the same for decision making. The World Health organization points out that public health decision making depends critically on timely availability of sound data (WHO, 2005). However there is the problem of duplication, distortion or manipulation of data, lack of reliable data on health inequalities and misuse of constrained resources associated with inability to link budget allocations and health needs. To implement these actions we will need baseline data on health inequalities but this data may not be available. Lastly there have been powerful ties between business and political elites (UNRISD, 2010) with international attention in developing countries being on corruption and crony capitalism. There are great strides that developing countries are making with support of civil society organizations and the private sector. Governments in developing countries need political capacity building to be able to link health and economic growth. Developing countries have different political systems and this will pose a challenge in implementing universal health. The political shift should be on building political capacity whether it is a democratic or authoritarian state and increasing public awareness and transparency. Conclusion Addressing health inequalities requires consultative efforts with shift on evidence based information and localization of strategies that will leverage on the sustainable goal three. Focus should shift from instant impact to gradual and sustainable results..
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