Documente Academic
Documente Profesional
Documente Cultură
Graduate School
Master of Arts in Nursing
A report to
Health Reform
Submitted By:
Submitted To:
All countries, whether developed, developing, or least developed, are in various stages of
health sector reforms. This paper aims to define and understand what health sector reform
is and what forces driving or the reasons for health sector reform? Health Reform cycle/
This paper will able us to identify and understand the ethical issues and theories
underlying in the health sector reforms. This paper also discusses the Political Analysis
and Strategies and Goals for Evaluating Health Systems. The current health reform
strategies in the Philippines specifically the “Fourmula One for Health” and its goals and
“Health Sector” means those who deliver health care- private or public, western
and institutional arrangements of the health sector, usually guided by the government.
(World Health Organization). These processes are usually guided by the respective
governments on a technical and political basis. They are designed to improve the
functioning and performance of the health sector and, ultimately, the health status of the
population.
II. Forces Driving Health Reform
Four forces are driving health reform in countries around the world. Their relative
roles vary from place to place, but these four forces have led to certain widespread
dilemmas that now confront many nations in our increasingly globalized world.
In nearly every country, increases are forcing governments to rethink their policies
and approaches to the health care system. many forces driving costs upward such as
aging of the population, other epidemiological diseases (most notably AIDS), the seller of
health care goods and services, and most particular important force driving up health care
2. Rising Expectations
As citizens demands more both from government in general and from the health care
system in particular. Rising expectation derives from 3 sources: economic, social and
political. Typically, national health care demand rises as quickly as, and in some cases
more quickly than national income. Yet, even if health care spending only rises in
proportion to income, the absolute amount of additional money that nations are under
pressure to mobilize for health care, as income increases, is substantial. Moreover, the
share of such spending that goes through the public sector (example through new social
Global social development are reinforcing these demand. Films, television, and the
internet have given the citizens of many countries an image of life in the worlds’s high
income nations. Rising expectation leads patients to want the latest and best care, the
governments confront limits on their capacity to pay the costs of health care.
challenge because more is being demanded and more options must be analyzed, and an
opportunity because the resulting crisis often leads to more openness to change and
innovations.
In idealized form, the process of policy change moves through a cycle of six stages:
problems are defined, a casual diagnosis is made, plans are developed, a political decision
is made on reform initiatives, those reforms are then implemented, and their
consequences are evaluated. The cycle then begins again, as a new problem arises that
In the real world reform rarely takes place in such a simple fashion. Instead
reform efforts begin in different places and skip stages, or several stages may occur at the
same time. For example, health reformers might begin with a diagnosis, declaring, “the
cause of all our problems is that public clinics and hospitals do not have enough
resources to provide good services”. Or reform advocates might start with their favorite
solution: ”what our country needs is a new national social insurance scheme.”
makers confront ethical and political issues throughout the reform cycle. Questions like
“What are the right priorities?” and “How can political pressures be manage?” pervade
It is the most overlook but yet most important steps in health sector reform.
Problem definition and health reform priorities are always based on value choices. In
philosophy.
shape, how problems perceived? What factors determine the problem definition
also has to undertake a diagnostic journey. After defining problems based on health
system outcomes, the next task is to work backwards to identify the causes of
unsatisfactory results. If the physicians explore anatomy and physiology, health sector
reformers have to examine the causes of problems by exploring what we call the five
• Financing refers to all mechanisms for raising the money that pays for activities in
the health sector. These mechanisms include taxes, insurance premiums, and
direct payments by patients. The design of the institutions that collect the money
(e.g., insurance companies, social insurance funds) is also part of this control
• Payment refers to the methods for transferring money to health care providers
(doctors, hospitals, and public health workers), such as fees, capitation, and
budgets. These methods in turn create incentives, which influence how providers
behave. Money paid directly by the patient is also included in this control knob.
• Organization refers to the mechanisms reformers use to affect the mix of
providers in health care markets, their roles and functions, and how the providers
government delivery. It includes who does, what and who competes with whom,
as well as the managerial aspects of how providers work internally, such as how
• Regulation refers to the use of coercion by the state to alter the behavior of actors
note that just because a regulation is on the books does not mean it is
• Behavior includes efforts to influence how individuals act in relation to health and
health care, including both patients and providers. This control knob includes
behavior for HIV prevention, to using the medical society to influence physicians’
Once the causes of a problem have been diagnosed, the next question is what to
do. What is the right therapy for the problem? What is an appropriate policy to address
the cause? The process of the policy development is more difficult than it might seem. In
this section, we first consider why new policy ideas are difficult to develop and where
such ideas come from. Where, then, can reformers look for new ideas? International
learning is one helpful approached, policy innovations outside the health sector is another
We also want to explain why it is important to look forward in the policy cycle to matters
how the process of option development influences what happens at later stages of the
policy cycle.
