social determinants of health and primary health … determinants of health and... · social...

Social Determinants of Health and

Primary Health Care


Primary Health Care

Jean Yan, Coordinator Health Professions Networks Chief Scientist Nursing and Midwifery WHO, Scientist Nursing and Midwifery WHO, Geneva


Primary Health Care


Primary Health Care

Jean Yan, Coordinator Health Professions Networks Chief Scientist Nursing and Midwifery WHO, Scientist Nursing and Midwifery WHO,

Our world, Our health…Our world, Our health…

20

Primary health care: Now, more than ever | 12 August 20092 |


What are the

social determinants of health?

What are the

social determinants of health?


social determinants of health?social determinants of health?

Framework of the major c

of determinants

Framework of the major c

of determinants


r categories and pathways r categories and pathways

Under 5 mortality (per 1000

by wealth group

Under 5 mortality (per 1000

by wealth group

350

Poorest Less poor

50

100

150

200

250

300


0

50

Mali India Morocco

(Houweling et al, 2007)

1000 live births) 1000 live births)

Middle Less rich Richest

Morocco Peru Kyrgyz

Republic

Mortality over 25 years according to level in the

occupational hierarchy: Whitehall

Mortality over 25 years according to level in the


80

All c

au

se m

ort

ality

(p

er

1000 p

ers

on

yrs

) Admin Prof/Exec

20

30

40

50

60

70

All c

au

se m

ort

ality

(p

er

1000 p

ers

on

yrs

)


0

10

20

40-64yrs 65-69yrsAll c

au

se m

ort

ality

(p

er

1000 p

ers

on

yrs

)

years according to level in the


years according to level in the


Prof/Exec Clerical Other

65-69yrs 70-89yrs(Marmot & Shipley, BMJ, 1996)

Growing inequalities in global health: the widening gap in infant mortality experience


160

IMR 1960-1981 1981-1999

IMR: babies dying before age 1 per thousand born live

80

100

120

140

IMR decline

(Percent)

1960-1981 1981-1999

World 38.5 26.9

Sub- 19.2 15.1


40

60

Sub-Saharan

Africa (SSA)

19.2 15.1

(UNICEF, 2003)



160

IMR: babies dying before age 1 per thousand born live

80

100

120

140

World

SSA

40

60

1960 1981 1999

World

80

70

80

90 Infant mortality rate

(deaths per

54

3935 35 34 33

25 2522

20 1920

30

40

50

60


20 19

0

10

20

HA

I

BO

L

GU

A

DO

R

NIC

HO

N

PE

R

BR

A

EL

S

EC

U

ME

X

VE

N

Infant mortality rate

(deaths per 1,000 live births)(PAHO, 2005)

19 19 1819 19 1815 15 15 14

10 9 8 7 6 5

PA

R

VE

N

CO

L

PA

N

UR

U

GU

Y

BE

L

PR

CO

R

CH

I

US

A

CU

B

CA

N

Life expectancy of Indigenous PeoplesLife expectancy of Indigenous Peoples


Life expectancy of Indigenous PeoplesLife expectancy of Indigenous Peoples

(Bramley et al, 2005)

Percent Population with access to health care services

1996-1998

Ecuador (98)

29.9Bolivia (97)

Primary health care: Now, more than ever | 12 August 200910 | 0 20

Peru (96)

Indigenas No Indigenas

Percent Population with access to health care services

1996-1998

39.8

65.2

29.9

54.8

Access

to health

services

according

to ethnicity(IDB, 2004)

33.9

56.9

40 60 80

The widening trend in mortality by education in

Russia,1989-2001

The widening trend in mortality by education in

Russia,1989-2001yrs

wh

en

ag

ed

20

yrs

)(p

rob

ab

ilit

y o

f li

vin

g t

o 6

5 y

rs w

he

n a

ge

d


(pro

ba

bil

ity o

f li

vin

g t

o

The widening trend in mortality by education in The widening trend in mortality by education in

l, 2

00

5)

