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-Policy and Programs (corporations and other businesses, government agencies, schools)
-Social Inequities (class, race/ethnicity, gender, immigration status, sexual orientation)
-Government, schools, CBOs



-Physical Environment (housing, land use, transportation, residential segregation)
-Behavior (smoking, nutrition, physical activities, violence)
-Parks and housing



-Disease and Injury (infections disease, chronic disease, injury)
-Mortality (infant mortality, life expectancy)
-Hospitals and clinics


Examples of Upstream Interventions for Physical Inactivity

Healthy Public Policy
-Tax incentives for physically active people
-Change environment to facilitate activity
-Insurance coverage for athletic facility membership


Examples of Midstream Interventions for Physical Inactivity

-Target communities to provide exercise facilities for seniors
-Training clinicians to do activity counseling
-Media campaigns to change norms re: Exercis
-Exercise training studies (almost downstream..)


Examples of Downstream Interventions for Physical Inactivity

-Clinical Exercise Interventions
-Patient Education


Liberal Paternalism

-Public institutions (i.e. gov) might nudge people in specific directions without eliminating freedom of choice to improve their lives
-possible and legitimate for private and public institutions to affect behavior while also respecting freedom of choice
-it tries to influence choices in a way that will make choosers better off, as judged by themselves
-people should be free to opt out of specified arrangements if they choose to do so
-Thaler & Sunstein, 2003
-Health systems can help nudge people toward healthier behaviors
-Default option is the healthiest but it isn't the only option/people have the choice to opt out (Fluoride in public water)


"Choice Architecture"

Menu labeling example
-Premise: individuals will make rational decisions based on nutrition info
-Patterns of behavior that may play a role in poor nutrition choices: tendency to stay with the usual, motivated by actions with immediate benefit
-"Choice architecture" refers to the framing or presentation of choice options
-Health systems can help nudge people towards healthier behaviors


Selective Primary Health Care

Focus on single disease interventions


Comprehensive Primary Health Care

Focus on prevention, provision of basic health services and addressing the overall disease burden in low-income countries


Improving Health Systems (General)

-Eliminate multiple vertical programs to more horizontal approaches
-Small reforms > big-bang reforms
-End goal of reform = improved health outcomes
-Performance-based financing possible if monitoring is adequate
-Capacity strengthening at all levels
-Health systems are based on theory, but inputs and outputs must be testable


Behind Doing the Behavior Associated with Improved Health Outcomes

Attitudes and beliefs about the behavior, perceived social norms about the behavior, perceived self-efficacy to (avoid) the behavior -> intention toward the behavior -> doing the behavior


National Health Model

(Beveridge): Universal health care coverage of all citizens by a central government; financed through general tax revenue; providers can be private or controlled by government.


Social Insurance Model

(Bismarck): Compulsory coverage funded by employer, individual and private insurance funds; production is controlled/owned by governments or private organizations; financed through employment taxes


Private Insurance Model

Employment-based of individual purchase of private health insurance; financed by individual and employer contributions; service delivery owned/managed by private organizations


Demand Side Health Care

Health care is like any other good; customers can exercise control over what services to buy and at what price; customers and suppliers are matched and suppliers have little control to induce demand therefore set rates of charge
South Korea and Singapore


Supply Side

Health care is a good that needs to be reasonably available to all and is an entitlement; government agencies control resources rather than allowing the market to determine cost/access to care
-Drawback: cost, and even if you provide healthcare it doesn't mean that they'll use it, there must be incentive/demand
former Soviet Union


Major Goals of Health Reform

-Controlling health costs and improving outcomes
-Universal coverage


Issues with the WHO Health System Framework (Service delivery, health workforce, info, medical products, vaccines & tech, financing, leadership/governance)

-Missing: people receiving care, gender/class (more social, upstream things)
-Very hard to measure outcomes and variables
-Very hard to effectively implement (multisectoral)


Leadership, Management & Governance in Afghanistan Case Study

-What is capacity development? How do we measure governance?
-Control group?
-Funding must be flexible, plans must change to adapt to on the ground conditions
-Money must go to what's needed, not necessarily what donors want to fund


MDGs vs. SDGs

-MDGs: Poverty, hunger, disease, unmet schooling, gender inequality, environment
-SDGs: Economic development, environmental sustainability, and social inclusion
-Crossroads: how do we spur econ development (Asia and Africa) but be sustainable and promote social inclusion?
-Family planning huge here


Why Do People Engage in Risky Behavior?

