The Basque Country Action Plan: Health in All Policies for 2013-2020

The new Action Plan of the Basque Country is the roadmap of the Department of Health and the Basque Government to maintain and improve citizen’s health for the next 8 years. It is led by the Lehendakari (President of the Basque Government) himself since it aims to promote health in all policies. The structure is interdepartamental, intersectoral and interinstitutional.

The plan, elaborated with the participation of more than a 100 professionals, experts, patients and institutions, it is based on the analyses of countries with a long tradition in public health, such as Finland, Norway, Sweden and the United Kingdom. It incorporates the perspective of social determinants of health and gender.

The plan has 5 priority areas, 35 objectives, 146 actions and 110 outcome indicators. The first priority area is basic and horizontal to the rest: to incorporate health and equity into all public policies and strengthen the Basque health system with equity and quality. It seeks to reduce health and gender inequalities, improving the health of the disadvantaged.

The second, third and fourth priority areas include objectives, actions and indicators to reduce morbidity and mortality and reduce disability caused by health conditions with the greatest impact on the population, with emphasis on people with special needs (elderly, women, children, those who are sick and with chronic conditions). The aim is to achieve health ageing, improve the opportunities for health during the early years of life and youth and strengthen health care for the sick populations who need it the most.

The last area is health promotion. The plan seeks to promote healthy environments and behaviours, supporting intersectoral collaboration, grassroots (at the neighbourhood-town level) and community work. It also promotes the empowerment of people in their own health.

The Basque Parliament is responsible to monitor the implementation and held the government accountable. There is a commitment from the government to present to the parliament a yearly progress report. Monitoring and evaluation of the Action Plan deals with two objectives closely intertwined: governance for health, understood as the common efforts of the public and private sector and citizens to improve health; and governance of health, understood as the strengthening and good management of our own health system.

The implementation of the Action Plan and its governance for health dimension is supported by the leadership of the Lehendakari and the Directive Commission and Technical Commission on Health in All Policies, both with intersectoral composition. The interinstitutional level, including the participation of the private sector and the citizens is done by a structure called Health Council. The governance of health dimension is led by the Health Commissioner and involves all the government structures and the Health Department.

More information on the Basque Country Action Plan can be found: ttp://www.osakidetza.euskadi.net/r85-pkpubl01/es/contenidos/informacion/publicaciones_informes_estudio/es_pub/adjuntos/plan_salud_2013_2020.pdf

*Article written by guest blogger Jon Zuazagoitia, Subdirector of Public Health and Addictions, Department of Health, Basque Government. For more information, contact him at: jzuazagoitia@ej-gv.es

 

Corporate power and Health in All Policies: a window of opportunity?

Over the last months I have been (mentally) drafting a column titled “An elephant in the room: the private sector and HiAP”. My expectations were that the 8th Global Conference on Health Promotion, happening now in Helsinki, would not discuss much of this issue and it would be looming over the conference. A dark cloud in the horizon that we would all prefer to ignore.

To my surprise this has not been the case. It started on Sunday with the book seminar discussing issues of global economic integration, trade and intersectoral action against health from tobacco companies. But this was unsurprising, as we challenged the authors to do so.

The great surprise came on the opening speech from WHO’ Director General Margaret Chan, who in a powerful intervention stated that

Efforts to prevent noncommunicable diseases go against the business interests of powerful economic operators. In my view, this is one of the biggest challenges facing health promotion.

As the new publication makes clear, it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.”

This was a much stronger statement than two weeks ago at the World Health Assembly, when DG Chan argued that

There are no safe tobacco products. There is no safe level of tobacco consumption. But there are healthier foods and beverages, and in some cultures, alcohol can be consumed at levels that do not harm health.

I am fully aware that conflicts of interest are inherent in any relationship between a public health agency, like WHO, and industry.”

The issue of corporate power rose again in a heated discussion on the role of the private sector with speakers from the World Bank and the World Economic Forum. The right choice would have been to balance the panel with a speaker from a civil society watchdog. Nonetheless, dissenting voices where heard on a steaming message wall and the interventions from the audience.

