International Health Policy: The WHO

International Health Policymaking

• The World Health Organization(WHO) is the focus
• Health policymaking occurs at the international level

World Health Organization

• World Health Assembly consists of delegations from WHO’s 193 member countries
• World Health Assembly is the decision-making and policymaking body
• The executive board facilitates the work of the World Health Assembly
• The executive board advises on technical issues related to health for the UN
• The secretariat is the main policy implementation body of the WHO

WHO's Six Core Functions

• The WHO acts as a leader and partner on health issues worldwide for the UN
• Sets research priorities and encourages the sharing of health-related knowledge
• Establishes standards of practice, support and monitors their adoption, helping individual countries
• Advances policy options founded on ethical and evidence-based principles
• Lends technical support to health initiatives and contributes to capacity building, also providing emergency aid
• Monitors health issues around the world and identifies patterns and trends

WHO’s Policymaking Process

• New resolutions or motions submitted
• Preliminary impact analysis by WHO’s director-general
• Appropriate committee examines the proposal and related report at plenary meetings
• Vote in the World Health Assembly
• Policy implementation by the Secretariat

WHO’s Health Programs

• Currently operates more than 150 programs and projects
• Chronic disease monitoring
• Infectious disease prevention and eradication
• Coordinating responses to public health emergencies
• Campaign to Eradicate Smallpox
• Global Polio Eradication Initiative (GPEI)
• WHO Global Task Force on Cholera Control
• Current programs focused on HIV control and limiting hepatitis A, B and C, and monitoring Avian Influenza (“Bird flu”)
• Criticisms include being bureaucratic, biased, slow to act, and lacking transparency

WHO’s Involvement in Health Policy

• The WHO is the global leader in formulating health policy
• Writes and distributes regular policy reports on major diseases
• Issues policy statements in response to disease outbreaks and natural disasters

Health-Related Policymaking in Selected Countries

• Canada
• Sweden
• China

Health-Related Policymaking in Canada

• Population: 38 million
• % GDP on HC: 11.5%
• HC Per capita: $5,751
• Area: 3.85 million square miles
• Compared to the US
• Population: 333 million
• % GDP on HC: 18.3%
• HC Per capita: $11,700
• Area: 3.53 million square miles

Canada’s Political System

• House of Commons is the main legislative body
• The House of Commons is composed of elected local representatives called Members of Parliament (MPs)
• Electoral districts are called ridings, and one MP is elected per riding
• The Senate is a review board for legislation introduced by House of Commons
• Senators are chosen by prime minister
• Government is formed by the party with the most elected representatives, with the Head of party in power as Prime Minister
• Cabinet is formed by MPs selected by prime minister from his or her party
• Cabinet ministers take on special responsibility for one or more federal platform issues in addition to representing the members of their electoral riding

Canadian Healthcare System – Canadian Medicare

• Administered by the 10 provinces and 3 territorial governments, allowing for some variability between provinces
• Funded at national level through income taxes
• Residents are insured for all medically necessary primary and tertiary care, supplemental insurance increases access and scope of care
• Physicians
  • Work in for-profit private practices
  • Not government employees
  • Paid through the public insurance system of their respective province or territory
  • Fee-for-service
• Many large hospitals are not for profit and are associated with a religious group or university

Canada Health Act, 1984

• The primary piece of health-related legislation at the federal level, also known as Canadian Medicare
• Ensures that all eligible Canadian citizens and residents have access to prepaid health insurance and services
• Provides the legal framework for provincial healthcare plans receiving federal funding
• Several private insurers who provide a standard policy

Key Health Policy Stakeholders In Canada

• Federal government provides strategy, care minimum standards, and funding
• Health Canada is comprised of multiple private insurers supplying the "standard plan" plus supplemental ones
• Provincial governments administer the plan and negotiate prices with providers
• Physicians’ and nurses’ associations and the Canadian Medical Association use a FFS with limited negotiating power
• Industry and trade groups use limited negotiating power but possess direct supplemental insurance “policy”
• The Canadian public is reasonably satisfied

Major Health Issues In Canada

• The Report on the Health of Canadians reflects the Canadian government’s overall focus on preventive health until the next report issued
• Overall budget is rising
• Physician and other personnel shortages
• Access issues, particularly for elderly and remote areas
  • Long wait times
• Coordination of care for referrals to specialists and hospital discharge planning
• Health disparities are rising, particularly among indigenous population

