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innovation in health policy

innovation in health policy

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Published by Renata Albuquerque
innovation in health policy
innovation in health policy

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Published by: Renata Albuquerque on Mar 24, 2011
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338
Gac Sanit. 2007;21(4):338-42 
POLÍTICAS DE SALUD Y SALUD PÚBLICA
Abstract
The 21st century health society is characterized by 2 majorsocial processes: the expansion of the territory of health andthe expansion of the reflexivity of health.The boundaries of whatwe call the «health system» are becoming increasingly fluid andhealth has become integral to how we live our everyday life.Health itself has become a major economic and social drivingforce in society. This shifts the pressure for policy innovation froma focus on the existing health system to a reorganization of howwe approach health in 21st century societies. The dynamics ofthe health society challenge the way we conceptualize and lo-cate health in the policy arena, the mechanisms through whichwe conduct health policy and they redefine who should be in-volved in the policy process. This concern is beginning to beaddressed within government through joined up government ap-proaches, beyond government through making health every-body’s business and beyond nation states as a new interfacebetween domestic and foreign policy.
Key words:
Health policy. Politics. Public health.
Innovation in health policy: responding to the health society
Ilona Kickbusch
Graduate Institute of International Studies, Ginebra, Suiza.
(Innovación en políticas de salud: respondiendo a la saludde la sociedad)
Correspondence: 
Ilona Kickbusch.Graduate Institute of Internacional Studes (HEI).Rue de Lausanne, 132. CH 1211 Genova 21. Switzerland.E-mail: kickbusch@bluewin.ch
Received: 
March 19, 2007.
Accepted: 
April 10, 2007.
Health policy innovation has hitherto been a concernmainly for the managers of health systems. The way inwhich we view health in the 21st century entails an openapproach to policy innovation in order to improve pop-ulation health. The aim of this paper is to revise thegrounds for policy innovation in all health territories andto identify the required processes of development.
The shift to the health society
Over the last decade we have begun to witness amajor shift with regard to health and its role in society.I argue that we now live in a health society which is char-acterized by two major social processes: the expansionof the territory of health and the expansion of the re-flexivity of health. The boundaries of what we call the«health system» are becoming increasingly fluid andhealth has become integral to how we live our every-day life. It appears that every policy decision a govern-ment makes also impacts on health and that at the in-dividual level every behavioral choice also has a healthconsequence. Most discussions on health policy do notyet take this deep seminal change into account. We areclearly in the midst of what in the next ten years canbecome a change in the way we understand and ap-proach health policy.Many analysts make the point that the changes fa-cing the health sector will be as phenomenal as thosewe have witnessed in information technology and com-munications over the past 2 decades. This is due tothe fact that health itself has become a major economicand social driving force in society
1
. It is in this contextthat the understanding of what constitutes a policy in-
Resumen
La sociedad de la salud en el siglo
XXI
se caracteriza por2 procesos sociales destacables: la expansión del territorio dela salud y la expansión de la reflexividad de la salud. Los lími-tes de lo que llamamos «sistema de salud» son cada vez menosfijos y la salud se ha convertido en elemento esencial de nues-tra vida cotidiana. La salud en sí misma se ha convertido enuna fuerza fundamental del impulso económico y social. Todoello lleva la presión sobre la innovación en política desde unaorientación sobre los servicios de salud a centrarse en una re-organización de cómo enfocamos la salud en las sociedadesdel siglo
XXI
.La dinámica de la sociedad de la salud pone a prueba la formaen cómo se conceptúa la salud, en cómo la situamos en el te-rreno político y los mecanismo de aplicar políticas de salud. Todoello redefine quién debe ser el sujeto del proceso político. Esteasunto se comienza a tratar dentro de los gobiernos por mediode acciones coordinadas, más allá de los gobiernos haciendoque la salud sea una cuestión de todos los ciudadanos, y másallá de los países como una nueva intersección entre políticainterna y exterior.
Palabras clave:
Políticas de salud. Política. Salud pública.
Documento descargado de http://www.doyma.es el 24/07/2007. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
 