Corporations have incentives to favour irresponsibility rather than responsibility. And the evidence of corporate power trumping efforts to improve population health has been increasing over the years. Together with the (now) well-known tactics of the tobacco industry, evidence shows similar behaviours from alcohol, soda and food industries. The recent articles from Baum and Hastings on corporate power, Casswell on vested interests on alcohol and the Plos Medicine series on Big Food provide plenty of food for thought on this, just to name a few. A recent Reuters investigation showed how Coca Cola, Nestlé and Unilever have contributed with U$ 350 000 to the Pan-American Health Organization. PAHO’s response, arguing that this contribution only accounted for 1% of PAHO’s investment, in my opinion, only made it worse.

There is a window of opportunity that the Helsinki conference would give a much stronger, clearer guidance to countries to address the influence of corporations in policy-making and health.

But perhaps more importantly, we would need to draw a clear line between private sector (that broad array of small, big, good and bad companies) and corporate power. The term corporations denote those private enterprises with shareholders and perhaps a greater incentive to behave unhealthily in the quest of profit maximization. Others use “transnational corporations” or focus on the nature of their production in relation to policy-making, such as vested interests and conflicts of interest. Health in All Policies makes this question even more difficult, as one would need to consider the impact of corporate power on social determinants of health and policy-making processes across sectors.

A powerful conference statement would need to be paired with commitment to develop a code of practice providing clear guidance on how to act.

The Helsinki conference can be history on the making. Would we seize the opportunity?

 

Further reading:

WHO. WHO Director-General addresses health promotion conference. Link

WHO. WHO Director-General addresses the Sixty-sixth World Health Assembly. Link

Leppo, K et al. Health in All Policies: Seizing opportunities, implementing policies. Ministry of Social Affairs and Health, 2013

Baum F, Sanders D. Ottawa 25 years on: a more radical agenda for health equity is still required. Link

Hastings G. Why corporate power is a public health priority. Link

Casswell S. Vested interests in addiction research and policy. Why do we not see the corporate interests of the alcohol industry as clearly as we see those from the tobacco industry? Link

Plos Medicine Series on Big Food. Link

Reuters. Special Report: Food, beverage industry pays to seat at health-policy table. Link

PAHO. Fighting NCDs requires commitment from All sectors: with clear rules of engagement including conflicts of interest. It can be done. Link

*Post written by Sebastián Peña, MD, MSc, Editor

**A disclaimer is needed here. The views expressed by the author do not necessarily represent the view of the book authors and editors nor their institutions

Online Book Seminar – June 9 – 15.00-18.00 (EEST) Finlandia Hall

A seminar to present the book “Health in All Policies: Seizing opportunities, implementing policies” will be held at the Finlandia Hall in Helsinki June 9 at 15:00-18:00.

The book is a Finnish contribution to the WHO Global Conference on Health Promotion by the Ministry of Social Affairs and Health of Finland, the National Institute for Health and Welfare, the European Observatory on Health Systems and Policies and the UN Research Institute for Social Development.

Join us for an exciting discussion around three themes:

  • Theme 1: The challenge of Social Determinants of Health –HiAP as a solution?

The first theme will bring Fran Baum (Flinders University, Australia) and Raúl Mercer (Flacso, Argentina) around an exciting discussion on how HiAP can contribute to strengthen the implementation of the SDH agenda since the final report of CSDH and the World Congress on Social Determinants of Health in Rio de Janeiro 2011.

  • Theme 2: Health in All Policies in Low-Income Settings

It has been claimed that HiAP is “difficult” as it would require high levels of capacity, resources and skills from the health sector. Can HiAP work in low-income settings? The second theme will bring Shufang Zhang (UNRISD), Ravi Ram (AMREF, Kenya) and Kimmo Leppo (Editor-in-Chief, Finland) in a crucial discussion for low and middle-income countries.

  • Theme 3: Health in All Policies in a globalized world

The third theme will discuss the impact on globalization on Health in All Policies. Does globalization narrow the scope of national policy-makers to improve the health of their population? Can it be a health-enhancing opportunity? Ronald Labonté (U. of Ottawa, Canada) and Vera da Costa e Silva (FIOCRUZ, Brazil) will explore these issues from the perspectives of national policy space for health and tobacco policies.