Health-Related Policymaking in Sweden

• Population: 10.2 million
• % GDP on HC: 10.9%
• HC Per capita: $6,302
• Area: 0.74 million square miles
• Compared to the US
  • Population: 333 million
  • % GDP on HC: 18.3%
  • HC Per capita: $11,700
  • Area: 3.53 million square miles

Sweden’s Political System

• Constitutional monarchy and parliamentary democracy
• Riksdag is the legislative assembly
  • Members are elected by citizens every four years
• Government is formed by the political party whose members win the most seats
• Prime minister leads the government
• Cabinet is comprised of 21 ministers selected by prime minister
• Swedish head of state is a reigning monarch with no political powers

Swedish Healthcare System

• Central government regulates HC
• Country Councils deliver the majority of HC
• 290 Municipal governments provide care for elderly and disabled
• Patients are charged a small fee-for-service (“copays”)
• Country council pays the remaining costs
• Annual out-of-pocket ceiling for individuals is set by the national government
  • Currently 16% of all HC costs
• About 10% of the population has private insurance for quicker access and slightly broader coverage

Swedish Healthcare System (Cont.)

• Primary healthcare centers:
  • Provide basic medical and public health services
  • General practitioners are the first contact for residents and refer patients to a specialized care provider as needed
    • Most are salaried employees
• County and district hospitals specialize in care
  • Ex: dermatology and ophthalmology
• 70 Regional hospitals provide a higher level of specialty care
  • joint replacement, cancer surgery, heart surgery, etc
• Centers of teaching and research
  • 7 university hospitals

Major Health Issues In Sweden

• National Board of Health and Welfare’s health reports
• ↓ Tobacco use
• Health inequities exist along SES lines, a universal issue
• Access to healthcare is understaffed with long wait times, worsened in rural areas
• Rising costs and utilization are approximately 11% GDP in an aging population
  • An aging population is older and require more care
  • Less working adults results in fewer taxpayers and more outflow than inflow $

Health-Related Policymaking in China

• Single-party socialist system
• Communist Party of China (CPC)
• National People’s Congress (NPC)—legislative body
• State Council
• Executive body
• Nominate vice premiers and other ministerial posts
• President
  • Elected by the NPC
  • Leads the government
• Premier
  • Appointed by the president
  • Leads the state council

China's Healthcare System

• Utilizes a universal healthcare insurance system
• Four government insurance schemes include:
  • Basic scheme for urban workers
  • Urban resident scheme for other urban residents
  • Rural cooperative system for the rural population
  • Medical assistance program for the poor
• Healthcare is primarily delivered by local governments

Health Policymaking in China

• The Fundamental Health Law and Hygienic Common Law are in place
• 2009 healthcare reform
• The China’s State Department sets regulations
• Other governmental departments institute Department rules concerning public health
  • e.g., State Food and Drug Administration

Health Policymaking in China (Cont.)

• The Political Bureau of the CCCPC plans legislation in five-year periods
• Bills are introduced to NPC or Standing Committee by the State Council
• Important bills are published for public feedback before being submitted to the NPC
• The President and the Council of Chairmen decide whether to add the bill to the agenda
• Bills submitted by the President are automatically considered
  • The remaining bills on the agenda for consideration are then debated by the delegates
• The bill becomes formal law after it passes a majority vote and is signed by the President

China's Health Policy Stakeholders

• Central government sets strategic policy
• Relevant ministries set logistic policy
• Local governments deliver HC
• Hospitals and medical institutions are state owned
• Medical staffs are employees
• The pharmaceutical industry has limited market power
• The public tends to accept the outcome
• Think tanks are present
• Media is state owned propaganda
• Social media has a very powerful force on public opinion

Major Health Issues In China

• Data collection must be improved
• Ministry of Health surveys
• Surveillance systems
• Policy foci
  • Infectious disease outbreaks
  • Noncommunicable diseases
  • Tobacco control
  • Family planning
  • Care for the elderly

COVID Challenges

• Both inpatient and outpatient health services utilization declined significantly after the COVID outbreak due to massive mobility restrictions
• Significant healthcare capacity shortages
• Insufficient grassroots public health efforts and control capacity, and untimely information disclosure
• Unorganized reopening causing surge in COVID mortality and morbidity

COVID Challanges Study Examples

• Case Study One discusses a bias approach towards WHO.
• Includes remarks about shortcomings of WHO COVID response.
• Case Study Two discusses a WHO Healthy Cities Initiative.
  • Also identifies specific improvements that occurred.
• Case 3 discusses Primary Care Workforce
• An impetus for International HC Reforms is required
• China has 4 Insurance Programs