The policy process in health and care
The policy process in health and care
Abstract and Keywords
This chapter focuses on policies as continuous processes, characterised by conflicts of interest and the unequal exercise of power. It is argued that the presentation of demographic trends as a problem to be grappled with by policy-makers coincides with neo-liberal economic agendas to the detriment of older people. The impact of global-level liberalisation of markets and production on health and care policies is considered and a critical analysis is developed of the actions of global actors, including the World Bank, in shaping policies of direct relevance to the health and care of older people. The outputs of the UN and the World Health Organisation are also critically examined for their roles in the policy process and the impact these have on health and age-related inequalities. In this chapter the influence of the capabilities approach on policy-making for health is discussed and the relevance of age to equity in resource distribution is considered.
The discussions in the previous chapters have made a number of references to the role of policy in shaping the concepts of ageing, health and care. The aim of this chapter is to focus more specifically on policies as processes which are continuous, characterised by conflicts of interests and shaped through the exercise of power. An important aspect of the exercise of power is the production of knowledge to inform policy agendas. In health and social care policies, discourses surrounding demographic trends play a crucial role. As is argued, older people are frequently characterised en masse as an economic problem, and changes in dependency ratios within ageing societies as a threat to the intergenerational contract. Paradoxically, while ageing populations are firmly established on policy agendas everywhere as a policy maker's headache, it still remains the case that policy success is measured by reference to increased life expectancy and the prevention of premature deaths. ‘League tables’ of life expectancy are produced regularly as a record of national success or failure, with Japan currently in the position of world record-holder.
Gross inequalities in health have provided and continue to provide a strong moral imperative for policy action, but demographic trends are influencing ideas about what kind of action is needed. As discussed, health systems in low-income countries are experiencing a double burden because the need to address the growth of chronic diseases combines with an unfinished agenda of tackling communicable diseases, and it is increasingly recognised that addressing this double burden will require global rather than national policies and strategies. Age is an increasingly important element in the debate concerning the moral case for policy action on health. Beaglehole and Bonita (2009), for example, drew attention to the need for a new approach in public health which is more aware of the effects of demographic trends. Demographic trends raise questions concerning distributive justice, including whether the claims of different age groups for healthcare are in competition. The question of whether the age of an individual should have a bearing on their entitlement to resources and their eligibility for services is often perceived to apply at the micro-level of professional decision making, such as making renal therapies available to older people. At the macro-level, age emerges also as a central issue in debates surrounding the moral basis of resource allocation in health (Daniels 2008). Hence both socioeconomic inequalities in health and age-related inequalities in access to healthcare provoke debate about equity.
Concerning the role of policies, an important question to consider at the outset is what the evidence is that policies make a difference to health. Debates on health (p.48) inequalities have for many years reflected differences of view about whether policy action should target health inequalities or should simply rely on economic growth to improve living standards and – as a consequence – health, but the argument that economic growth and not policy action will improve health is less prevalent now. The World Bank now acknowledges the value of social policies. Its 2010 Global Monitoring Report noted that without effective policy responses the social impact of the economic crisis of the 1990s in low-income countries would have been far worse and that, although the outcomes of the 2008 crisis are not yet fully understood, the hope is that social policy action will have the effect of dampening the worst effects (World Bank 2010). A further twist to the debate about this relationship between economic growth, policies and health is that there is increasing acceptance of the view that policies on health and welfare have a positive impact on economic growth (Mkandawire 2001). Evidence on the social determinants of health demonstrates that, in order to have an impact on health, policy action would need to go far wider than health policy per se, to include a range of measures, including on income security, housing and environmental health (Marmot 2005). Another argument, from Wilkinson and Pickett (2009), is that in the context of high-income countries the relationship between income and health is more a function of inequality, with social position and relative income being determining factors, rather than differences in living standards per se. From this perspective, material living standards need to be understood for what they signify in terms of social position. Social life, social networks and social support are strongly associated with health and have a bearing on policy decisions. The discussion in this chapter focuses, in turn, on the idea of policies as process; the context of policy making, including the impact of globalisation; ideological factors that influence policy agendas and priorities; political and organisational factors that reflect the exercise of power and the governance of health and welfare; implementation issues; and the processes of bargaining and compromise that occur within the policy process. In the final section of the chapter the discussion is of values and ethics in relation to equity, with particular attention drawn to the capabilities approach.
Policy as process
The idea of policy as a process underpins the discussion in this chapter (Hill and Hupe 2009). The aim is to elaborate on key features of this process and to provide a framework for understanding the themes of prevention, treatment and care that are picked up in subsequent chapters. An ideal-type of the policy process would be that a social phenomenon is identified as a problem requiring attention. It then gets on to the agenda of policy makers, who design a remedy that is produced as a policy on paper, which in turn is given to appropriate bodies to implement in practice. However, this neatly sequential ideal-type bears little resemblance to the reality. Instead, the policy process is better understood as a patchwork of actions and non-actions by a range of governmental and non-governmental organisations (p.49) which is influenced by material resources, cultural values and political power. Particular socioeconomic, political, historical and environmental contexts will shape and influence decisions that are made. Issues do not emerge uninfluenced by political concerns, and individual policy actions are influenced by wider policy agendas and what are understood to be the most pressing problems.
The context of the policy process: the impacts of globalisation
The impacts of globalisation on health and care have been subjected to far broader debate than is possible to cover in this text. Of particular concern here are the global-level liberalisation of markets and production and the consequences of these, which affect national-level policies on health, social security and care in the context of population ageing. From a critical gerontology perspective, Phillipson (2006) identified three aspects of globalisation that are of particular relevance to ageing. The first is its influence on the ideological terrain: that is, ageing has been socially constructed as a new form of risk. The influence on the ideological terrain, from Phillipson's perspective, is that global-level interactions and the intensification of global ties have contributed to a politicisation of ageing as well as a strengthening of the perception that population ageing is a worldwide problem. The dominance of neoliberal economics, he argued, is reinforced through these global ties and affects profoundly the ways in which national governments set their own policy priorities, including those relating to old age.
