Print version ISSN 0213-9111
Gac Sanit vol.21 n.4 Barcelona Jul./Aug. 2007
Innovation in health policy: respondign to the health society
Innovación en políticas de salud: respondiendo a la salud de la sociedad
Graduate Institute of International Studies, Ginebra, Suiza.
La sociedad de la salud en el siglo xxi se caracteriza por 2 procesos sociales destacables: la expansión del territorio de la salud y la expansión de la reflexividad de la salud. Los límites de lo que llamamos «sistema de salud» son cada vez menos fijos y la salud se ha convertido en elemento esencial de nuestra vida cotidiana. La salud en sí misma se ha convertido en una fuerza fundamental del impulso económico y social. Todo ello lleva la presión sobre la innovación en política desde una orientación sobre los servicios de salud a centrarse en una reorganización de cómo enfocamos la salud en las sociedades del siglo XXI.
La dinámica de la sociedad de la salud pone a prueba la forma en cómo se conceptúa la salud, en cómo la situamos en el terreno político y los mecanismo de aplicar políticas de salud. Todo ello redefine quién debe ser el sujeto del proceso político. Este asunto se comienza a tratar dentro de los gobiernos por medio de acciones coordinadas, más allá de los gobiernos haciendo que la salud sea una cuestión de todos los ciudadanos, y más allá de los países como una nueva intersección entre política interna y exterior.
Palabras clave: Políticas de salud. Política. Salud pública.
The 21st century health society is characterized by 2 major social processes: the expansion of the territory of health and the expansion of the reflexivity of health. The boundaries of what we call the «health system» are becoming increasingly fluid and health has become integral to how we live our everyday life. Health itself has become a major economic and social driving force in society. This shifts the pressure for policy innovation from a focus on the existing health system to a reorganization of how we approach health in 21st century societies. The dynamics of the health society challenge the way we conceptualize and locate health in the policy arena, the mechanisms through which we conduct health policy and they redefine who should be involved in the policy process. This concern is beginning to be addressed within government through joined up government approaches, beyond government through making health everybody's business and beyond nation states as a new interface between domestic and foreign policy.
Key words: Health policy. Politics. Public health.
Health policy innovation has hitherto been a concern mainly for the managers of health systems. The way in which we view health in the 21st century entails an open approach to policy innovation in order to improve population health. The aim of this paper is to revise the grounds for policy innovation in all health territories and to identify the required processes of development.
The shift to the health society
Over the last decade we have begun to witness a major shift with regard to health and its role in society. I argue that we now live in a health society which is characterized by two major social processes: the expansion of the territory of health and the expansion of the reflexivity of health. The boundaries of what we call the «health system» are becoming increasingly fluid and health has become integral to how we live our everyday life. It appears that every policy decision a govern-ment makes also impacts on health and that at the individual level every behavioral choice also has a health consequence. Most discussions on health policy do not yet take this deep seminal change into account. We are clearly in the midst of what in the next ten years can become a change in the way we understand and approach health policy.
Many analysts make the point that the changes fa-cing the health sector will be as phenomenal as those we have witnessed in information technology and communications over the past 2 decades. This is due to the fact that health itself has become a major economic and social driving force in society1. It is in this context that the understanding of what constitutes a policy innovation in health gains a larger dimension2. In my view the issue at stake is not just another reorganization of the health system but a reorganization of how we approach health in 21st century societies. The dynamics of the health society are challenging not only the way we conceptualize and locate health and conduct health policy but they also redefine who should be involved in policy making.
Conceptualizing and locating health
The creation of the health society of the 21st century has been a process long in the making, beginning from about the mid 17th century onwards. Health is integral to modernity and our modern societies would not be possible without the health gains achieved in this 250 year period3. During this time the balance of power between the four domains of the health system -personal health, public health, medical health and the health market- has shifted continuously. The systems of personal health and public health dominated the 18th and 19th centuries, while during the 20th century the medi-cal health system gained increasing strength both in terms of its power over the social construction of health and its governance structures; this process of dominance has been referred to as medicalization. As a consequence in both political and public perceptions the social organization of health resides in the health care system and concerns over how to ensure the long term sustainability of these systems in view of the major demographic shifts and technological development dominate the health policy debate.