(Mu

rph

y e

t a

l, 2

Infant mortality in Brazil by race and mother's

education, 1990

Infant mortality in Brazil by race and mother's

education, 1990


Infant mortality in Brazil by race and mother's Infant mortality in Brazil by race and mother's

(Pinto da Cunha, 1997)

Social exclusion in health and environmentSocial exclusion in health and environment


•152 million people without access to safe

drinking water and basic sanitation

Social exclusion in health and Social exclusion in health and

drinking water and basic sanitation

InequitiesInequities

� Access to health care

1.3 Billion individuals globally with no access to health care

58 million of women ( out of 136M) who will give birth in a year, will receive no

medical assistance during childbirth and postpartum period – endangering lives of

mothers and babies

� Health outcomes

Life expectancy : 40 years difference between the high country

Child health (under 5 mortality rate) : vast difference exist within countries and individual cities

. Nairobi)

- below 15/1000 in high income group,


- below 15/1000 in high income group,

- 254/1000 in slums in the same city

In many cases – people who are well-off are generally healthier , have best access to the best care while the poor are left to take care of themselves

Billion individuals globally with no access to health care

M) who will give birth in a year, will receive no

endangering lives of

difference between the high –income and low-income , Norway – 12 years within

mortality rate) : vast difference exist within countries and individual cities - e.g

off are generally healthier , have best access to the best care while the poor are left to take care of themselves

Commission on Social Determinants of HealthCommission on Social Determinants of Health

� Improve daily conditions

- early childhood development, affordable housing, quality health

care services

� Tackle the inequitable distribution of power, money and resources

- responsibility for health at highest of government, coherence in policies across

sectors


sectors

� Measure and understand the problem and assess the impact of action

- monitoring system for health equity at all levels, sharing of new evidence

Commission on Social Determinants of HealthCommission on Social Determinants of Health

early childhood development, affordable housing, quality health

Tackle the inequitable distribution of power, money and

responsibility for health at highest of government, coherence in policies across

Measure and understand the problem and assess the impact

monitoring system for health equity at all levels, sharing of new evidence

Why emphasize social determinants?Why emphasize social determinants?

� Social determinants of health have a direct impact on health

� Social determinants predict the greatest proportion of health status variance (health inequity)

� Social determinants of health structure health behaviours

� Social determinants of health interact with each other to


� Social determinants of health interact with each other to produce health

Why emphasize social determinants?Why emphasize social determinants?

Social determinants of health have a direct impact on

Social determinants predict the greatest proportion of health status variance (health inequity)

Social determinants of health structure health behaviours

Social determinants of health interact with each other to Social determinants of health interact with each other to

(Dennis Raphael)

Social Determinants of Health

and Primary Health Care (Synergy)



� Much common ground – Both advance holistic view of health, with primary value of health equity

– The Declaration of Alma implicitly referred to the social determinants– The Declaration of Alma implicitly referred to the social determinants

� Different relationship to health systems and broader contex– Primary health care starts with the health sector and reaches out to other

sectors

– Social determinants discourse sees health sector as one of the social determinants

� Synergistic


� Synergistic – Report of the Commission and the World Health Report thus complement

each other, and the Commission's findings will inform WHO's revitalisation of primary health care





Both advance holistic view of health, with primary value of health equity

The Declaration of Alma implicitly referred to the social determinantsThe Declaration of Alma implicitly referred to the social determinants

Different relationship to health systems and broader contextPrimary health care starts with the health sector and reaches out to other

Social determinants discourse sees health sector as one of the social

Report of the Commission and the World Health Report thus complement each other, and the Commission's findings will inform WHO's revitalisation of

The Essence of Primary Health Care The Essence of Primary Health Care

"health is not a commodity that is given, "health is not a commodity that is given, "health is not a commodity that is given, "health is not a commodity that is given,

it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".