Online streaming

The event will be streamed online through the link http://www.videonet.fi/who/20130609/ The online audience will get the chance to participate and ask questions using the hashtag #hiap

Where and when

The seminar will be held at the Finlandia Hall Congress Wing (Mannerheimintie 13 E) on the 9th of June at 15:00-18:00 (before the Reception in the same venue). The program can be found here: http://www.hiap2013.com/wp-content/uploads/2013/06/HiAP-book-seminar-_final.pdf

Further information

The event is open to participants of the WHO Global Conference on Health Promotion and as well as those interested policy-makers, researchers, civil servants and members of civil society and general public. Please kindly register here or by email to sebastian.pena.fajuri@thl.fi

Health in All Policies: Seizing opportunities, implementing policies

 

Click here to download the book

Incorporating health into policies across sectors is often challenging and even when decisions are made, implementation may only be partial or unsustainable.

‘Health in All Policies (HiAP): Seizing opportunities, implementing policies’, published by the Ministry of Social Affairs and Health of Finland, identifies practical opportunities and challenges for raising health on political agendas. It stresses the importance of seizing opportunities for negotiating and implementing feasible policy solutions. The publication is a Finnish contribution to the 8th Global Conference on Health Promotion.

Global perspective on health

The publication draws on case studies from all continents to demonstrate how Health in All Policies works in different contexts. The examples cover eight policy areas including early childhood development, work and health, agriculture and tobacco.

‘HiAP: Seizing opportunities, implementing policies’ provides valuable insights for policy-makers, including politicians, researchers and civil society advocates. It brings a global perspective on improving health and health equity through decision-making and implementation.

The volume is published in collaboration with the National Institute for Health and Welfare of Finland (THL), the European Observatory on Health Systems and Policies, and the UN Research Institute for Social Development.

Contents

Part I

1          Introduction to Health in All Policies and the analytical framework of the book

2          History of HiAP

3          Health and development: challenges and pathways to HiAP in low-income countries

4          Prioritizing health equity

5          Globalization and national policy space for health and a HiAP approach

 

Part II

6          Promoting equity from the start through early child development and Health in All          Policies (ECD-HiAP)

7          Work, health and employment

8          Promoting mental health: a crucial component of all public policy

9          Agriculture, food and nutrition

10        Tobacco or health

11        Alcohol

12        Lessons from environment and health for HiAP

13        Making development assistance for health more effective through HiAP

 

Part III

14        The health sector’s role in HiAP

15        Lessons for policy-makers

 

For further information, please contact:

Dr Eeva Ollila, Ministry of Social Affairs and Health, tel. +358 29 516 3327, eeva.ollila@stm.fi

Dr Sebastián Peña, Finnish National Institute for Health and Welfare, tel. +358  40 169 8726, Sebastian.pena.fajuri@thl.fi

California’s Health in All Policies Task Force

The State of California created a Health in All Policies Task Force in 2010 in order to build inter-agency partnerships across State government to address issues of health, equity and environmental sustainability.  This initiative brings together 18 state agencies, departments, and offices including education, transportation, land use planning, social services, food and agriculture, and forestry. The Department of Public Health in partnership with the Public Health Institute facilitates the Task Force, and uses a co-benefits approach to identify opportunities to promote multiple goals and pursue innovative approaches that could not take place without collaboration.

The Task Force gathered input from diverse stakeholders, developed recommendations, and is now carrying out implementation plans geared at promoting health and sustainability while improving the efficiency, cost-effectiveness, and collaborative nature of State government.

The Task Force’s recommendations address two strategic directions:

  1. Building healthy and safe communities with opportunities for active transportation; safe, healthy, affordable housing; places to be active, including parks, green space, and healthy tree canopy; the ability to be active without fear of violence or crime; and access to healthy, affordable foods.
  2. Finding opportunities to apply a health lens during public policy and program development.

The Task Force’s work ranges from one-time actions to eliminate barriers or open doors to ongoing opportunities to consider health impacts as a priority in “non-health” decision-making.  Examples of Task Force projects include evaluating the use of health and equity criteria in state grant-making programs, leveraging government spending to support healthy and sustainable food procurement, and adding a health lens to transportation and city planning guidance documents. The Task Force’s work has also led to capacity building and infrastructure development such as the creation of a new inter-agency Farm to Fork office to support policies that facilitate local and regional food distribution systems, with a particular focus on increasing healthy offerings in schools.