The second aspect identified by Phillipson concerns the new forms of risk that have emerged in conjunction with globalisation. These have removed the securities of social institutions like pensions and other social support for old age and placed responsibility on the shoulders of individuals. Ageing itself thus becomes a matter of individual, not pooled or collective risk. The third impact identified by Phillipson is the role played by globalisation in the creation of new structures for the control and management of ageing. People's rights have become more fragmented and the spread of powerful global organisations has generated new social and political forms. Phillipson argued that globalisation has also exacerbated socioeconomic inequalities in later life. The globalisation of financial markets has particular effects, as highlighted in a study of pension-fund capitalism by Vincent (2006a). As Vincent pointed out, the concerns of the wealthy about the security of their pension funds are very different from the concerns of the poor, and these inequalities are played out at a global level. Hence, risk is ‘exported’ to developing countries, where insecurity is borne by the rural poor, particularly the old and women, in order to sustain the pension funds of the richer nations. Within developing countries, pension policies are often modelled on those in high-income countries, so that those in pensionable employment enjoy benefits in retirement that are denied to the majority (Lloyd-Sherlock 2006). The banking crisis of 2008 has exacerbated this divergence of interests and generated greater insecurity among the poorest, and greater inequalities. These themes – ideological, (p.50) political and organisational – are echoed in a range of debates about globalisation that are of relevance to this discussion.
The ideological terrain: the development of dominant policy discourses on ageing
The processes by which particular concepts and ideas come to dominate policy processes represent power struggles between interested parties. Bozorgmehr observed that what have come to be understood as ‘common goals’ are better understood as ‘successes in the battle of theories’ (2010: 12). The policy process inevitably entails the shaping of ideas so that they fit overarching policy agendas. Hence, the ageing of populations is seen as a policy problem. Why particular issues come to dominate the policy process as problems is a matter of debate. Indeed, Colebatch (2005) argued that that the policy process is to a large extent about negotiation and the creation of shared meaning and the questions: ‘what requires attention and what is the nature of this problem’ are wide open to interpretation. This point is highly relevant to the issue of how demographic trends are interpreted and what policy actions are pursued as a consequence. The UN's 2007 World Economic and Social Survey showed that increases in healthcare expenditure in a number of countries over recent decades can be attributed only in part to ageing populations. In spite of this, changes in dependency ratios push concerns about care to the top of policy agendas and frame these in over-simplistic ways.
There is a high degree of consensus over the ideological impact of globalisation on welfare. Yeates (2005), for example, made the pertinent point that in the global debates and struggles over the future of welfare, the dominant themes that emerge are all variants of liberalism. She identified these themes as the increasing emphasis on individual responsibility and choice; a restricted role for the public sector in both financing and welfare service provision; a more substantial role for the commercial sector; and minimum regulation of the commercial sector. She also noted that there are no international governmental organisations advancing a democratic or redistributive agenda for welfare, of the kind that exists in Nordic countries. The underlying assumption about the superiority of the commercial sector is open to question. Leaving older people's health and care to the market has evidently had negative effects. For example, in the UK in 2011 the collapse of Southern Cross, one of the largest for-profit care companies in the care-homes business, raised serious questions about the role of the commercial sector, particularly private equity firms, in providing care. Nevertheless the view that the private sector is preferable to the state has come to dominate at a global level and, as Baars (2006) argued, has provided a convenient rationale for national governments to overlook older people's welfare needs.
A related point is the way in which particular discourses dominate and eclipse others. In the previous chapter it was argued that policy makers often fail to grasp the realities of life for those who need or provide care. As an example, the United Nations Research Institute for Social Development (UNRISD) programme on (p.51) Gender and Development pointed to the invisibility of unpaid care within global economic policies (Razavi 2007, Abe 2010). As a consequence, a whole raft of activities that have demonstrable economic benefit to societies is completely overlooked when it comes to establishing policies. This is to the detriment of people involved in care relationships because the conditions of their lives are not seen and understood and therefore not supported. However, it is also to the detriment of societies more generally because the value of evidently productive activities is not recognised and counted. As discussed in the previous chapter, the development of health and social care policies would be enhanced immeasurably by a fuller understanding of the extent and nature of unpaid care. It is because the practices of care do not fit underlying assumptions about what are suitable subjects for policy makers that they are absent from public policy discourses. Instead, policies have tended to adopt a narrow, commoditised view of care that focuses on processes of commissioning and trade between government agencies and commercial corporations and the regulations that govern these, which offer only a partial picture. It is important to emphasise that, although unpaid care work has been all but invisible in global economic policies, there is ample evidence to show how these policies affect the giving and receiving of care. This evidence is discussed further in Chapter Seven.
The political and organisational terrain
Phillipson's point about the increased power and influence of global non-governmental organisations has also been analysed at length by a range of commentators, again with broad agreement about their rising importance. An important aspect of these debates concerns the shifting levels of power of different global organisations in the sphere of health and care. Deacon (2007) identified what he termed ‘global policy advocate coalitions’ which represent widely divergent interests. These include the UN, the WHO, the World Bank, a range of international corporations, pharmaceutical companies, healthcare providers, social and political movements and international non-governmental organisations (INGOs). He pointed to the increased influence of the World Bank through the funding of national projects, the development of public–private partnerships and the direct provision of goods and services. The increased influence over health and welfare systems of international financial institutions (IFIs) such as the International Monetary Fund and the World Bank is regarded as a matter of concern by many commentators. Hein and Kohlmorgen, for example, argued that there is ‘hardly any other field of global politics where new institutional forms have gained comparable significance as in global public health, particularly in relation to financing’ (2008: 84). Evidence that economic growth facilitated by IFIs has been followed by increased social inequalities, higher unemployment, more insecure forms of employment and environmental degradation has amassed over the years (Soubbotina 2004, Hassim and Razavi 2006). Relationships between governmental and non-governmental bodies in health and care services have (p.52) been particularly contentious in recent decades. The WHO's 2008 World Health Report acknowledged that ‘the blurring of boundaries between private enterprise and public institutions’ has transformed relations between citizens, professionals and politicians in different parts of the world (WHO 2008a: xiii).