In general this debate is still focused on costs rather than health outcomes4. In some countries the fear gene-rated by this relentless growth has led to proposals -as for example by the Wanless report in England- to embark on an organizational shift within the system. It is suggested that more money needs to be invested in prevention, health promotion and public health. Within the health sector itself so far very few policies, institutions, organizations and funding streams have differentiated between investing in health and the expenditures for providing health care. Where such an accounting is attempted, countries rarely reach more than a 2.9% average of the overall «health» budget for prevention, health promotion and public health, as OECD data tell us5. Every penny of this paltry amount is subject to critical evidence reviews while to this day most health service organizations are still not accountable for their health outcomes and demonstrate a severe lack of transparency for patients and consumers. It is high time that a European minimum standard for national public health expenditure be set which should take as its starting point not to fall below the 5,5% invested by the Netherlands in 2003.
But even such a shift would not be sufficient to address the challenges at hand as it is becoming increasingly clear that policy innovation must reach beyond the health system and its present form of organization. It is specific to the health society that all four domains of the health system -personal health, public health, medical health and the health market- not only continue to expand but that the balance between the systems is shifting. As health has become both a major factor in 21st century economies and a critical component of citizen's expectations we witness the ascendancy of the health market and a newly defined role of the citizen in personal health. Many investors see health as «the next big thing» and recent global happiness surveys have identified health next to wealth and education as one of the three key factors for societal wellbeing. The dominant issue at stake no longer is «medicalization» and the power of the medical profession, rather the debate evolves around social inclusion and exclusion, public and private, privatization and commercialization, health and wealth and empowerment and participation. The health debate has again become fervently ideological seeking to redefine the historically evolved division of responsibilities between the citizen, the state and the market in health. This in itself is a sign that the present form of organization has reached its limits.
It is one of the characteristics of the health society that the do-ability of health has expanded far beyond the ever rising expectations of the curative medical care and repair system. Health is considered a right and its do-ability is driven also by the promise that health can be created, managed and produced by addressing the determinants of health as well as by influencing behavior and lifestyles. More health is always possible. Health governance is now challenged by a conceptualization of health as «well being beyond the absence of disease» as first defined by the World Health Organization in its constitution6.
Reconsidering the territory of health
While the territory of the medical system can be re-latively clearly circumscribed and framed in terms of delivery and utilization of health care services the territory of health becomes ever less tangible and increasingly virtual. Disease has boundaries; health does not. This infinite nature of health has consequences for all four domains of the health system. While the health care system struggles to include more health, the expansion proceeds elsewhere, heralding the new social organization. Health becomes more central for the aspiration of personal goals in life and social inequalities are increasingly measured in health terms, highlighting differences in health and life expectancy. A rapidly growing health market attaches the added value «health» to an ever growing set of products and services. And the role of the state in public health is expanded through new types of regulations which influence the both behavior of individuals and their health environments.
Who would have imagined even five years ago that a health minister would regulate the body mass index of fashion models as in Spain? That television advertising of fast foods to children would be severely restricted as in England? That a country could accept a total ban on smoking in public places - including restaurants and bars as in Ireland? The health society not only means that health is present in every dimension of life; it also implies that risk is everywhere. As every place, setting, product or message in society can support or endanger health the potential stakeholders in any health poli-cy decision expand exponentially; transport policies relate to the obesity epidemic, the beer tax influences young people's alcohol consumption and low literacy increases health inequalities.
An additional complexity is added by the fact that health in the 21st century is inherently global and many determinants of health are no longer in the control of nation states. Global and regional agreements of an economic and political nature can seriously endanger health -as experienced in rising alcohol rates in Finland and Sweden when they joined the European Union- or they can move the health agenda forward through transnational and global health agreements. The last five years have seen the acceptance by the WHO Member States of both the International Health Regulations and the Framework Convention on Tobacco Control. But other less binding approaches such as the forceful move on a global strategy to combat chronic diseases, the policy by the European Union to consider the health impacts of all policies of the EU, the discussions on health at the Davos World Economic Forum, the new priority assigned to health in the OECD and the product shift of many global companies all illustrate the global driving force that health has become. Concerns arise around the global pharmaceutical market as much as over the global spread of sugary soft drinks, the global movement of health professionals as much as over the rapid global spread of viruses. A small number of countries have begun to address this fact through the formulation of national global health strategies and by bringing health into the foreign policy arena7. Indeed this global nature of health will become one of the most significant driving forces of the reorganization of health in the 21st century.