"health action should not be imposed from outside, "health action should not be imposed from outside, "health action should not be imposed from outside, "health action should not be imposed from outside,

foreign to the people, foreign to the people, foreign to the people, foreign to the people,

it must be a response of the communitiesit must be a response of the communitiesit must be a response of the communitiesit must be a response of the communities


to problems they perceive, supported by to problems they perceive, supported by to problems they perceive, supported by to problems they perceive, supported by

an adequate infrastructure" an adequate infrastructure" an adequate infrastructure" an adequate infrastructure"

ce of Primary Health Care ce of Primary Health Care

"health is not a commodity that is given, "health is not a commodity that is given, "health is not a commodity that is given, "health is not a commodity that is given,

it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".it must be generated from within".

"health action should not be imposed from outside, "health action should not be imposed from outside, "health action should not be imposed from outside, "health action should not be imposed from outside,

it must be a response of the communitiesit must be a response of the communitiesit must be a response of the communitiesit must be a response of the communities

to problems they perceive, supported by to problems they perceive, supported by to problems they perceive, supported by to problems they perceive, supported by

an adequate infrastructure" an adequate infrastructure" an adequate infrastructure" an adequate infrastructure" (Mahler, 1998)(Mahler, 1998)(Mahler, 1998)(Mahler, 1998)

Social determinants and Primary Health CareSocial determinants and Primary Health Care

Socio-political

determinantsdeterminants

Socio-economic

cultural,

environmental

conditions

Universal coverage

Quality health services

Meet population

health needs


PHCSD

Primary Health Care – the key to attaining acceptable level of health for all people

Social determinants and Primary Health CareSocial determinants and Primary Health Care

Universal coverage

Quality health services

Meet population

health needs

Equity in health

And

Well-being

Outcome

the key to attaining acceptable level of health for all people

The renewed PHC : 4 reform areas(WHR 2008)


Universal

Coverage

Leadership


Health care responsive to the expectations of the public

patient-centered, fair, affordable and efficient

reform areasreform areas

Service

Delivery

Public

PolicyPolicy

Health care responsive to the expectations of the public –

centered, fair, affordable and efficient

Progress can be achieved in short time periodsProgress can be achieved in short time periods

LIFE

In 7 years

ACCESS TOLIFE EXPECTANCY

56 yrs

ACCESS TOPOTABLE

WATER15m


48 yrs

Sri Lanka1946 - 1953

South Africa1994 - 2001

7m

Progress can be achieved in short time periodsProgress can be achieved in short time periods

POVERTY PRIMARY SCHOOL

In 9 years In 15 years

POVERTY

33%

PRIMARY SCHOOL ENROLMENT

89%

18%

China1990 - 1999

46%

Botswana1970 - 1985

Renewed PHC Renewed PHC

Progress is not a given: child deaths in


child deaths in 1975 and 2006

PHC’s Impact on Population HealthPHC’s Impact on Population Health

� PHC was a significant contributor to improved population health in OECD countries

1000010000

PYLL

5000

PYLL= Potential


Lost Premature Mortality and PHC Performance

In 18 OECD Countries,

1970 19800

PYLL= Potential

Years of Life Lost

(Measure of

premature mortality)


PHC was a significant contributor to improved population health in

High PC Countries

Low PC Countries

Macinko et al., 2003

Lost Premature Mortality and PHC Performance

OECD Countries, 1970-1998

1990 2000


� PHC reforms in Costa Rica significantly reduced mortality in adults and childrenand children

–– With reform

++ Without reform

… and adult mortality was


Trends in Under-5 Mortality in Districts With and Without PHC Reform

Costa Rica,

… and adult mortality was reduced by 4%


PHC reforms in Costa Rica significantly reduced mortality in adults

With reform

++ Without reform

For every 5 additional years after PHC reform, child mortality was reduced by 13%

Rosero-Bixby, 2004

Mortality in Districts With and Without PHC Reform

Costa Rica, 1985-2001

Health Systems with Strong PHC Are More EfficientHealth Systems with Strong PHC Are More Efficient