The role of the World Bank in relation to healthcare policies and practices has received a great deal of attention. As the single biggest donor of money for health projects, the World Bank has had direct influence on national health and welfare policies. Gorman (2002) argued that the World Bank virtually monopolised debates in the 1990s over pension reform, while others have argued that the actions of the World Bank systematically undermined the ideals of Alma Ata as the aim of equity in healthcare was overtaken by the drive for economic efficiency, with little attention to the wider determinants of health. The World Bank has been in competition with the WHO over the conceptual underpinnings of global health politics, although within the World Bank itself the conceptualisation of health has also been hotly contested (Hein and Kohlmorgen 2008). The 1993 World Bank report Investing in Health and the 1994 report Averting the Old Age Crisis were both highly instrumental in the restructuring of health and welfare services. The ‘time-bomb’ thesis contained within the 1994 report gave legitimacy to neoliberal, ‘safety-net’ models of health and welfare services and to the promotion of the private sector as the most efficient provider of services to older people.
The World Bank was in the mainstream of economic thinking at the time, taking a similar line to that of the International Monetary Fund (IMF) and playing a major role in the entrenchment of neoliberal political values. Lloyd-Sherlock (2010) made the point that in many developing countries the health sector reforms shaped by the World Bank have resulted in a dramatic expansion of private healthcare services, with INGOs seeking to compensate for declining state capacity. Without such voluntary interventions, he commented, there would be no healthcare at all for the poorest groups who are unable to pay for services in the private, commercial sector. Navarro (2008) regarded the relative weakness of the WHO in comparison with the World Bank as a problem, but he was also deeply critical of the WHO, which he argued had shown an underlying commitment to the very political and economic systems that have proved so counter-productive to its aims at Alma Ata and Ottawa.
The contest within the World Bank over its economic strategies highlights the centrality of values to policy actions. In its 2002 report The Policy Roots of Economic Crisis and Poverty the World Bank acknowledged that the very structural adjustment policies it had so enthusiastically promoted in the 1990s had in fact exacerbated socioeconomic inequalities and contributed to further impoverishment and marginalisation of the poor. This report signalled a major shift in the World Bank's policies, which changed to prioritise poverty reduction. Its 2006 World Development Report, Equity and Development, was explicit in its support for human rights as a basic policy principle. It argued for public health reforms, better sanitation, clean water supplies and immunisation programmes (p.53) for the benefit of the many rather than the privileged elite – policies that were entirely in line with those of the WHO and INGOs.
It would be a gross oversimplification to conclude that differences of opinion over policy priorities for health and welfare were resolved by this change of tune. As Anderson (2006) argued, deeply entrenched problems caused by structural adjustment programmes had lasting effects which persisted long after these programmes were replaced with poverty-reduction strategies. Furthermore, while the aims have changed, the underlying economic models have not and the World Bank remains committed to the private sector as the best option for service provision, albeit in partnership with public and voluntary sectors. A recent World Bank publication still claims that a shift of resources away from public to private sector organisations is the best approach to tackling chronic and noncommunicable disease in developing countries (Adeyi et al 2007). Neoliberal economics still permeate global policies, including, for example, the ‘pro-poor’ policies of the OECD, which are deeply compromised by neoliberal assumptions and corrupted by conflicts of interest (Anderson 2006).
The governance of health and social care is a crucial point which draws attention to the relationship between global institutions and national governments. Deacon (2007) argued that the relative power and influence of global policy actors and nation-states is a matter of debate and in any case differs between policy areas. There are particular concerns in relation to healthcare, the governance of which has been weak in the context of a rapidly growing market. Lee et al (2009) identified four particular consequences of this: first, globalisation changes the distribution of power and authority, causing national governments (and hence their regulatory regimes) to be weakened. Second, globalisation is strengthening the connections across different spheres of policy. For example, policies on trade and migration have knock-on effects on healthcare systems in relation to both healthcare provision and staffing. Third, the proliferation of institutions, particularly those that are market-based, has a negative effect on governance. Transnational corporations, civic and social organisations, as well as ‘hybrid’ organisations such as public-private partnerships, have radically altered traditional lines of accountability. A fourth effect is the shift in power and authority that can be seen in the rise in influence of the World Bank through its activities in lending to the health sector since the 1980s and the parallel loss of power by the WHO. The rise in the World Bank's power and authority is evident in other spheres of welfare provision also, including over pension policies, where it has eclipsed the previously preeminent authority of the International Labour Organisation (Yeates 2005). An analysis of pensions policies by Orenstein (2005) highlighted how transnational non-governmental policy actors are often responsible for their formulation and transfer to individual countries – what he termed a form of ‘governance without government’ at the global level.
The pressures faced by governments from transnational corporations can be seen in relation to public health measures, such as policies to tax products and industrial production methods where these are known to be harmful to health (p.54) but are also associated with economic growth and job creation. For example, the Framework Convention on Tobacco Control still has not been fully implemented and tobacco companies continue to resist attempts to deter smoking. At the time of writing, the tobacco company Philip Morris has threatened to sue the Australian government over a plan to introduce plain packaging on cigarettes (Guardian 2011). These pressures are hard in any context, but in low-income countries the capacity for action is more restricted and policy strategies on health can be frustrated. Labonté et al (2011) analysed the nature of the impact of global trade treaties and pointed to the policy space and policy capacity of national governments to take effective action on chronic diseases. Policy space refers to the freedom and scope of governments to choose the policies that meet their particular aims, while policy capacity refers to their fiscal ability to enact those policies or regulations. Trade treaties can enhance or erode national governments' space and capacity. With reference to food, tobacco and alcohol in particular, Labonté et al concluded that the liberalisation of trade and finance has increased ‘the global diffusion of risk factors for chronic disease’ (2011: 18).