Each stage in the policy cycle is affected by politics, including problem definition,
provides a focus for political decision making, often by the executive and legislative
branches of government. Getting health sector adopted is not just matter of political
commitment and risk taking (political will); it is also a matter of effective political
strategy and coalition building (political skill). A key political task in all situations is
Step 5: Implementation
Many allegedly good health reform ideas have failed because, in practice, they
were not good ideas, exactly because they could not be implemented. Health sector
reform always require organizations and individuals to behave differently. Without such
changes, nothing new would be accomplished. Yet changed is almost always resisted.
One reason is psychological, for many, the mere fact of newness creates anxiety
and resistance. Resistance to change arises because change can bring costs to specific
groups and individuals. New procedures and arrangements takes time and effort to learn.
Moreover, those most successful under the old system have the most to lose, hence, the
Another force that inhibits change is the difficulty we all have in giving up
familiar ways of thinking. If a doctors wants to treat a nurse differently, or a patient wants
to relate to a doctor differently, they can encounter all sorts of pressures to conform to
expected behavior.
about change, health sector reform efforts must be continuously and closely monitored,
Step 6: Evaluation
Experienced evaluators know that successful evaluation has to begin well before a
world is inherently difficult. The simplest evaluation approached is a before and after
comparison. This involves examining how outcomes change over time as reforms are
implemented.
Below are three major ethical perspectives as a basis for making such judgments:
Utilitarianism is the idea that the moral worth of an action is determined solely by
its utility in providing happiness or pleasure as summed among all sentient beings.
Utilitarianism is often described by the phrase "the greatest good for the greatest number
of people"
This approached generally assumes that “the end justifies the means.” It says we
should judge a policy by asking how it affects the individuals in a society and pick the
option that most improves the sum total of their well-being. There are 2 major intellectual
a. Subjective utilitarianism
The first positions derive from English Philosopher Jeremy Bentham. Who believed that
individuals could best judge for themselves what makes them happy. He argued that
greatest total utility. This involves finding out how much all potential beneficiaries of a
policy or a program would be willing to pay for its benefits. If the estimated benefits are
greater than the costs, then the policy would advance the greatest good for the greatest
number and should be adopted. This analysis thus evaluates both costs and benefits.
b. Objective Utilitarianism
Reformers who want to promote individual wellbeing, but are skeptical of reliability and
validity of individual choices, argue for basing decisions on individual wellbeing defined
in objective terms by a group of experts. These experts develop an index that embodied
the “rational knowable” components of wellbeing, and that index is used to evaluate
everyone’s circumstances.
Liberalism (from the Latin liberalis, "of freedom") is the belief in the importance of
individual liberty. According to Immanuel Kant, all human beings have the capacity for
moral action, the power to know what is morally correct, and to decide whether to follow
to treat some people as means. Liberals have developed arguments about how states
should operate and how policies should be determined. The critical concepts for liberals
are RIGHTS, they claims that all individuals can make each other by virtue of their
humanity. Libertarians believe also that only negative rights deserve protections.
In deciding how much to spend on health care, a critical issue for liberals is the
legitimacy of taxation. For libertarians, the negative right to be left alone includes a right
• Ethical theory 3: Communitarianism (What are the boundaries and values of the
good community?)
This perspective focuses on the nature of the community. What matters in judging
public policy is the kind of society and kind of person that state action to create. This
theory argues that the character of the individuals who compose it. The state,
therefore, should ensure that individuals develop good character and help produce a
good society.
Four factors are particular important in understanding how to manage the politics of
health sector reform. These factors affect the origins of health reform as an issue, the
content of reform policies, and the implementation of adopted programs. The four factors
are:
a. Players: the set of individuals and groups who are involved in the reform
process, or who might enter the debate over the policy’s fate.
b. Power: the relative power of each player in the political game (based on the
c. Position: the position taken by each player, including whether the player
supports or opposes the policy and the intensity of commitment for or against the
d. Perception: the public perception of the policy, including the definition of the
problem and the solution, and the material and symbolic consequences for
particular players.
These four factors can be influenced through the political strategies adopted by health
sector reformers.
Political Analysis
A basic building block in designing political strategies for reform is stakeholder analysis.