 

To learn more, visit www.sgc.ca.gov/workgroups/hiap.html or write to hiap@cdph.ca.gov.

 

Post by: Julia Caplan, MPP MPH, Program Director, Public Health Institute, Project Lead for Health in All Policies Task Force, California Department of Public Health

 

Health in All, Health for All: Promoting Active, Healthy Lifestyle in Israel with HiAP

In December 2011, the Israeli government, municipalities and civil society joined together to launch the National Program to Promote Active, Healthy Lifestyle.  In the following post, we present the program, describe where it echoes Health in All Policies, identify HiAP-inspired directions we aim to pursue and raise questions that accompany us midway through the program’s second year. A detailed version can be found here.

Obesity levels have increased steadily in Israel over the last four decades, more drastically among individuals of lower socio-economic status. 50% of the adults and 20% of our children are overweight or obese. More than 3,000 Israelis die every year because of obesity and chronic disease. Costs add up to six billion shekels per year.

Less than a third of Israeli adults engage in the recommended amount of physical activity. Our children are among the least physically active, and spend more time playing computer games, than children in almost all other countries in the WHO’s Health Behavior among School Children (HBSC) survey. All segments of the population consume sweetened drinks every day. Average salt intake is more than double the recommended level. In the past, we have eaten enough fruits and vegetables. Recent evidence, though, suggests a decrease, especially among low income groups.

In short, we’ve become sedentary, do not eat as healthfully as we should and it’s making us sick. In order to address the challenge, the Government’s Social and Economic Affairs Cabinet adopted the National Program. Led by the Ministries of Health, Education and Culture & Sport, the program’s aims are to foster health promoting environments in the settings that comprise Israeli life, enhance our population’s understanding of what it takes to be healthy and incentivize organizations and municipalities to promote health.

Legislative initiatives include removing junk foods from schools, providing tax breaks on workplace purchases of healthy refreshments, lifting a requirement to obtain a doctor’s permission to join a health club, banning junk food ads during children’s TV, requiring restaurants to calorie-label menus and mandating front-of-package food labeling. The Ministries of Health and Finance are working together to identify economic interventions to make healthy foods more accessible and/or unhealthy foods more expensive.

The Ministry of Education declared 2011-12 to be “The Year of Active, Healthy Lifestyle.” Schools appointed councils of health-promoting students, and 85 schools gained accreditation as health-promoting schools. Another 100 will be recognized in 2013. The Ministry added health promotion to its list of educational objectives and launched a fruit and vegetable scheme with the Ministries of Agriculture and Health.

15 municipalities are participating in the “Municipalities Promoting Active, Healthy Lifestyle” program. In addition to creating opportunities for all to engage in active, healthy lifestyle, each municipality must affect policy change at public institutions, community centers and schools. In parallel, the National Program is strengthening Israel’s Healthy Cities Network, via added cities and funding for local and national staff.

Incentives for Israel’s four health providers include rewards for hiring health promoters and providing guidance for chronically ill and/or overweight patients and their families. The Health Ministry has oriented district offices’ health promotion programs to focus on active, healthy lifestyle, including programs like health-promoting nursery schools and women’s walking groups. NGO-led programs include active transportation to school, edible gardens in nursery schools and providing bicycles and training to disadvantaged youth.

Finally, the Health Ministry is (cautiously) working with the food industry to reduce salt content in processed foods and fortify flour for the Bedouin community, which suffers from malnutrition and high infant-mortality. Additional initiatives include a game-based website for children, health-related content for children’s TV, health promotion in the military and the police and a healthy workplaces pilot set to begin in 2013. The National Program also includes Israel’s largest ever social marketing program, with a focus on both social media and community-based social marketing.

THE COLLABORATIVE nature of the National Program is its defining characteristic. The choice to share leadership with the Ministries of Education and Culture & Sport reflect the Health Ministry’s recognition of the fact that HiAP’s success is, in part, a function of the extent to which non-health sectors own a stake in the process. The program therefore includes several examples of budget-sharing between ministries. Legislative progress has often depended on engaging stakeholders, like the Israeli Union of Restaurateurs, national councils of family doctors and pediatricians and television networks.