On the other hand, it is also argued that the nation-state remains an important actor and the relative importance of the role played by global institutions in the erosion of welfare systems at the national level is a matter of debate (Palier and Sykes 2001). National governments have always been able to facilitate or restrict opportunities for private healthcare provision through measures such as subsidies or tax relief for private health insurance schemes. Moreover, nation-states remain a significant force not only in making decisions about whether or not to advance international practices but also in the way these practices are adapted in different national settings (Labonté 2008, Nolte and McKee 2008b). As Gough pointed out, the implementation of neoliberal models at the local level will inevitably be ‘refracted through domestic regimes’ (2001: 185). The concept of policy transfer encapsulates this process. Ideas about how policies, practices and institutions in health and social care should be developed have had remarkable success in becoming dominant discourses, but there are discernible differences between nations in the extent and nature of their impact. For example, Yeates (2005) argued that differences in impact on welfare systems can be understood by reference to political and economic contexts and historical traditions. These include how well-established and well-resourced a welfare system is and what local priorities are for social protection. Local priorities were also emphasised by Silva et al (2011), who argued that while neoliberal policies had a profound and lasting effect on the healthcare system in Bolivia, this effect cannot be attributed entirely to the World Bank because the national governments in power at the time were receptive to the Structural Adjustment Programmes. They also suggested that left-wing governments tend to separate control over action on the social determinants of health, on the one hand, and provision of curative healthcare, on the other, the former being in the public sector and the latter in private hands.
Governmental action can also support the transfer of ideas. For example, in 2004 the European Union instituted the Open Method of Co-ordination (p.55) in social protection and social inclusion, including in the fields of healthcare and long-term care, in order to enable member states to identify practices that could be transferable between them (Glendinning and Moran 2009). Nolte and McKee (2008b) observed that while there is a high degree of consensus about how to respond effectively to the treatment and care of chronic disease, there are wide variations between countries in the ways that they adapt and develop their responses (Zhan and Montgomery 2003, Wilson 2006). The concept of ‘path dependency’ in the policy process provides an explanation for these variations, highlighting how innovations in policies and practices are shaped by existing policies and practices. Izuhara (2010), for example, discussed the cultural context of intergenerational relations in East Asia and the way in which care has become socialised and marketised. The concept of ‘filial piety’ describes the long-standing framework that has defined family obligations in East Asian cultures. The effect of socialisation and marketisation has changed traditional boundaries between families and the state, and affected ideas about family loyalties and obligations. However, individual countries are changing in different ways. In China, a market in institutional care has opened up, paralleled by a gradual change of view about institutional care as a source of family pride rather than shame. This is because the willingness of one's children to bear the high cost of institutional care has increasingly come to be interpreted as a form of filial piety. In Japan, as in China, the expectation that long-term care is a family obligation has changed, but there change has occurred over a longer period than in China and has included the introduction of social insurance for older people and home-centred care services. In this context, family support has increasingly meant emotional support and the organisation and management of community-based resources.
Policy implementation: fine on paper but poor in practice?
Much has been written about the gap between the rhetoric and the realities of policies – the implementation gap that seems to dog progressive policies – and many explanations have been developed (see, for example, Hill and Hupe 2002). Policy-making on poverty reduction is a case in point. In the year 2000 the Millennium Development Goals (MDGs) – to eradicate extreme poverty and improve the health and welfare of the world's poorest people by 2015 – replaced the ‘Health for All by the Year 2000’ declaration of the 1977 World Health Assembly. Since the two policies are so similar, questions are raised about why, in 23 years, so little progress was made on the first. According to Global Health Watch (2005), the answer lies in the macro-economic contexts and the economic crises that occurred soon after the 1977 conference. The Structural Adjustment Programmes introduced by the IMF and the World Bank at the time were regarded as being of primary importance, although, as discussed, these exacerbated rather than addressed the health problems of the world's poor
Fast-forward to the present day, and the impact of the 2008 banking crisis on the MDGs has been significant, as people's disposable income in low- and (p.56) middle-income countries is reduced. Access to healthcare is one of the areas badly affected. In middle-income countries such as Turkey, for example, spending on healthcare and medicines was one of the areas where people reported that they had been forced to cut back. Of course, access to healthcare that is free at the point of delivery ameliorates the impact of a drop in disposable income – a point that reinforces the relevance of local context. More generally, the observation of the Global Health Watch team concerning the overriding impact of the macroeconomic context coincides precisely with Tronto's argument raised in Chapter One, that the moral agenda of rights (as in the Health For All programme) is easily eclipsed by more pressing political concerns because it is conceptualised separately from the political agenda of resources (Tronto 1993).
In the context of this discussion on implementation, an important point concerns whether policies are too vague and idealistic to have practical application. For example, since the Second World War the WHO and others have campaigned for intersectoral action to promote health and for a broad-based primary healthcare system. In its 1978 conference in Alma Ata the WHO called for primary healthcare to be the main focus of healthcare systems and an integral part of the overall social and economic development of societies. Again, in 1986, the WHO's Ottawa Charter proposed a framework for action by policy makers on primary healthcare which recommended a reorientation of health services beyond clinical and curative functions, to multisectoral preventive work (WHO 1986). Over the succeeding decades numerous criticisms of the Alma Ata declaration have emerged, frequently targeted at its idealistic, rhetorical and impractical nature.
From this history emerge questions about the value of policies that have only symbolic strength. Arguably, the ideals of the Alma Ata declaration still hold out a model for a possible alternative to contemporary health policies, even though the commitment to equity and justice in health that it encapsulated is evidently hobbled by more dominant political agendas. Its influence is significant as a focus for organising for equity in global health, but the lack of progress in achieving its aims draws attention to the compromise of its ideals over the years. For example, in 2008 the World Health Report drew a distinction between the broad-based model of primary healthcare (multisectoral and ‘upstream’) and primary care, which is specifically focused on the practices of health services. Primary care in its newly defined form has had evident practical application: Kickbusch (2010), for example, pointed to its direct influence on the South Australian government's Strategic Plan for health. From this perspective, compromise can pave the way for change, albeit slow and partial. Katz (2009), on the other hand, was critical of the way in which the 2008 World Health Report neglected any reference to health as a right (as defined in the Alma Ata declaration), but sought instead to prioritise the economic case for primary healthcare. Katz contrasted this report with the report of the Commission on Social Determinants of Health, published the same year (CSDH 2008). He argued that the CSDH provides clear evidence of social policies and programmes as among the determinants of marked health inequalities, and that the case for a rights-based approach to health still stands.