2

Prim

ary

Care

Score DK

UK

Stronger PHC

0

0.5

1

1.5

Prim

ary

Care

Score

NTH

CANAUS

SWEJAP

GER

SP

DK

FIN


0

1000 1500 2000

Per Capita Health Care Expenditures

BEL FRGER

Weaker PHC

Health Systems with Strong PHC Are More EfficientHealth Systems with Strong PHC Are More Efficient

USGER

2500 3000 3500 4000

Per Capita Health Care Expenditures

Starfield & Shi, 2002

USGER



Universal

Coverage

Leadership


reform areasreform areas

Service

Delivery

Public

PolicyPolicy

Now More than Ever : Nursing and Midwifery

Contributing to PHC


Contributing to PHC

� Universal Coverage: rural and remote areas

Source: Compendium of PHC studies : 38 teams from

remote areas

- Korea : utilization of nurses as community health practitioners

(CHP) – a total of 1850 , each responsible for 1500 – 2000

population. High satisfaction level from clients, improved health

status and decreased risk behaviors ( smoking and drinking

alcohol)

- Belize : Community – based psychiatric/mental health program

by trained nurse practitioners ( 10 months). Mental health

hospital – closed ( only six beds in acute hospital), .National

program staffed by nurse practitioners, only two psychiatrist

needed at national level..


- Bahrain – Adequate number of nurses and midwives trained to work

in the 4 tiered health system. Results: 22 health centers opened

through out the kingdom providing 12-24 hours of care. 2.8

million visits to health centers, increased diabetic visits, children

screening and immunizations

Now More than Ever : Nursing and Midwifery Now More than Ever : Nursing and Midwifery

� Service delivery

teams from 29 countries across 6 regions

- Yemen . Use of community midwives , increase in clinic attendance

- Botswana : nurses providing family health . Sustained intervention

for care of stroke patients resulting in families assuming

responsibility for own health

- Brazil : nurse – led care during deliveries … no maternal deaths

from pregnancy or childbirth

- Australia : Renal replacement therapy provided by nurse

practitioners, no medical officers needed

- Denmark : Care of the elderly provided by nurses . Health

assessment, activities of daily living higher, average bed days

lower, running costs for care- lower and life expectancy

increased by 30%


Contributing to PHC


Contributing to PHC

� Leadership

- Haiti – nurse –led care in ambulatory and clinic care ,

Source: Compendium of PHC studies : 38 teams from

- Haiti – nurse –led care in ambulatory and clinic care , resulted in gains in controlling malnutrition, malaria and TB

- China – nurse –led innovation in community health ( rehab and palliative care) : Nurse coordinated the care provided by multi-disciplinary teams – physiotherapists, nutritionists, optometrist, psychologist, music therapist , Results : improved aged persons ability to manage own well –being, decrease in hospitalization

- Canada – nurse-managed care for medically deprived communities. Nurses coordinate and supervise the work of volunteers, community partners, town councils, business organizations , referrals to physicians. . 16 sites, 24 nurse managers, 18,500 clients( 1 nurse per 800 clients, average of 8-25 clients per day)


25 clients per day)

Now More than Ever : Nursing and Midwifery Now More than Ever : Nursing and Midwifery

� Public Policy

- Oman : government commitment to increase access to basic

teams from 29 countries across 6 regions

- Oman : government commitment to increase access to basic health care brings long-term improvements, five year national health plan. Includes use of 1400 nurses, resulting in 85% increase in clinic visits, 1 PHC per 10,000 population, high immunizations coverage, fall in infant mortality rate ( from 170/1000 in 1970 to 16/1000 in 2006)

- Thailand : one PHC per every village, Nurses of the Community Program 33 educational institutions, 300 administrative organizations , 60 community hospitals. Provide essential services : maternal and children, elderly, disease surveillance and control, involve in local policy development to improve quality life. All graduates are working in their own or nearby community .