novation in health gains a larger dimension
2
. In my viewthe issue at stake is not just another reorganization ofthe health system but a reorganization of how we ap-proach health in 21st century societies. The dynamicsof the health society are challenging not only the waywe conceptualize and locate health and conduct healthpolicy but they also redefine who should be involved inpolicy making.
Conceptualizing and locating health
The creation of the health society of the 21st cen-tury has been a process long in the making, beginningfrom about the mid 17th century onwards. Health is in-tegral to modernity and our modern societies would notbe possible without the health gains achieved in this 250year period
3
. During this time the balance of power be-tween the four domains of the health system –perso-nal health, public health, medical health and the healthmarket– has shifted continuously. The systems of per-sonal health and public health dominated the 18th and19th centuries, while during the 20th century the medi-cal health system gained increasing strength both interms of its power over the social construction of healthand its governance structures; this process of dominancehas been referred to as medicalization. As a conse-quence in both political and public perceptions the so-cial organization of health resides in the health care sys-tem and concerns over how to ensure the long termsustainability of these systems in view of the major de-mographic shifts and technological development domi-nate the health policy debate.In general this debate is still focused on costs ratherthan health outcomes
4
. In some countries the fear gene-rated by this relentless growth has led to proposals –asfor example by the Wanless report in England– to em-bark on an organizational shift within the system. It issuggested that more money needs to be invested in pre-vention, health promotion and public health. Within thehealth sector itself so far very few policies, institutions,organizations and funding streams have differentiatedbetween investing in
health 
and the expenditures for pro-viding health care. Where such an accounting is at-tempted, countries rarely reach more than a 2.9% ave-rage of the overall «health» budget for prevention, healthpromotion and public health, as OECD data tell us
5
. Everypenny of this paltry amount is subject to critical evidencereviews while to this day most health service organiza-tions are still not accountable for their health outcomesand demonstrate a severe lack of transparency for pa-tients and consumers. It is high time that a Europeanminimum standard for national public health expenditurebe set which should take as its starting point not to fallbelow the 5,5% invested by the Netherlands in 2003.But even such a shift would not be sufficient to ad-dress the challenges at hand as it is becoming in-creasingly clear that policy innovation must reach be-yond the health system and its present form oforganization. It is specific to the health society that allfour domains of the health system –personal health, pu-blic health, medical health and the health market– notonly continue to expand but that the balance betweenthe systems is shifting. As health has become both amajor factor in 21st century economies and a critical com-ponent of citizen’s expectations we witness the ascen-dancy of the health market and a newly defined role ofthe citizen in personal health. Many investors see healthas «the next big thing» and recent global happiness sur-veys have identified health next to wealth and educationas one of the three key factors for societal wellbeing.Thedominant issue at stake no longer is «medicalization»and the power of the medical profession, rather the de-bate evolves around social inclusion and exclusion, pub-lic and private, privatization and commercialization, healthand wealth and empowerment and participation. Thehealth debate has again become fervently ideologicalseeking to redefine the historically evolved division ofresponsibilities between the citizen, the state and themarket in health. This in itself is a sign that the presentform of organization has reached its limits.It is one of the characteristics of the health societythat the do-ability of health has expanded far beyondthe ever rising expectations of the curative medical careand repair system. Health is considered a right and itsdo-ability is driven also by the promise that health canbe created, managed and produced by addressing thedeterminants of health as well as by influencing behaviorand lifestyles. More health is always possible. Healthgovernance is now challenged by a conceptualizationof health as «well being beyond the absence of disease»as first defined by the World Health Organization in itsconstitution
6
.
Reconsidering the territory of health
While the territory of the medical system can be re-latively clearly circumscribed and framed in terms of de-livery and utilization of health care services the territo-ry of health becomes ever less tangible and increasinglyvirtual. Disease has boundaries; health does not. Thisinfinite nature of health has consequences for all fourdomains of the health system. While the health care sys-tem struggles to include more health, the expansion pro-ceeds elsewhere, heralding the new social organization.Health becomes more central for the aspiration of per-sonal goals in life and social inequalities are increasinglymeasured in health terms, highlighting differences inhealth and life expectancy. A rapidly growing health mar-
339
Kickbusch I. Innovation in health policy: responding to the health society
Gac Sanit. 2007;21(4):338-42 
Documento descargado de http://www.doyma.es el 24/07/2007. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
 