(p.57) In 1982, between the Alma Ata conference and the Ottawa Declaration, the UN's Vienna International Plan of Action on Ageing – the first international policy on ageing – was passed (UN 1983). This drew attention to demographic trends and the envisaged ageing of societies, and argued in favour of urgent policy action at a global level. It also considered issues of equity across age groups both in relation to the distribution of the benefits of development and in the potential for conflict between age groups arising from changes in dependency ratios. Like the Ottawa Charter, the Vienna Plan maintained that the way to promote older people's health and well-being was necessarily intersectoral in nature, encompassing health promotion throughout the lifecourse in order to combat the detrimental effects of premature ageing. The evidence on the outcomes of the Vienna Plan is not resoundingly positive. Sidorenko and Walker (2004) identified that when asked about its impact on their policies, governments responded that it had been ‘useful’ but several issues were raised that still needed to be addressed, including concerns about violence and neglect experienced by older people and the welfare needs of older people in rural areas of developing countries, in particular. Gorman (2002) was critical of the Vienna Plan, noting that its aims were far beyond the means of many governments in the developing world and that it accorded little or no role to NGOs in its implementation. From this perspective, the problems of implementation lie in lack of attention to the practical relevance of policies and to the potential for ideals to be translated into action.
The Madrid International Plan of Action on Ageing (MIPAA) attempted to by-pass the problems that had limited the effectiveness of the Vienna Plan. Two primary principles underpin the MIPAA. The first is a ‘development approach to population ageing’, which entailed mainstreaming into plans and policies the concerns of age. The second is a ‘lifecourse intergenerational approach’ to policy, which stresses equity and reciprocity between age groups. The MIPAA is, as Sidorenko and Walker (2004) commented, comprehensive in its coverage. Thus, the developmental focus was intended to incorporate the concerns of older people into existing strategies for national development and poverty eradication. The mainstreaming approach committed signatory governments to incorporating a perspective on ageing into their policies as a first step towards the implementation of the Plan. This was seen as a relatively cost-neutral way of making progress on raising awareness of older people's concerns and of the effects of societal ageing on social development.
A review of progress on the MIPAA, however, noted major shortcomings in progress towards the mainstreaming of ageing, which was a particularly disappointing finding, given that this was acknowledged to be the approach of choice for developing countries with limited resources (UN 2008). The global financial crises that have occurred since the MIPAA was passed will doubtless have played a part in downgrading the importance of policies on ageing within the broader political agendas of national governments. However, shortcomings in the implementation of the MIPAA cannot be explained entirely by reference to a lack of resources. As Harper (2006) argued, ageing is not a pressing issue in many (p.58) developing countries and the MIPAA will not have been seen as a policy priority. Lloyd-Sherlock argued that there is ‘a failure of most policies in most countries to promote financially sustainable interventions that maximise well being for all in later life’ (2010: 235). From this perspective, the inadequacy of policies in relation to age is deeply embedded, in all contexts, including at a global level. It is deeply ironic that, despite its strong official support for the MIPAA, the UN's own 2011 summit on non-communicable diseases omitted Alzheimer's disease and other dementias from its planned programme.
Engagement in the policy process: struggle and compromise
The discussion so far has highlighted how the policy process is never tidy and straightforward but always reflects a struggle between diverse interest groups with more or less muscle to flex. Kickbusch (2010) represents a highly pragmatic approach to involvement in this process, as pointed out above. She took the high level of political interest in health issues as an indication that health has moved from being a vertical, ‘sectoral’ issue to being a horizontal issue of relevance to a wide range of societal goals. For Kickbusch, this has provided a good reason for groups interested in promoting health to organise, develop ideas and get involved with the policy process. Policy agendas, she argued, are ‘actions triggered by windows of opportunity which can be opened by policy entrepreneurs’ (2010: 263). Kickbusch suggested that it is the convergence of ‘problems, policy alternatives and politics’ that makes policy. When issues are defined as problems, policy makers need to address them by reference to alternative strategies, informed by current knowledge and experience. The trickiest aspect of this process is political. The skills of bargaining, compromise and negotiation are not easy to sustain by those unused to involvement in the policy process.
As discussed, the WHO's 2008 World Health Report, Primary Healthcare: Now More than Ever, presented a more pragmatic and context-specific form of primary healthcare than that espoused within the Alma Ata declaration. This report sees the reduction of inequalities in health, universal coverage of healthcare and intersectoral action on health as important ongoing aims for the WHO. However, it highlights that three ‘worrisome trends’ put these at risk:
• health systems that focus disproportionately on a narrow offer of curative care
• health systems where a command-and-control approach to disease control focused on short-term results is fragmenting service delivery
• health systems where a hands-off or laissez-faire approach to governance has allowed unregulated commercialisation of health to flourish. (WHO 2008a: xiii)
The combined effect of these trends is the lack of a comprehensive and balanced approach to healthcare, inequitable access, impoverishing costs to individuals and an erosion of trust in healthcare systems as regulatory regimes are undermined. Certainly these trends do not bode well for older people who have incurable (p.59) chronic health conditions that require integrated services to support them. The lack of effective regulation of private sector services and care homes is a significant problem (Lloyd-Sherlock 2010). Even within this non-contentious approach to primary care, there are evident problems, and the report itself has been criticised roundly. In a scathing commentary Katz (2009) argued that its presentation of primary healthcare is a ‘lite’ version that makes no reference to the broader economic structures that exacerbate the very inequalities and injustices that primary healthcare has been grappling with for decades, nor to the social determinants of health; nor does it recognise the power differentials that exist between the ‘stakeholders’ involved in the policy dialogues that the WHO envisages regarding the governance of primary care.
