By: Adam Izzeldin, BPEH, MPHDepartment of International Health, TMDU

Martin Gulliford, Oxford Text Book of Public Health

Components

• Introduction and definition of healthcare • Concepts and values in healthcare• Efficiency-driven approaches• Problems and proposed solutions• Healthcare and population health• Investing in Health• Equity-driven approaches• Primary health care• Conclusion

‘What is the role of health services in improving population health?’

Introduction

• A number of efficiencyoriented strategies have been developed to increase the health gains from healthcare (needs, cost, technology, research , organization, delivery).

• Estimates suggest that healthcare now adds about 5 years to life expectancy at birth in high-income countries.

• About a quarter of the overall burden of disease in middle- and low-income countries could be prevented through implementation of packages of low-cost but highly effective interventions.

• Pro-rich inequity exists in accessing preventive medical interventions and specialist care for more serious illnesses

Definition of healthcare• Health system: All the activities whose

primary purpose is to improve or maintain health’ (Murray & Frenk 2000).

• Healthcare: Services provided to individuals or communities by agents of the health services or professions to promote, maintain, monitor, or restore health (Last 2001).

• Health services: Services that are performed by healthcare professionals, or by others under their direction, for the purpose of promoting, maintaining, or restoring health(Last 2001).

Aspects of health• Healthcare need: Capacity to benefit

from health care (Stevens et al. 2004)• Health improvement: Population health

benefit associated with intervention on the determinants of health.

• Health gain: Individual or population health benefit associated with healthcare intervention

• Health outcome: Change in individual or population health status associated with utilization of needed healthcare.

Concepts and values in healthcare• Healthcare represents a tangible expression

of the value placed on life and health.• healthcare is valued as a private good that

can be utilized to preserve or improve health• The risk of illness is unpredictable.• the costs of healthcare can be extremely

high. • Consumers may have limited information on

which to base choices.• Communities and national governments are

usually involved in arrangements for the delivery of healthcare

Dimensions for evaluation of health services

• Effectiveness: Extent to which a healthcare intervention achieves the intended outcome (Last 2007)

• Efficiency: Outcome achieved in relation to expenditure of resources (Last 2007)

• Equity: Fairness, or justice, in respect of treatment of different individuals or groups (Last 2007)

• Access: Extent to which services are available, can be utilized, deliver needed services, and achieve appropriate outcomes (Gulliford et al. 2002)

• Appropriateness: Relevance to need (Maxwell 1984)• Responsiveness: Social acceptability (Maxwell 1984)

Health expenditures and health services indicators at different levels of economic development around 2003-2004.source: world bank, 2006.

Country Grossnationalincomeper capita(2004)

Healthexpenditure(per centGDP)

Publicexpenditure(per centtotal)

HealthexpenditurePer capita (US$)

Doctorsper 1000population

Hospitalbeds per1000population

Lifeexpectancyat birthyears)

Low-income:Kenya 480 4.3 38.7 20 0.1 1.6 48Pakistan 600 2.4 27.7 13 0.7 0.7 65Middle-income:Albania 2120 6.5 41.7 118 1.3 3.1 74CostaRica

4470 7.3 78.8 305 1.3 1.4 79

Indonesia 1140 3.1 35.9 30 0.1 0.7 67High-income:Japan 37050 7.9 81.0 2662 2.0 14.3 82UK 33630 8.0 85.7 2428 2.2 4.2 79USA 41440 15.2 44.6 5711 2.3 3.3 77

Ideological and philosophical drivers• Governments or externally funded health services may not be available and

families necessarily make out-of-pocket payments to private providers or do not obtain healthcare.

• According to utilitarian doctrine, society in general and health services in particular should aim to maximize the health gains obtained across all individuals.

• Based on the concepts of human rights and social justice, equity may be regarded as a moral value which health services should strive to prompte (Braveman et al. 2001).

• Equity of access is an objective, but this is only to the extent to which it is considered acceptable to compromise efficiency.

• In other systems, such as the United States or in middle-income countries, private financing of healthcare through insurance or out-of-pocket payments may predominate.