Conducting health policy as network governance
Yet there are very few policy mechanisms that allow «joined up» approaches that allow health impacts to be considered in an integrative manner and in both their national and global dimensions. Each policy (sub)system works to its own logic and intentions without regard for the impact on other areas of society or it global impact. There are also few political rewards in the present system of politics and government for considering long term effects, despite increasing lip service to sustainability objectives.
This concern is beginning ot be addressed through the increasing debate about the need for policies that focus on the determinants of health. Within government this implies a «Health in All Policies» approach as put forward by the Finnish presidency of the European Union in 2006; beyond government it means that health becomes everybody's business, beyond nation state it means a new interface between domestic and foreign policy. This approach has also been called network go-vernance because increasingly the policies in the health sector and in other sectors of national governments need to be complemented by policy commitments at different levels of government and in the private and non-governmental sector; the Wanless report speaks of a fully engaged scenario. In consequence a new type of policy mix is emerging between governmental measures, global initiatives, consumer pressure and demand, and policies -such as self regulation- put into place by companies and the private sector at large.
In many countries a first step to engage a broad range of actors around common goals was the development of health targets8. But in taking the conceptualization of health beyond disease one step further some countries have now begun to disentangle the responsibility for health and the responsibility for health care at the political level. This creates a new political space for network governance: Canada for a while had a minister for public health with cabinet rank, England and Sweden both have junior ministers for health, and the Australian Labour Party shadow cabinet now also includes a shadow minister for health promotion. A visionary proposal was also put forward by the European Commission in 2005 when it proposed to combine health and consumer protection in a common programme, as many of the new health challenges can only be approached through would argue that any country wanting to seriously address the health challenges of the 21st century needs to separate the political responsibility for the health care system and the network governance for health and wellbeing.
Involving a broader range of actors
The new health challenges make this need for reorganization blatantly obvious. The stakeholders in the response to obesity are not only the health ministry, but for example the ministries of transport, education, agriculture, trade and consumer affairs. Outside of government the producers of unhealthy food and drink pro-ducts are as much in focus as are the settings of everyday life where they are consumed (such as canteens), global marketing and advertising practices, the media messages and the role model celebrities to name but a few. Smoking acts regulate not only who can buy tobacco products, where and at what price but they define where it is permitted to smoke, in consequence owners of bars and restaurants, retailers, the management of airports and railway lines to name but a few, all need to be concerned with health in ways they were not before. Consumers and voters as well as a wide array of health action groups and patient organizations make their preferences heard.
One approach to overcome the political and organizational impasse is the ever increasing number of platforms, coalitions, alliances and networks built around health issues. A good example is the European Platform on Diet, Physical Activity and Health initiated in 2005 by the DG Sanco of the European Commission, which allows the Commission to work with a wide range of pla-yers across the public, private and non-governmental sectors. The stated intent is to create a platform for concrete actions designed to contain or reverse current trends, platform members must commit to action and be willing to be monitored. The visibility and legitimacy conferred through such alliances is gaining increasing importance as a policy mechanism as are a myriad of public private partnerships. Actors and issues gain prominence through media presentation and public debate as the health society is a media dependent society. This frequently leads to a preference for highly visible actions and campaigns rather than on the ground long term community action programs.
The broadening of actors is further exemplified by the wellness revolution which translates health into a product that promises wellbeing. These health goods and services include health tourism, the fitness market, cosmetic surgery, lifestyle drugs such as Viagra and the market for vitamins, minerals and health foods. They also include new types of health insurance, which pay for health not sickness services and which in turn reimburse the tools and services the new industry has to offer. For many existing industries health has become an «active added value» either as a sales pitch or in the form of supplements and product enhancements. Providing access to information on health and new health products and services including e-health becomes one of the greatest business opportunities of the foreseeable future9.