The WHO's plans to develop age-friendliness in different settings might appear somewhat naïve and insignificant, compared with the scale of the ‘worrisome trends’. The concept of age-friendliness is difficult to pin down, as it is associated with such a wide range of activities (Kalache 2009). It can also be regarded as a compromise of the principle of a rights-based approach to healthcare and of action against age discrimination. Indeed, following Katz (2009), it could be seen as a ‘lite’ form of campaigns to abolish age discrimination in healthcare. WHO guidelines on Age-friendly Primary Healthcare (WHO 2004b), for example, focus on healthcare staff, aiming to improve attitudes as well as knowledge and skills in treating the diseases of old age. At the same time, age-friendliness also entails a focus on the management of primary healthcare so as to raise awareness of how to make services more approachable, and easy to access physically. Age-friendly primary care centres are seen as models for promoting social inclusion, providing inspiration to other sectors such as transport and housing. Age-friendly primary care is also about the empowerment of older people, giving them information about healthy living so as to prevent or delay the onset of chronic diseases and disabilities. In this sense it is very individualistic and entirely compatible with a neoliberal agenda.
Global Age-friendly Cities (WHO 2007b) take a more ‘upstream’ approach, emphasising the importance of preventive healthcare, salutogenic environments and physically accessible buildings, spaces and transport systems. In the context of other global trends that are apparently antithetical to the ideas underpinning age-friendliness, the question arises: are age-friendly cities likely to be implemented in practice? The evidence from the Age-friendly Cities movement suggests that it can provide a platform for local actions that are of benefit to older people. In addition, it can play a part in the development of what the WHO is calling an ‘age-friendly movement’ (WHO 2007b), promoting the possibilities for networks between older people's groups in different parts of the world and of bottom-up approaches to the development of policies and practices that affect older people. This suggests that the benefits are relatively small scale rather than signalling a fundamental shift in attitudes towards older people, although the benefits to the particular groups participating should not be overlooked.
(p.60) Bottom-up influences are frequently associated with NGOs. As noted by Klein and Kohlmorgen (2008), during the 1990s NGOs assumed a more prominent position in the policy process and through their combined political weight achieved results in influencing international discourses on health and pushing a view of health as social justice. However, NGOs vary in terms of their power and influence. In the field of ageing there are large NGOs in areas where the demographic transition is advanced, but in the developing world the picture is less positive and a negative view of ageing prevails (Gorman 2002). Here, there are fewer organisations working with older people and those that exist are more charitable than political in nature. Gorman called for NGOs in ageing to move beyond the immediacy of service provision, to make the links between their experiences of working with older people at the community level and the wider policy agendas.
A problem for NGOs is that even where they succeed in getting involved in the policy process and expanding their sphere of influence they run the risk of becoming co-opted by those who have greater power and influence within global health governance circles. NGOs act where they can and take advantage of windows of opportunity – as Kickbusch (2010) suggested; but, as already discussed, wider policy priorities limit their influence. For example, in the field of public health the tendency has been to opt for ‘vertical’ strategies, focused on particular infectious diseases such as HIV, tuberculosis and malaria rather than on general public health measures. McIntyre (2004), for example, pointed to the role of the World Bank in restricting the scope of African health policies to actions, in this way. The major philanthropic foundations in the global health governance field have reinforced the disease-specific focus of health policies, thus tying NGOs to this policy agenda. Hein and Kohlmorgen (2008) noted how NGOs have been successful in improving access to medicines and how their successes were in part due to the convergence of interests of national governments who wished to make progress in tackling diseases such as HIV/AIDS, and of pharmaceutical companies who stood to gain from increased activity on disease-specific programmes. As Kickbusch argued, ‘in health it seems easier to address vertical, disease-based problems with medical solutions rather than systemic issues and approaches’ (2010: 263). Thus, while NGOs can benefit as participants in the policy process, they run the risk that their critical stance will be muted.
Values and ethics in health and care policies for ageing societies
This part of the chapter will analyse in greater depth particular underlying philosophical and ethical debates on health concerned with equity in health and healthcare. There are particular implications within these debates for ageing, and it is crucially important to explore them within the overall discussion in this text. Policy actions to promote equity in health have been influenced by different philosophical and ethical traditions. Labonté (2008) identified five discourses of (p.61) health, which he analysed for their potential to generate action towards health equity. These are: health as security; health as development; health as a global public good; health as a commodity; and health as a human right.
Health as security concerns action to address global-level risks of infection, such as SARS, as well as risks related to political and economic instability. Health as security can be used to distort policy priorities and shift attention from equity concerns. On the other hand, security is a prerequisite for health and should, arguably, be a key feature of public health policy. Health as development is also a prominent discourse, which influenced the MDGs, but, as Labonté argued, it has been narrowly focused on economic performance and not enough on human potential. Health as development, arguably, could be a core feature of policies to promote equity through a focus on strengthening solidarity and social cohesion. Thus, in principle both health as security and health as development have potential to inform policies to promote equity, but in practice have not proved to be effective in this way.
The idea of health as global public good refers to an ethic that places collective benefit over individual gain. Its collective potential is not confined to individual nations, and from this perspective the actions of one country should not have negative ‘spill-over’ effects on another. The idea of health as a public good is in direct competition with the idea of health as a commodity. Hence, Labonté argues, cross-border flows of pharmaceuticals, new technologies and services such as insurance and health and care facilities have been designed to maximise profit and not promote health. In addition, international regulations developed through the World Trade Organisation, such as Trade Related Aspects of Intellectual Property Rights (TRIPS) and the General Agreement on Trade in Services (GATS), mean that elite groups and private companies benefit from the privatisation of health and care services and this is to the detriment of those who are unable to pay the costs.
Labonté regarded the health as a human right discourse as having great potential for equity in health. He argued that the rights discourse is one of the most highly globalised political values of our time. The WHO's own Commission on the Social Determinants of Health (CSDH 2008) provided clear evidence of the need to reassert a rights-based approach. In the context of health it is the most widely shared language of opposition to the idea of health as a commodity, although, as Labonté observed, it remains relatively weak in practice. This last point is a strong reminder of the frequently observed weakness inherent within moral agendas related to health discussed above.
Labonté's typology provides a useful basis for a discussion of values and ethics and their roles in the policy process at a global level. From the perspective of the ethics of care, the emphasis on rights would need to be assessed by reference to the limitations of the ethic of justice discussed in the introductory chapter. Health as a human right has undoubtedly been important as an alternative discourse to neoliberalism (Shrecker et al 2010), but the danger is that it will remain an abstract discourse while the health-as-commodity discourse continues to dominate political and economic actions. Since health cannot be separated from (p.62) consideration of social well-being and the need for caring relationships, the aim of promoting equity must go further than the conferring of rights to individuals.