2. Assess their political resources and their roles in the political structure to
The most important task for analysts is to determine the core position and the
power of stakeholders, what they are not willing to give up, and the amount of resources
group analysis, this consists of understanding the social groups that are seeking to move
among agencies and individuals within government. For health sector reform in
developing countries, one also needs to consider the activities of international agencies,
• Producer groups: doctors, dentists, nurses, pharmacists and other health care
health policies (example tobacco farmers, drug sellers) and workers who gain or
lose jobs.
organization.
Having identified a list of players (the groups and individuals who are relevant to the
policy proposal), the next step is to estimate the power and influence of each player. The
The first set of political strategies involves bargaining within the existing distribution of
power to change the position of players. This can involve deals, promises, trades, and
treats.
enemies.
The second set of political strategies is designed to change the distribution of power
among key players. Examples give or lend money, staff, or facilities to groups that
support reform, provide information and education to supporters in order to increase their
expertise.
♥ Player Strategies: Change the number of players by creating new friends and
discouraging foes.
Reform advocates can also consider political strategies that try to change the set of
friends and foes. These strategies seek to mobilize players who are not yet organized and
demobilize players who are already organized. It means changing the balance of
mobilized players by recruiting political actors to the health reform cause and away from
♥ Perception Strategies: Change the perception of the problem and the solution.
Political strategies directed at perceptions seek to change how people think and talk about
a policy problem, how the issue is defined and frame, and which values at stake. The
national symbols or values. This connection can influence the priority given to the issue
In Philippines- The Current Health Reform Strategy: “Fourmula One for Health”
implementation strategy, known as “Fourmula One for Health”. The strategy organizes
the reforms into four implementation components, namely: Health Financing, Health
Sector Regulation, Health Service Delivery (covering both public health and hospital
management and its sector coordination and leadership role, of stewardship over the
whole health system). The new implementation strategy emphasizes the role of
PhilHealth’s national social insurance program as the main level to effect desired changes
and outcomes in all four implementation components at national and local level.
What is FOURmula ONE for Health?
Defining the Road Map for Reforms FOURmula ONE for Health is the implementation
framework for health sector reforms in the Philippines for the medium term covering
This document provides the road map towards achieving the strategic health sector
reform goals and objectives of FOURmula ONE for Health from the national down to the
local levels.
Over-all Goals:
The implementation of FOURmula ONE for Health is directed towards achieving the
following end goals, in consonance with the health system goals identified by the World
Health Organization, the Millennium Development Goals, and the Medium Term
General Objective:
FOURmula ONE for Health is aimed at achieving critical reforms with speed, precision
and effective coordination directed at improving the quality, efficiency, effectiveness and
equity of the Philippine health system in a manner that is felt and appreciated by
Specific Objectives:
Fourmula One for Health will strive, within the medium term, to:
* Ensure access to and availability of essential and basic health packages; and
1. Health Status
The health status of the population is the first performance goal. As the subject of
much public debate as well as policymaking, it surely meets the test of political
relevance. It embodies concern of objective utilitarians- for whom health status is a key
In deciding which health problems should be given priority, a country may want to
pay special attention to the disease that are causing the greatest harm. If a country is
tetanus, then controlling those conditions might well be a focus of reform efforts.
2. Citizen Satisfaction
Our second performance goal is the degree to which citizens are satisfied with the
take account of how citizens themselves evaluate and respond to their care.
individual’s willingness to pay for various kinds of benefits. For example, to put a value
of human life, individuals have been asked hypothetical questions about their willingness
to take specified risks in return for various payments. These studies have revealed
systematic inconsistencies between the behavior that decision theory says is rational and
typical patterns of choice. For example, sick people may rate their quality of life as
Financial risk protection is a major goal of much health sector policy making and
frequently a focus of the politics of health reform. It is also greatly influenced by how the
sector is financed.
Measuring financial risk is complicated by the fact that the significance of a given
risk depends on both the size of the risk, the closer someone is to the poverty level, the
smaller the expense that will put them below that line. Hence the more they need
An additional complication is that financial risk can also affect health status. The
seriously ill may not receive adequate care if the financial burden on them contributes to
a decision not to seek care. Their injury from a lack of risk protection, therefore, may
Guide to Improving Performance and Equity. ©2006: Oxford University Press, Inc
2. http://en.wikipedia.org/wiki/Utilitarianism
3. http://en.wikipedia.org/wiki/Liberalism
4. http://www.doh.gov.ph/fourmulaone/primer
5. www.dfidhealthrc.org/.../PHILIPPINES%20health%20sector%20background
%20note.doc