Module 3 Flashcards
(204 cards)
1
Q
Age specific mortality declined between 1970 and 2010
A
Lozano et al 2013
2
Q
Under 5 mortality has decreased; v low in Western countries, still high in Africa, large declines in Latin America, Southern Europe and North Africa compared to Southern Africa
A
Rajaratnam et al 2010
3
Q
Adult mortality decreased 1970-2010 but period of no improvement in late 80s/early 90s (HIV and fall of Soviet Union caused drinking)
A
Wang et al 2012
4
Q
Adult mortality is high in SSA, men in former soviet union, increased in these areas
A
Wang et al 2012
5
Q
Adult mortality is higher in men because of RTAs, injuries, homicides, HIV/TB
A
Wang et al 2012
6
Q
Ischaemic heart disease was top cause of death in 1990 and 2010, followed by stroke and then COPD & LRTIs (COPD now 3rd, was 4th)
A
Lozano et al 2013
7
Q
HIV AIDS has massively increased as a cause of death
A
Lozano et al 2013
8
Q
Protein energy malnutrition has decreased as a cause of death, but still relevant as a contributor to other causes
A
Lozano et al 2013
9
Q
Chronic kidney disease and lung cancer have increased as causes of death globally
A
Lozano et al 2013
10
Q
Not a lot of change in YLDs per person from 1990 to 2010 but absolute YLDs have increased due to ageing population
A
Vos et al 2012
11
Q
Top YLD causes are lower back pain, major depressive disorder, and iron deficiency anaemia
A
Vos et al 2012
12
Q
Top causes of DALYs are ischaemic heart disease, LRTIs, stroke
A
Murray et al 2013
13
Q
DALYs per 1000 decreased globally 1990 to 2010, most noticeably in the developing world (but not Eastern Europe or Southern SSA)
A
Murray et al 2013
14
Q
1990; biggest death risk factor was childhood underweight
A
Lim et al 2013
15
Q
Blood pressure is now top mortality risk factor worldwide; decreasing in high and some middle income countries, stable in East Asia, increasing in SSA and south Asia
A
Lim et al 2013
16
Q
Top 3 risk factors for women worldwide: high BP, household pollution from solid fuels, high BMI
A
Lim et al 2013
17
Q
Top 3 risk factors for men worldwide: tobacco smoking, high BP, alcohol use
A
Lim et al 2013
18
Q
Alcohol is a leading risk factor for young adult mortality
A
Lim et al 2013
19
Q
Epidemiological transition has shifted risk factors e.g. higher bp
A
Lim et al 2013
20
Q
Smoking now becoming more important in low and middle income countries
A
Lim et al 2013
21
Q
Life expectancy in UK shows north-south gradient, varies with deprivation quintile (deprivation explains most of the variation)
A
Woods et al 2005
22
Q
Average US life expectancy has increased, but disparities have increased; CVD reductions halted in the poor and deaths due to homicides, HIV/AIDS, other NCDs increased in the poor
A
Ezzati et al 2008
23
Q
Patterns in global mortality are mostly due to epidemiological transition, increase in the total population number, and increasing average age
A
Lozano et al 2013
24
Q
MDG conditions only accounted for 42% years of life lost; the non-MDG deaths often affect young adults e.g. RTAs
A
Lozano et al 2013
25
Shift from ID risk factors to NCD risk factors globally
Lim et al 2013
26
Large burden of risk from not enough fruit, vegetables, nuts, omega 3's in diet; larger than people thought (but needs to be taken with a pinch of salt)
Lim et al 2013
27
Define health system & where this definition comes from
The sum total of all the organisations, instututions, and resources whose prime purpose is to improve health. It needs staff, funds, information, supplies, transport, communications, and overall guidance and direction. Needs to provide services that are responsive and financially fair, while treating people decently (WHO report 2000)
28
What are the fundamental objectives of a health system & according to whom
Improve the health status of individuals, families and communities
Defend the population against what threatens its health
Protect people against the financial consequences of ill health
Provide equitable access to people centred care
Make it possible for people to participate in decisions affecting their health and health system
WHO Report 2000
29
What are the 3 main goals of health systems
Promote good health
Responsive to expectations of the population
Fairness of financial contributions
30
Why is financial fairness important as an objective of health systems in LMICs
Because it is there that people can often end up in a 'catastrophic illness' scenario
31
What are the 4 main functions of health systems
Stewardship (overall system oversight)
Public and private health service provision
Health service inputs (managing resources)
Health system financing (revenue collection/risk pooling/strategic purchasing)
32
Define primary care & whose definition
Essential healthcare that is made universally accessible to individuals and families in the community; it is the first level of contact (Alma Ata 1978 - this isn't the whole quote)
33
Key features of primary care
First contact care
Longitudinal
Coordination of care
Comprehensiveness
34
Aspects of effective primary care (Starfield 2009)
```
Systemic level
Equitable distribution of resources
Progressive and universal financing
Low/no copayments
Comprehensive coverage
Clinical level
Access to first contact care
Patient rather than disease focused
Comprehensive and timely services
Coordinated care
```
35
What was the general gist of the declaration of Alma Ata