Age-related equity and the development of policies to combat age discrimination have featured strongly in the campaigning activities of older people's organisations in parts of the developed world, and at the UN the rights of older people have been given specific consideration since the General Assembly in 2010, when a working group on strengthening the human rights of older people was established. Initial reports to this group have identified, for example, that the abuse and neglect of older people (particularly older women) is a widespread problem not limited to any particular context or region (UN 2009). It remains to be seen if this action by the UN has greater impact than the WHO's 2002 Toronto Declaration on elder abuse referred to in Chapter One, but an ethics of care perspective would suggest that the human rights agenda will continue to be overshadowed by the wider political agenda of resources.
Equity in health: the capabilities approach
The capabilities approach, first developed by Amartya Sen (Sen 1999), has had significant impact within the UN, as is evident in its Human Development Reports (UN 2010b), and in the European Union's social policy agenda (Carpenter 2009). The capabilities approach was a reaction to the dominant economistic measures of social development, which Sen regarded as inadequate to the task of measuring well-being because they overlooked non-material values. The capabilities approach holds that what is important is equity in the distribution of capabilities, capabilities being the things that a person can effectively do or be. In Sen's view, following Aristotle, capabilities are positive freedoms, the freedom to do or be something, together with the means of exercising those freedoms. The capabilities approach ascribes a strong role to human agency also, as it includes what a person chooses to be or to do in line with his or her own values (Sen 1999, 2004).
Sen's ideas were developed by Nussbaum (2000) into a universal rights-based approach to capabilities which, she argues, should be relevant in any cultural setting. Unlike Sen, who resisted consolidating the idea of capabilities into defined universal measures, Nussbaum produced a list of ‘central human capabilities’. These include life; bodily health; bodily integrity and mobility; senses, imagination and thought; emotions; practical reason; affiliation; awareness and concern for nature; play; and control over one's political and material environment. Nussbaum emphasised that this list is best understood as an integrated body of capabilities, but at the same time she also argued that the loss of any individual element would lead to a loss of human dignity.
The capabilities approach is highly regarded among international NGOs as applicable to the promotion of both material well-being and human rights. Barrientos (2010), for example, applied the capabilities approach to a study of pensions in Chile. He defended its value in policy making on social protection because, he argued, it provides a basis for a better understanding of vulnerability (p.63) than is the case with straightforward ‘welfarist’ economics. Also he argued that the emphasis on individual agency is important because, while welfarist economics focus on generally available material goods, they do not differentiate between people in terms of the variability of their needs or how they would choose to spend their pensions.
There are, however, several critiques of the capabilities approach. A ‘critical but sympathetic’ view was given by Carpenter (2009), who argued that it has potential for the development of new models of citizenship which incorporate economic and social rights as well as civil and political rights. However, he argued that because growth-oriented global capitalism is embedded within it, there are limitations to its value as a basis for citizenship. Nevertheless he claimed that it is important because it ‘asserts the essential similarity of our human needs and potentialities’ and because it values social activities, including caring work (2009: 355). Lloyd-Sherlock (2002) is a similarly critical supporter. He argued that the capabilities approach lacks attention to the complexity and dynamics of the lifecourse. He maintained that Nussbaum's view of capabilities is too linear, failing to grasp the ways in which capabilities fluctuate through life and may diminish with ageing. Thus, while Nussbaum recognises that health in later life will be affected by earlier lifecourse experiences, she tends to see earlier experiences as external constraints rather than as inherent aspects of human experiences. For Lloyd-Sherlock, a more dynamic lifecourse model would also take better account of individuals' capacity to mitigate the disadvantages of structural constraints. In policy terms this would entail a better understanding of older people's values and preferences and the extent and variety of older people's internal capabilities, as well as a commitment to reducing structural constraints.
A more fundamental critique of the capabilities approach is that it is essentially individualistic rather than recognising the fundamental importance of relationships between people (Held 2006, Lewis and Giullari 2006, Dean 2009). The capabilities approach acknowledges that human beings are at times dependent on others and that sympathy with those who lack independence is important. However, it regards dependency as a deviation from the norm rather than a basic human characteristic. In this sense, the capabilities approach stands in contrast to the ethics of care – indeed, Nussbaum was critical of the ethics of care, which she regarded as disadvantageous to women who might become locked into caring roles. Lewis and Giullari (2006) made the point that a person's freedom to be and to do what he or she has reason to value will depend to a large extent on the needs and actions of others. Thus, the capabilities approach sees individuals as independent first, while the ethics of care conceptualises the individual as dependent on others in order to achieve independence and autonomy.
A post-colonialist critique of Nussbaum's approach by Charusheela (2009) argued that, despite Nussbaum's claim that her list of capabilities stands up in any cultural context, it in fact represents a colonialist perspective with modernist assumptions embedded within it. She gives as her example the identification of literacy, which is linked to the list of capabilities in several ways and has emerged (p.64) as a key indicator of development. Drawing on Nzegwu (1995), Charusheela argued that within developing countries literacy has become institutionalised as a filter for access to a range of opportunities and that this leaves those who are illiterate further disadvantaged, whereas, in pre-colonial times literacy was not a prerequisite for a good quality of life or good standard of living. This is an important consideration in the context of international policy priorities for health that are linked to development strategies. It draws attention to the need to take account of local contexts, cultures and priorities.
Capabilities and healthcare policies
The capabilities approach is of particular relevance to policies on health because of its close association with social development. Ruger (2010) developed what she has termed a ‘health capabilities paradigm’, which places at its foundation the idea of health as capabilities. This idea embraces both function and agency. Function refers to what an individual is able to do or to be, while agency refers to the freedom to achieve this. In Ruger's paradigm, some capabilities are more central than others: disease, disability and malnutrition, for example, are central. In common with the public health approaches discussed above, this paradigm emphasises that policies for health, rather than health policies per se, are important for health equity. Hence, good health policies are a part of what is needed, rather than the whole picture, although achieving equity in capabilities is a key role of health policy specifically. Therefore the allocation of resources in health policies should be calculated so as to advance equity. Since measures of life expectancy represent one of the indicators of health capabilities, a core task of policy is to prioritise the avoidance of premature death and enable people to achieve the life expectancy that is known to be achievable. This priority inevitably means that resources should be targeted where life expectancy is lowest, which means that Ruger's paradigm is congruent with global movements for justice and equity that seek a redistribution of resources away from the wealthiest to the poorest.