Governance structures include an intergovernmental steering committee, and committees charged with workplace health promotion and identifying regulatory measures to encourage healthy eating. An illustration of the National Program according to the WHO’s recently published Analytical Framework for Intersectoral Governance can be found here.

While aspects of the National Program resonate with HiAP, we have identified the following steps to strengthen the program’s intersectoral potential:

A first step: Strengthening the intersectoral steering committee. This committee was intended to lead the National Program. In practice, it became a forum for status updates between members of the Health Ministry, while other ministries played passive roles. This must change in order to facilitate a health-promoting cross-governmental agenda.

Another step: The Health Ministry participates in committees which address issues like food imports, agriculture and urban planning. These memberships should be leveraged to coordinate policies which promote healthy lifestyle. More broadly, our presence in such forums can be utilized to defend values which promote health equity, like access to services, community, environmental justice and fair housing. We must step out of our “health box” to become acquainted with other policymaking environments, in order to identify additional “win-win” situations between sectors and strengthen the networks that anchor HiAP.

We must focus on knowledge translation. Health information should be accessible to and disseminated toward non-health sectors, synthesized and framed according to their language and policymaking needs. Health Impact Assessment, for example, can be utilized to build a common language between health and other sectors, as shown in this study. A panel of experts from Israel’s five universities as well as the Ministries of Health, Education and Culture & Sport are leading the National Program’s evaluation. Academic representatives from outside of health should be added. In addition, the Ministry of Environmental Protection and the National Economic Council are leading an effort to design an indicator of national wellbeing beyond GDP – the National Program can strengthen this effort, as well.

18 months into the National Program’s implementation, questions remain: How, why, where and when is each sector the most/least responsive? How important is informal collaboration? Does joint budgeting lead to more or less financial support for health promotion? How can evidence be framed in order to turn the Finance Ministry into an advocate? Each sector has its own needs and is entrenched in its own policy narratives. To what extent will the health sector adapt to these needs? Finally, how will the Health Ministry address the clear risks of collaborating with the food industry?

Health Ministry workers will be impacted by the HiAP approach, as well. To what extent will intersectoral action distract from competing responsibilities? Will the Health Ministry equip its staff with the skills to engage beyond health? Clearly, there is a need to strike a balance between fulfilling health’s classic roles and exploring unchartered policy terrain.

The National Program to Promote Active, Healthy Lifestyle represents a paradigm shift for the Ministry of Health, featuring unprecedented investment in public health and health promotion and opening new channels for fostering population-wide health. Alongside HiAP efforts worldwide and inspired by an incredible population at home, we are excited to continue moving forward.

Further reading:

Kranzler Y, Davidovitch N, Fleischman Y, Grotto I, Moran D, Weinstein, R: A health in all policies approach to promote active, healthy lifestyle in Israel. Israel Journal of Health Policy Research 2013, 2:16. http://www.ijhpr.org/content/2/1/16

* Post written by Yannai Kranzler, Department of Education and Health Promotion, Ministry of Health, Israel

Launching the book “Health in All Policies: Seizing opportunities, implementing policies” at the World Health Assembly

After two years of hard work, we are extremely excited to be launching our book “Health in All Policies: Seizing opportunities, implementing policies” at the World Health Assembly! The launch will be on May 23, Salle XV from 12.30 to 14.00. The event will be hosted by the Finnish Ambassador and the editorial team will be present (Kimmo Leppo and Eeva Ollila from MSAH; Sebastián Peña from THL, Sarah Cook from UNRISD and Matthias Wismar from the EOHSP) as well as some of the authors.

The event at the World Health Assembly will also set the beginning of the electronic release and the book will be widely available both in PDF and e-book format. The goal is to fuel the discussions during the 8th WHO Global Conference on Health Promotion where we hope the book can be a significant contribution.