Governments have a responsibility for the health of their people; a main social target is to help people attain a level of health that will permit them to lead a socially and economically productive life. Primary care is key to attaining this target as part of development in the spirit of social justice
36
Sharp reduction in premature mortality in countries with stronger primary health care
Macinko et al 2003
37
GPs didn't order unnecessary gastroscopies/x-rays compared to private GPs or hospital doctors; therefore primary care is cost saving
WHO
38
Greater numbers of primary care physicians per capita associated with lower cost care in a study that examined the two in different US states
Starfield et al 2005
39
Individuals reporting a good primary care experience are more likely to self report better health
Starfield et al 2005
40
Individuals in states with high income inequality are more likely to self report better health if they have a good primary care experience
Starfield et al 2005
41
Primary care reduces racial/ethnic disparities; 2.5 times the benefit in mortality rates in black residents rather than white residents with the addition of 1 primary care doctor per 10,000 population
Starfield et al 2005
42
Criticisms of Starfield's research
Quality of primary care not well captured, mortality not morbidity, limited to OECD countries
43
Key challenges for health systems (WHO Now more than ever 2008/primary care)
Costs are growing
Health gains unevenly distributed
Increasing burden of NCDs
44
Primary care reforms set out in Now More Than Ever (WHO 2008)
Universal coverage reforms - ensure health systems contribute to health equity
Service delivery reforms - reorganise health services as primary care
Public policy reforms - integrate public health with primary care
Leadership reforms
45
Increase health are coverage to universal coverage by reducing cost sharing, including more services, and extending insurance coverage to all people
WHO report 2013 - Research for Universal Health Coverage
46
Programa Saude da Familia, Brazil - what does it do
Team of doctor, nurse, CHW covers 55% of the population. Proactive - knock on doorsand ask about health, health promotion, first point of contact/coordinates other services
47
Programa Saude da familia has led to decreases in infant mortality rate, post-neonatal mortality, and diarrhoea mortality
Macinko et al 2007
48
Programa saude da familia is “Associated with some of the most dramatic changes in public health ever experienced at a national level, far exceeding that required by the Millennium Development Goals”
Harris 2011
49
Determinants of child and adolescent mental illness in LMICs:
Poverty
Substance misuse
Family problems
Cousin marriages
Poor maternal health/child undernutrition
(and more)
Patel et al 2008
50
Components of a needs assessment for child and adolescent mental health
Epidemiology and risk factors
Review of current local service provision
Effectiveness of treatments available for children and adolescents
Views of carers and users of CAMHS
51
WHO guidelines for elaboration and management of national mental health programmes (1996)
```
Magnitude of the problem
Severity of the problem
Controllability
Available resource
Institutional commitments
Importance attached to the problem by those directly affected, their families, the professional sector, the public and policy makers
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52
What are the 3 main ways of doing a needs assessment
Epidemiological
Comparative
Corporate
53
Outline the epidemiological approach to needs assessment
Uses epidemiological research conducted either in another area or in that area nationally or internationally in order to estimate rats of the disorder in the population
Limited for 3 main reasons:
1)Information lacking on population numbers, and often high rates of illiteracy which makes surveys difficult
2)Seldom feasible o carry out such surveys specifically for needs assessment in local populations, so you usually have to extrapolate results from other surveys and the findings might not be relevant to your population
3)Unclear whether rates of disorder ascertained by epidemiological approaches translate into the needs for services or interventions and tells you little about what the community wish to prioritise
54
Outline the comparative approach to needs assessment
Basic premise: certain constellations of health and social characteristics can pinpoint areas whose individuals have increased vulnerability for a wide array of psychosocial and mental health problems
Can use:
Indirect measures e.g. birth weight, prematurity
Other proxy measures e.g. indices of social deprivation, number of children in employment
Information on service use and provision can be compared with other districts or national estimates
55
Outline the corporate approach to needs assessment
Synthesis of views from people or agencies involved in the care of the target population
Key informant technique - key informants are the people in the population who have a lot of contact with the target group and a lot of information about them
Limitations:
Might give incorrect information
Might not know the true burden
Trust issues
This is the easiest technique of the three
56
What are the negative impacts of conflict on public health and health systems?