However, by using life expectancy as an indicator of inequality and a basis for setting priorities, Ruger's paradigm also highlights ethical questions related to age. Ruger maintained that her approach ‘provides the basis for prioritizing health goods and services to individuals below the average life expectancy rather than to those above that level’. Ruger equivocates somewhat on the question of whether this actually constitutes age-based rationing. She argues that:
if a choice must be made due to resource constraints, efforts to extend life up to the maximum average life expectancy for all societies should be prioritised over extending life beyond that threshold level, but many societies will have the resources to devote to health beyond the threshold and should invest in extending the threshold further. (Ruger 2010: 201)
(p.65) Not age-based rationing per se, perhaps, in that age is not regarded as a basis for rationing in general, but her argument opens an ethical can of worms, since extending the threshold of life expectancy would inevitably draw resources away from efforts to reduce global inequalities in life expectancy and could have the effect of increasing them. Ruger pointed to evidence on inequalities in life expectancy between low-, middle- and high-income countries and argued that any society should aim to reach the maximum average life expectancy that is known anywhere (currently the average of almost 83 years in Japan would be the goal). How this would be achieved is a moot point. Should more resources go into life extension in affluent countries when global inequalities in life expectancy are so great? If resources are diverted from affluent to low-income countries, how would that square with older people's campaigns in those countries against age discrimination in healthcare? And what kind of actions would be seen to constitute life extension? Would it be confined to developments such as artificial organs or include more run-of-the-mill procedures such as pace-makers for people aged over 83? How would procedures (such as the removal of cataracts) that are primarily about improving quality of life but that can also have the effect of extending life expectancy be regarded? Ruger's line of reasoning demonstrates that even where a health policy framework can lay claim to moral legitimacy through its focus on justice and equity, there remain thorny ethical questions related to age. General principles for setting priorities for resource allocation cannot be separated from contemporary political and economic contexts which place limits on the resources available for healthcare.
A related set of questions is raised by Daniels (2008). Daniels developed what he termed a ‘prudential life-span account’, which he claims overcomes some of the moral questions associated with a view of rationing at a particular point in time between different age-groups. A life span account would mean that any individual would have equal access to healthcare throughout life but that this might mean reduced access in later life. He denied that his approach to justice in healthcare is a form of age-based rationing but claimed that it is a means of identifying how resources for health can be allocated to secure opportunities across the life span, while recognising that these differ at different stages.
There are several arguments against the approach taken by Daniels, summarised by Macnicol (2006) as follows. First is the argument that the individual rights of patients to treatment should be based on clinical need irrespective of age. Second, setting an age as the point at which an individual's rights to healthcare are reduced is arbitrary, given the differences in health between people of the same age. Third, it is morally and politically unacceptable to withhold treatment from anyone because that group has a poorer-than-average health outcome. Such a decision would not be made in respect of gender, ethnicity or class and therefore should not be made in respect of age.
Daniels protested that his approach does not make assumptions about the value of a life at different ages, nor does it judge that more social benefit would be derived from saving the young than the old, or that the old have a duty to the (p.66) young (or vice versa). He claimed that he was not arguing for age-based rationing as a general policy but saw his life-span approach as morally permissible in certain specific circumstances, when no alternative can be found. His conclusion is therefore similar to Ruger's, although Ruger argues that because there are sufficient resources in high-income countries to cover the cost of healthcare for all age-groups, such theoretical questions are unlikely to arise.
However, Daniels regards his ‘life-span approach’ as more urgent now than before because of the challenge of global ageing, which he suggested may be the ‘greatest public health problem of this century’ (2008: 165). This puts things into a somewhat different perspective because a global perspective on ageing calls for a global rather than national response. Hence, contrary to Ruger's conclusion, these are not theoretical but actual questions concerning the equitable distribution of global resources for health care. Daniels also questioned whether it would be prudent to trade off some acute services that might produce a short life extension, for care services that would improve the quality of life rather than extend it. From this perspective, age should be treated differently from other forms of discrimination, and it is quite possible that many older people would prefer not to have life extended if the quality of that life were poor. A crucial point is who has control over such decisions.
This chapter has taken a broad view of policies, considering the importance of policy action on health because of the moral imperative for action and because evidence demonstrates that policies make a difference to health in later life. Globalisation has generated new challenges that have affected national systems of healthcare and have contributed toward the consolidation of dominant discourses on health and care that are compatible with neoliberal policies. The global reach of neoliberal policies has exacerbated inequalities and these are experienced in old age in particular ways, including health and access to healthcare in later life. Differentials in power between actors in the policy process have resulted in a framing of older people's needs in particular ways and in establishing policy priorities that privilege economic interests over public health and well-being. Global policy debates reflect the difficulties of asserting the interests of relatively powerless groups and of pursuing the moral case for healthcare as a human right. The capabilities approach offers an alternative to the dominant economistic approach of global bodies such as the World Bank, but also presents age-related ethical questions that also highlight the relatively low social status of older people. Ethical debates frequently occur in the abstract, but the discussion of age-related resource allocation draws attention to policies and practices in the here and now. In relation to health equity, two points need to be emphasised: the first is that socioeconomic inequalities are not all about the poor but also about the rich and about the extent and nature of inequalities between rich and poor. The second point that flows from this is that arguments concerning age-related rationing in (p.67) healthcare actually focus not on older people in general but on those who cannot afford to pay for healthcare and rely on public provision. These ethical questions are as much about socioeconomic inequalities as they are about age.
Throughout this chapter, the policy process has been identified as a patchwork of actions and non-actions, a process of negotiation that creates a shared understanding and perspective on phenomena such as health and care. The next three chapters focus on the ways that these shared understandings apply in particular contexts of health and care. (p.68)