ket attaches the added value «health» to an ever grow-ing set of products and services. And the role of the statein public health is expanded through new types of reg-ulations which influence the both behavior of individu-als and their health environments.Who would have imagined even five years ago thata health minister would regulate the body mass indexof fashion models as in Spain? That television adver-tising of fast foods to children would be severely restrictedas in England? That a country could accept a total banon smoking in public places - including restaurants andbars as in Ireland? The health society not only meansthat health is present in every dimension of life; it alsoimplies that risk is everywhere. As every place, setting,product or message in society can support or endan-ger health the potential stakeholders in any health poli-cy decision expand exponentially; transport policies re-late to the obesity epidemic, the beer tax influencesyoung people’s alcohol consumption and low literacy in-creases health inequalities.An additional complexity is added by the fact thathealth in the 21st century is inherently global and manydeterminants of health are no longer in the control of na-tion states. Global and regional agreements of an eco-nomic and political nature can seriously endangerhealth –as experienced in rising alcohol rates in Finlandand Sweden when they joined the European Union– orthey can move the health agenda forward throughtransnational andglobal health agreements. The last fiveyears have seen the acceptance by the WHO MemberStates of both the International Health Regulations andthe Framework Convention on Tobacco Control. But otherless binding approaches such as the forceful move ona global strategy to combat chronic diseases, the policyby the European Union to consider the health impactsof all policies of the EU, the discussions on health at theDavos World Economic Forum, the new priority assignedto health in the OECD and the product shift of many glob-al companies all illustrate the global driving force thathealth has become. Concerns arise around the globalpharmaceutical market as much as over the global spreadof sugary soft drinks, the global movement of health pro-fessionals as much as over the rapid global spread ofviruses. A small number of countries have begun to ad-dress this fact through the formulation of national glo-bal health strategies and by bringing health into the for-eign policy arena
7
. Indeed this global nature of healthwill become one of the most significant driving forces ofthe 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 beconsidered in an integrative manner and in both theirnational and global dimensions. Each policy (sub)sys-tem works to its own logic and intentions without regardfor the impact on other areas of society or it global im-pact. There are also few political rewards in the presentsystem of politics and government for considering longterm effects, despite increasing lip service to sustaina-bility objectives.This concern is beginning ot be addressed throughthe increasing debate about the need for policies thatfocus on the determinants of health. Within governmentthis implies a «Health in All Policies» approach as putforward by the Finnish presidency of the European Unionin 2006; beyond government it means that health be-comes everybody’s business, beyond nation state itmeans a new interface between domestic and foreignpolicy. This approach has also been called network go-vernance because increasingly the policies in thehealth sector and in other sectors of national govern-ments need to be complemented by policy commitmentsat different levels of government and in the private andnon-governmental sector; the Wanless report speaksof a fully engaged scenario. In consequence a new typeof policy mix is emerging between governmental mea-sures, global initiatives, consumer pressure and demand,and policies –such as self regulation– put into place bycompanies and the private sector at large.In many countries a first step to engage a broadrange of actors around common goals was the deve-lopment of health targets
8
. But in taking the conceptua-lization of health beyond disease one step further somecountries have now begun to disentangle the respon-sibility for health and the responsibility for health careat the political level. This creates a new political spacefor network governance: Canada for a while had a minis-ter for public health with cabinet rank, England andSweden both have junior ministers for health, and theAustralian Labour Party shadow cabinet now also in-cludes a shadow minister for health promotion. A vi-sionary proposal was also put forward by the EuropeanCommission in 2005 when it proposed to combine healthand consumer protection in a common programme, asmany of the new health challenges can only be ap-proached through would argue that any country want-ing to seriously address the health challenges of the 21stcentury needs to separate the political responsibility forthe health care system and the network governancefor health and wellbeing.
Involving a broader range of actors
The new health challenges make this need for re-organization blatantly obvious. The stakeholders in theresponse to obesity are not only the health ministry, but
340
Kickbusch I. Innovation in health policy: responding to the health society
Gac Sanit. 2007;21(4):338-42 
Documento descargado de http://www.doyma.es el 24/07/2007. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

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