-Outcome expectations (instant gratification)
-structural, things in the environment, barriers (if we want people to eat healthier we should change the built environment)
-interpersonal influences (peer pressure)
-individual values and beliefs
-so how do we intervene? structural, interpersonal, community, individual


Chapter 1, Jamison, Good News and Bad News in Health

Good news:
-Life expectancy has gone up, (but measurement has changed-HIV)
-decreasing of health inequality
-Recognition that health -> economic welfare
have to have good health systems before econ dev (Sen)
Bad news:
-emerging infectious (HIV/AIDS) and non-communicable disease (heart disease)
-influenza pandemic threat
-preventable deaths due to malaria, TB, diarrhea
-new pandemic on the horizon
-need: surveillance, structural/environment changes, health edu (more of a downstream), WASH (one of the best investments), waste management,
-hand washing is a very downstream intervention, have to do it over and over again, even here where we have access to water and soap we have to post millions of posters and educate providers


Global Health Systems and Global Progress

Health: key to economic development, security, governance, and human rights (health not absence of disease)
-Increased investment in health (infectious disease to NCD)
-Focus on strengthening health systems
-governance: strong health system is a good indicator of low corruption
1. Human resources, financing, health facilities, technologies, commodities: how do they all inter- relate?
2. Demand side is essential and often overlooked, along with the supply side
3. Goal: improve health, but also the distribution of health and recognition of human rights
4. Health systems must perform


LIST for Health System Improvement

Technologies: appropriate interventions with accompanying technologies
Systems Design: human, financial, knowledge resources
Institutions: Ministry of Health, etc.
Leadership: strategic vision


Rebuilding Health Systems Post-Conflict

-Deaths in post-conflict zones: fever/malaria, diarrhea, respiratory infection, malnutrition (not violence)
-Indirect mortality (conflict related deaths not caused by violence): disruption of livelihoods, inadequate food and water supplies, destruction of health systems
-Conflict destruction of health facilities, flight of skilled/health care workers, disruption of commodities
-Humanitarian assistance fills a void during conflict: how do you move from relief to development programming?
-Huge inequity due to loss of income, life, livelihood, and property
-Resettlement huge issue
-Mental Health


Liberia Case Study

-Basic package of services free of charge (communicable disease control, emergency care, maternal and newborn health, mental health)
-Referral between primary, secondary, and tertiary facilities
-Increases in government spending on health


Universal Coverage Approach

-Equity in access to health services: those who need
them should get them (not just those that can pay for them)
-Quality of health services is good enough to improve health of those receiving services
-Financial-risk protection: cost of using care does not people at risk of financial hardship


How Do You Mitigate Financial Hardship?

-Workforce systems: ensure adequate numbers of trained workers, working in the right place and in safe working conditions
-Systems to buy and distribute drugs/supplies
-Fair financing systems to protect people from being pushed into poverty when they fall sick
-Health information systems that alert health managers to issues related to marginalized people


Knowledge-Action Gap

Health providers need the right info at the right time to make the right decisions


The US in Liberia Should:

1) Be patient. "Quick Wins" on health will become harder to achieve as the health system moves from an emergency response phase to a period of consolidation
2) Prioritize strengthening the health system. Investments in the health system and supporting structures are the best way to build sustainable health service in the long run
3)Increase support for human resources. Offering more scholarships for medical training