EuroHealthNet and the implementation of a Health for All Policies approach

Crossing Bridges (Jan 2011 – June 2012) is an EC co-funded initiative coordinated by EuroHealthNet that aims to address the question of how the health sector can work more closely with other sectors to ensure that their policies and actions contribute to improved health and well-being. The initiative brought together 16 public health related organisations from 13 EU countries. The main results are :

• Overview of good practices and practical examples of how concepts of health in all policies are being put into practice in the EU in three areas 1: Health and Education, 2: Health, Planning and Transport, and 3: the EU School Fruit Scheme, which reflects a collaboration between the Health, Agriculture and Education sectors.

• A Capacity Building Training Programme to promote Health in all Policy: “Achieving the win-win for health and health equity.” The Programme is available on line, along with additional resources on this topic.

• A Conference to present and discuss outcomes on “Working together for Health and Well Being” took place in Brussels on 29 May, 2012.

• A publication “Health for All Policies: Working together for Health and Well-being” developed in three versions (full version with examples of HiAP for practitioners, a summary version and a leaflet). These publications and other Crossing Bridges reports are translated into nine languages (D, EL, HU, I, NL, SI, CZ, PL, Welsh).

It is broadly understood that public health is largely influenced by factors that are beyond the remit of the health sector and that public health and health promotion professionals must engage with other sectors to create the conditions that optimise health. Crossing Bridges outcomes reinforced that while there is growing awareness of this in theory, many public health professionals and institutes are not implementing this approach in practice. As a result, it remains difficult to identify examples where health successfully engages with other sectors to improve population health outcomes, to strengthen and fuel this approach. This may partly be due to language and may be better to communicate on Health for All Policies, to emphasize how a consideration for health in all policies can strengthen other sectors, by for example enhancing their contribution to productivity, sustainability, quality of life and well-being.

Crossing Bridges partners identified examples of HiAP in their countries. An analysis of the examples revealed that the factors leading to the success of HiAP is often contextually based, depending on for example the kinds of organizational structures in place, cultural factors and the individuals involved. While it is therefore difficult to develop a specific methodology to implement HiAP, Crossing Bridges identified important factors and entry points to this approach. These are: establishing mandates and regulations; building relations and negotiating interests; engagement through the joint implementation of policies and initiatives; and collecting and sharing the evidence. The partnership also identified common challenges to engaging with other sectors that must be considered and overcome. These include difficulties in attributing health related outcomes to interventions made through other sectors and therefore in justifying health expenditures that advance the objectives of other sectors.

It is only through continued attention and efforts and through an exchange of evidence and information to inspire and facilitate change, that HiAP objectives will be more systematically translated into practice.

Further information on Crossing Bridges and its outcomes are available on www.health-inequalities.eu or on www.eurohealthnet.eu.

Health in All Policies in Finland: 40 years of policy developments

In connection to the upcoming 8th Global Conference on Health Promotion, Tapani Melkas has published a recent article exploring over 40 years of policy developments for HiAP in Finland. Melkas, a former Director at the Ministry of Social Affairs and Health, has been a witness of much of this progress and his experience is reflected in the article. While it could have been tighter and shorter, the article offers a very thorough account of what Finland has done to incorporate health in all policies.

From my perspective, there are four interesting points emerging from the article:

First, it is remarkable how the move towards comprehensive policy-making started even earlier than the Alma Ata Declaration in 1978. The famous North-Karelia project to curb the cardiovascular epidemic of Finnish middle-aged men and women started already in 1972, same year when the Primary Health Care Act entered in force. Finland was also an active player in the first conference on health promotion in Ottawa. One tends to think mostly on the influence of global initiatives on national policy-making, but often forgets the key role that national governments can have in contributing to the agendas of global organizations and efforts.

Second, in Finland all major public health and societal problems have been dealt with an intersectoral perspective. This goes for a broad range of policies, including road traffic safety, diet and nutrition, physical activity, tobacco and alcohol consumption, extending working lives, occupational health and safety and suicide prevention. As a foreigner in Finland, I have experienced a shared spirit of collaboration and consultation in all the projects I’ve been involved. Most Finns I know are curious, low-key and extremely modest and humble, which might facilitate intersectoral collaboration.