Contributions of Nursing

Health Care ( improved health outcomes)

Contributions of Nursing

Health Care ( improved health outcomes)

Skilled attendant at birth saves mothers and babies


Nurses – a valuable resource for global health

ng and Midwifery to Primary

( improved health outcomes)

ng and Midwifery to Primary

( improved health outcomes)

� Trained N& M can deliver approximately 80% of the health care and up to 90% of the pediatric care currently provided by primary care physicians at equal or better quality and care physicians at equal or better quality and lower costs

Under utilization of nurse practitioners in the US – cost the country as much as $ 8.7 B annually (Tournquist ' 97)

� Health Prevention and promotion– better use of existing preventive measures reduces the global health burden of disease by 70% (WHR 08)

a valuable resource for global health

The Health Workforce Nurses and midwives : The main providers of health care , urban and rural (improved access and coverage)

The Health Workforce Nurses and midwives : The main providers of health care , urban and rural (improved access and coverage)


Source:

The Health Workforce Nurses and midwives : The main providers of health care , urban and rural

The Health Workforce Nurses and midwives : The main providers of health care , urban and rural

Australia's Health Workforce. Productivity Commission Position Paper. Canberra, 2005.

Investments in Nursing an

Global Health

Investments in Nursing an

Global Health

� AMRO HRH target for 2015

1 : 1 ratio ( physicians and nurses)

Argentina, Nurse Emergency Act – 8M

� India

National Rural Health Initiative ( deve

advanced practice nurses)

� Zambia


� Zambia

nation-wide opening-up schools of N&M

Government's investment and continued support for the profession are

Vital in making PHC a reality

and Midwifery for Improved and Midwifery for Improved

M

evelopment of centers of excellence, use of

up schools of N&M

Government's investment and continued support for the profession are

Nursing and Midwifery ServiceMessages from the Director Generals

Nursing and Midwifery ServiceMessages from the Director Generals

� Nurses Lead the Way …that nursing could serve as a powerhouse of leadership in making PHC a reality.

� Nurses form the backbone of health systems around the globe and provide a � Nurses form the backbone of health systems around the globe and provide a platform for efforts to address the MDGs and achieve its targets. If we are to succeed in achieving the MDG targets and improving health systems performance, urgent action is needed to overcome the problems that seriously undermine the contributionsmake to the vision for better health for all communities.

� One of the indicators for MDG5 , is that health professional. This should be a midwife, doctor or nurse been trained to proficiency in managing normal pregnancy, birth and the period


been trained to proficiency in managing normal pregnancy, birth and the period immediately afterwards… ( Director- General for the Health Millennium Development Goals)

Nursing and Midwifery ServiceMessages from the Director Generals- WHO

Nursing and Midwifery ServiceMessages from the Director Generals- WHO

…that nursing could serve as a powerhouse of leadership in making PHC a reality. ( Mahler, 1985)

Nurses form the backbone of health systems around the globe and provide a Nurses form the backbone of health systems around the globe and provide a platform for efforts to address the MDGs and achieve its targets. If we are to succeed in achieving the MDG targets and improving health systems

is needed to overcome the problems that undermine the contributions nursing and midwifery services can

make to the vision for better health for all communities. ( Director- General 2002)

, is that every birth be attended by a skilled health professional. This should be a midwife, doctor or nurse who has been trained to proficiency in managing normal pregnancy, birth and the period been trained to proficiency in managing normal pregnancy, birth and the period

General 2008, First year report 2008, The Global Campaign

World of Global Health : Nursing and Midwifery

Services

World of Global Health : Nursing and Midwifery

Services


GoodPolicymakers' continued investment and support for N&M are vital

in making PHC a reality

Great

World of Global Health : Nursing and Midwifery World of Global Health : Nursing and Midwifery

LeadershipInnovationAction (partnerships Action (partnerships

and team work )

Policymakers' continued investment and support for N&M are vital

All TOGETHERAll TOGETHER


The VisionThe Vision

… the attainment by all peoples … the attainment by all peoples

of the highest possible level of health


… a state of complete physical, mental and social well- being and not merely the absence of disease

… the attainment by all peoples … the attainment by all peoples

of the highest possible level of health

WHO Constitution

… a state of complete physical, mental and social being and not merely the absence of disease


20



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