• governments may facilitate access to basic health services for vulnerable groups such as the poor and elderly.

Underlying problems of efficiency-driven approaches

• Lack of effectiveness :(environmental influence not healthcare technology- medical errors and poor quality of care).

• Quality of care and variations in practice: (in Brazil 72% of women giving birth in private clinics had Caesarean sections, compared with 31 % in public hospitals).

• Iatrogenic illness and patient safety: (in US injuries caused by medical management occurred in 3.7 per cent of hospital admissions).

• Misallocation of resources and problems in service organization and delivery

Proposed solutions of efficiency-driven approaches

• Clinical effectiveness and health technology assessment :(evidence-based medicine-, technology assessment ,Cost-effectiveness analysis)

• Quality improvement, implementation research, and patient safety: (standards of good clinical practice, guidelines, invitations to educational meetings, provision of advice from respected peers, or the inclusion of prompts in the medical

• Systems redesign and service organization and delivery research: (workload, staffing levels, management strategies, organizational culture, transferring care from hospital to primary and community settings, utilizing staff with different types of training, or integrating specialist skills into primary care service delivery)

Healthcare and population health• Avoidable mortality: which known as a given

condition amenable to medical intervention, then there should be few or no deaths from the condition.

• Time-series analysis: If a health service intervention is implemented across a population over a short space of time, changes in trends in mortality or morbidity occur

• Modeling: concerning the incidence and prevalence of disease, the effectiveness of clinical interventions, and the expected coverage and quality of services in the population at risk

Healthcare and population health: High-income countries

• Medical care, including preventive and treatment services, contributed to add about 5 years additional life expectancy in the United States (Bunker et al. 1994)

• Cutler et al. (2006) estimated that cumulative increase in life expectancy during the period 1960- 2000 was 6.97 years with reduced mortality from cardiovascular disease accounting for 4.88 years (70%) and reduced rates of infant deaths accounting for 1.35 years (19%).

Measuring the effects of medical care. Estimated increases in life expectancy for the population from clinical preventive and curative services

Source: Bunker et al. (1994).

Examples: Condition treated

Relevantpopulation

Estimated gain in life years in those receiving the service

Estimated gain in life expectancy distributed across the US pop.Current Potential

Cervical cancerscreening

Adult women 96 days 2 weeks 1 week

Immunization fordiphtheria

All children 10 months 10 months 0

Cervical cancertreatment

Affectedwomen

21 years 2 weeks 1 week

Ischaemic heartdisease

Affected adults 14 years 1.2 years 6-8 months

Appendicitis Affectedindividuals

50 years 4 months 0

Trauma Affectedindividuals

24-38 years 1.5-2 months 3-4 months

Estimated overall gain from preventive and curative services

5 years 1.5-2 years

More evidences from high-income countries

• In US the estimated median survival of incident HIV cases after 25 years of age was 7.6 years in 1995-6, 22.5 years in 1997-1999, and 32.5 years in the period 2000-2005 attributed to (HAART) (Lohse et al. 2007)

• In UK evidence from randomized controlled trials to reduce breast cancer mortality through screening reported by (Gotzsche & Olsen 2000; Nystrom et al. 2002).

• About 53 % of the reduction in CHD mortality in Finland between 1982 and 1997 could be attributed to changes in risk factor levels, while 23% could be attributed to more effective medical care(Laatikainen et al. 2005

Healthcare and population health: Middle- and low-income countries

• Between 1967 and 1977, (WHO) organized a programme to eradicate smallpox, based on systematic delivery of smallpox vaccination.

• In 1967, there were up to 2 million deaths from smallpox annually, but there have been no naturally occurring cases since 1977.

• WHO established EPI programme which was estimated to reduce the overall burden of disease among children under 5 by 20-25 per cent.

• Between 1988 and 2005 an estimated 5 million people avoided long-term disability from Polio as a result of Global Polio Eradication Initiative.

Investing in Health• A healthy population is a major resource that can

contribute to stronger economic growth and improving standards of living (Bloom et al. 2004).