Thirdly, epidemiological evidence has played a remarkable role in supporting the health sector to negotiate for health with others. This involved expanding the role of the Institute of Public Health (nowadays called National Institute for Health and Welfare, THL) from infectious diseases to non-communicable diseases in the late 1970s. Evidence has been useful to support policy decisions but also contributed to monitor the impact of policy decisions and alert on worrying trends.

Finally, I find surprising that the system would need so few carrots and sticks as implementation seems to follow quite naturally from the enactment of legal framework and their obligations at the municipal level.  One would need to assess whether the uptake capacities at the municipal level distributes evenly across the country or there are inequalities in the implementing resources among municipalities.

 

Further reading:

Melkas T (2013). Health in all policies as a priority in Finnish health policy: A case study on national health policy development. Scandinavian Journal of Public Health. Available here.

 

By Sebastián Peña, MD, MSc

The First Wealth is Health: a HiAP case study from Bihar State, India

Bihar is India’s most populous state, representing around 10% of the country’s population (i.e about 110 million). The improved governance in last 7-8 years has led to an economic revival in the state through increased investment in infrastructure, better health care facilities, greater emphasis on education and a reduction in crime and corruption. Bihar has registered a GDP growth of 12% per year for the last 8 years; the fastest among major Indian states. During the same period, Bihar’s social progress has also been remarkable. Its social indicators used to be worse than national average but in 2011 it equaled national average, achieving an Infant Mortality Rate of 44/1000 live births. Literacy in the decade of 2001-2011 increased by 17% and female literacy improved even faster by 20%. Life expectancy in Bihar is now 65.8 years, close to national average of 66.1 years. Crude death rate is 6.7 /1000 persons compared to national average of 7.1 /1000 persons.

However, dark areas remain, such as:
i) It’s one of the states with lower female life expectancy (66.7) at birth than for males (67.1) as per SRS estimate for 2006-10;
ii) Rural poverty declined but just 0.4% as against national average of 8.2 mainly due to a major drought in 2009;
iii) It’s population expanded by 25% against national average of 17.6% in the 2001-2011 decade;
iv) MMR is 261 as compared to national average of 212;
v) Total fertility rate is around 3.7 per women as compared to national average of 2.5;
vi) Malnutrition and anemia are major challenges. vi. Similarly child marriage, unfavorable gender bias against girls and adverse sex ratio for females are key social challenges;
vii)Bihar provides only 2.8% of national income and gets about 8% of central funds;
viii) Its industrial growth and services sector need to improve a lot.

The state of Bihar follows the statement “The First Wealth is Health”. Health and welfare are prime concerns for Bihar’s state.  The Health Department has released a Road Map 2010-2015 that tries to put this into practice. The Chief Minister (elected head of State) will soon launch the Manav Vikas Mission to improve further development of the state. The health sector will be allocated 8 of the total 18 indicators, including MMR, IMR, TFR, malnutrtition, anemia, Life Expectancy at Birth, Sex Ratio and Child Marriage. As we know all these indicators depend on policies and actions outside health sector. The presentation made by the Principle Secretary Health to the Core committee (I am one of the persons who drafted the roadmap) suggests policies and actions outside of health sector including:
- Education department: supplementation of iron folic acid tablets in schools under direct observation;
- Social welfare department : universalization of ICDS and introduction of community level caretakers’ for child care and nutrition for the children of families below the poverty line whose both parents go to work
- Public works department and  Panchayti Raj: household toilet and safe drinking water
- Departments of Social welfare, Education and Home: conditional cash transfer to promote birth registration, education up to 10+2 class and marriage after 18 years
- Dept for Police: better implementation of PC-PNDT act to curb sex determination and MTPs.

The mission statement reads ” Bihar Health, Population and Nutrition Sector will complement the Manav Vikas Mission goals by: identifying and providing solutions for implementation bottlenecks; introducing out of the box interventions and processes for better outcomes; fast tracking of development of infrastructure and human resources; coordinating for improved intersectoral convergence; partnering with communities and strengthening community systems; and optimal utilization of available resources”. The Mission will be launched soon with a timeline up to 2022, involving development partners like UNICEF, WHO, UNFPA, BMGF and DFID.

There appears to be an unstinting political never seen before and gives great hope of public health people like us.

 

By Dr. K. Suresh Kishanrao (connect in Linkedin)