A number of governments have realized that their economic future could lie in the growth of these new health products and services. In Germany a group of Länder have established working groups and developed governmental plans for the expansion of the health industry. This means developing the synergies of their academic institutions with industries such as bio techno-logy, food and medical devices, creating centers of medical excellence, supporting the growth of a wellness market and health tourism and attracting the insurance industry. For example the government of Berlin in October 2004 decided to establish a health care cluster in Berlin Brandenburg and developed a Masterplan «Health Region Berlin 2005-2015» with the declared aim of establishing the city as a «health care metropolis». In doing so the city is competing with other German regions which also see their future potential in health-related industries, indeed given the economic potential of such developments in terms of job creation some German authors have called for a ministerial position that focuses on the development of a globally competitive German health industry. The Swiss health minister has also recently commissioned a study on the future of the health market in Switzerland.
Strengthen the role of citizens in health
In the health society health expands its territory and its expands reflexivity. Health is no longer a given, it is produced, maintained, enhanced. The results of health research are rapidly transported through the media: a new cure, a new method of prevention, a new confirmation of old behaviors, all have high currency in the health society. What is considered healthy today might not be so tomorrow, new risks continuously emerge10. As a consequence heath literacy plays a critical role. Risks are frequently not visible or seem intangible and they need to be well communicated and above all understood and translated into action. As more and new health information becomes available this can become a difficult challenge for ordinary citizens in particular of they are not well educated or even functionally illiterate, as about 20% of all citizens in the OECD countries are. The expansion of health choices and the complexity of health systems demand an ever higher degree of sophistication and participation and in consequence there is a growing offer and demand not only for health information, but for advice and knowledge brokering.
To be a passive and compliant patient who follows the physician's in structions is no longer sufficient -indeed the emerging model is one of active and critical consumers, an ideal that only few members of the po-pulation can aspire to achieve. Already today -despite the universal access to health care- health inequalities abound even in the richest countries and there is a clear danger that they will widen even further as the health society expands. The very presence of health in all areas of everyday life can also lead to a variety of reactions -either to attempts to reach an unrealistic body image, or to conscious risk taking in opposition to an overpowering set of health messages and expectations. While the health society offers many opportunities of empowerment it can also be prescriptive and exert social control through health11. Within a health society there has to be constant democratic dialogue about the societal value we attach to health, a debate that has barely begun. There is in general a big democratic deficit in relation to health and health policy which needs to be addressed with urgency. Both in health and in medical care the reorientation towards participation and user involvement will be one of the most important governance shifts.
To sum up
What will innovation in health policy imply in the 21st century? If innovation means a reorganization of how we approach health in 21st century societies I propose that the following five dynamic processes will be critical. Our societies will need to: a) develop a new understanding of health as an investment and productive force in society; b) develop separate governance mecha-nisms for health and for health care, with a strong focus on accountability for health gain; c) augment the concern for ethics and values with respect to health through a broad dialogue with citizens in order to increase democratic legitimacy and ensure solidarity; d) move beyond a narrow understanding of health outcomes in terms of only physical health measures to those that aim to include or even prioritize broader measures of wellbeing, and e) engage in network governance, partnership and multi-stakeholder approaches in order to achieve health goals.
The big 21st century health challenges call for more courageous policy approaches than applied so far. While our societies have now learned to recognize the urgency of the environmental challenge in terms of long term sustainability we are only just beginning to grasp the consequences that our way of life has in terms of health sustainability. Epidemiologists warn that due to the rapid growth in child obesity the next generation of children might be the first in the last 250 years to have a lower health and life expectancy than their parents. What a historical failure we would face if societies as wealthy and as technologically advanced as ours cannot ensure the health of the generations to come.
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Graduate Institute of Internacional Studes (HEI).
Rue de Lausanne, 132. CH 1211 Genova 21. Switzerland.
Received: March 19, 2007.
Accepted: April 10, 2007.