• On average, each 10% increase in life expectancy at birth in a country is associated with an increase in economic growth of 0.3-0.4% per year (Commission on Macroeconomics and Health 2001).

• World Bank's World Development Report for 1993 applied the tools of needs assessment, health technology assessment, and cost-effectiveness analysis to modeling potential solutions to a wider range of health problems in middle- and low-income countries in term of DALLYs.

Actual and proposed allocation of public expenditure on health in developing countries and potential health gains, 1990

Sources: World Bank (1993) and World Health Organization (2000).Package component Propos

edspending ($ percapita)

Estimatedactualspending1990

Reduction in disease burdenPe ｒ　cent

Millions of DALYs

Public health:Immunization (EPI), school health interventions, HIV/AIDS prevention, tobacco and alcohol control, nutrition and family planning education, STDs control, malaria prevention

5 1 6 77

‘Essential’ clinical services:Treatment of TB, maternal health and safe motherhood, FP, IMCI, treatment of STDs, malaria treatment, NCDs and injuries (selected early screening and secondary prevention)

10 4-6 19 225

‘Discretionary’ clinical services:All other services including low-cost-effectiveness treatment of cancer, cardiovascular disease, major trauma, neurological and mental health conditions

6 13-15

Total 21 21 25 302

Criticisms of Investing in Health• Technical criticisms of the methods used in

estimating the costs and outcomes of intervention in different conditions (no cases of wild-type poliomyelitis in the US since 1979, but polio control costs US$230 million annually).

• The lack of a well-developed strategy for implementation of essential packages of care (Cost-effectiveness analysis is useful in defining the set of interventions but has a more limited role in defining the systems that should be developed to implement them).

Equity-driven approaches• The unequal distribution of

determinants, especially income and education, fosters the development of inequalities in health

• Gini coefficients for countries generally fall in the range 0.2-0.6.

• Health systems should be organized so as to minimize inequalities in health and improve the health status of all groups in a population

Aspects of equity in health and healthcareParameter Definition Equity) Fairness, or justice, in respect of treatment of different

individuals or groups Horizontal equity

The extent to which equals are treated in proportion to their equality

Vertical equity The extent to which unequals are treated in proportion to their inequality

Equity in financialcontribution

The extent to which individual or household contributions are consistent with their capacity to pay

Equity in access tohealthcare

The extent to which there is a fair distribution of access to healthcare in relation to need, including equal access for equal need (horizontal) and unequal access for unequal need (vertical)

Equity in health

The extent to which there is a fair or just distribution of health among individuals and groups in a population

Effective coverage

The proportion of the population in need of an intervention that has received an effective intervention

Access to healthcare• In general terms, ‘access to healthcare’ is

said to exist when individuals or families can mobilize the resources they need to preserve or improve their health.

• Accessibility of healthcare judged by the availability and supply of health services, needs, obstacles to utilization include financial; physical; personal; or organizational barriers, as well as relevant to need and effective in addressing people's health problems.

primary healthcare• The Alma Ata Declaration 1978 promoted access to primary care,

with an emphasis on community participation and universality, as a means of facilitating equity in health.

• Institute of Medicine (1994) defined PHC as `Care which provides integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community`.

• The Cuban health system is frequently cited as one that has successfully adopted the primary care approach. In 2001, life expectancy at birth in Cuba was 76.3 years compared with 77.4 years in the United States, and the infant mortality rate was 7.2 per 1000 in both countries in spite of the great disparity in economic conditions .

Stop asking this but you could ask those.

Conclusion • Modern healthcare offers a wide range of

interventions of proven effectiveness that when implemented widely can be shown, at least indirectly, to contribute to improving trends in population health status in countries at different levels of economic development.

• Population health gains can be increased by investing resources in the most cost-effective interventions, by increasing effective coverage of the population, increasing quality of care, and optimizing systems for organizing and delivering care.

• Public health specialists should advocate principles of efficiency and equity through participation in processes of needs assessment, health technology assessment, quality improvement, and facilitating access to needed healthcare for all groups

Thank you for listening