Loss of lives, physical injuries, widespread mental distress (Iraq, Japan, Thailand)
Worsening of existent malnutrition (particularly among children) and outbreaks of communicable diseases (DRC, Haiti, Philippines)
IDPs and refugee populations are at particular risk (Bosnia and Herzegovina, Yemen, Mali)
Common, preventable diseases (e.g. diarrhoea) become life threatening (Syria, Darfur)
Chronic illnesses that can normally be treated lead to severe suffering and the dangers of pregnancy and childbirth are amplified (Somalia, Ethiopia, Nepal)
Effects are from Waters et al 2007 (not sure where the country examples are from)
57
Fragile states: health infrastructure is destroyed, or is not functional. Services are fragmented and ad hoc, differentially available depending upon where conflict-affected areas are located. Loss of human resources as medical personnel and management staff flee for their safety, are menaced or killed, or even if they remain are unable to provide services due to lack of medicines and ruined facilities
Brinkerhoff 2008 (USAID)
58
Global health is collaborative transnational research and action for promoting health for all
Beaglehole et al
59
What is GH governance
Governance in the health sector refers to a wide range of steering and rule-making related functions carried out by governments.decision makers as they seek to achieve national health policy objectives that are conducive to universal health coverage
Often thought of as including a notion of fairness, and justice
60
How has GH governance changed
GH governance - a revolution in the last 10-15 years
Increased global health actors
Increase in funding streams
Political profile raise din health and foreign policy
Global health challenges require inter-sectoral working e.g. smoking (not just health actors involved)
61
What are the four essential functions of the GH system
Production of global public goods
Management of externalities across countries
Mobilisation of global solidarity
Stewardship
62
Role/issues with multilateral and bilateral donors
Bring money and advice so can be better regarded in recipient countries than the WHO who just bring advice
Legitimacy: legal (bilateral contract) and results based
Accountability is to voters if it is a nation state donor e.g. DFID - need to show results so may be drawn to more ‘short term’ interventions
Often goes through multilateral assistance e.g. the World Bank rather than directly to recipient so some money (or a lot) may be filtered away through this process
Varying efficiency of intermediary actors - GAVI is ‘good value for money’, UNESCO is poor
Foreign policy can endanger health when diplomacy breaks down or when trade considerations trump health
Health can be used as an instrument of foreign policy to achieve other goals, and an integral part of foreign policy
Foreign policy can be used to promote health goals
Governance challenges:
Accountability to beneficiaries
Foreign policy issues as above
Spending money in a way that is effective (no diversion of funds) but does not undermine the health system
63
Role/issues with public private partnerships
Public-private partnerships (GAVI/Global Fund)
Can provide lots of funding - Global Fund is the main source of finance for programs to fight AIDS, TB and malaria
Partnership between state and non state actors
Many stages in the bureaucracy and they pay very high expat salaries
Vertical health programming comes at a cost - other things get neglected
Concerns raised about aid going to governments, such as corruption and lack of accountability
Governance challenges:
Continues vertical approach
Expensive transaction costs for donors having to deal with so many organisations and initiatives
Burden for ministries of health in recipient countries having to work with and report to a multitude of partners
Results in fragmented health programmes that compete
64
What is the legitimacy of civil society organisations
Legitimacy is mostly informal
Voice of the beneficiaries
Results based (effective and non-bureaucratic)
Moral (freedom from corruption)
And sometimes formal - may have a contract with the host country
65
What is the accountability of civil society organisations
Tend to self regulate in the absence of formal statutory framework
Many consider truly accountable to beneficiaries, some may be accountably to host governments or donors
1992 code of conduct gave a set of principles and ethical standards for organisations involved in humanitarian work
Sphere project to improve quality of humanitarian assistance and accountability of humanitarian actors to donors and affected populations
66
What is the governance challenges of civil society organisations
Balance between short term effectiveness and longer term destabilising/undermining of health systems
Balancing feasibility with fairness
Market wage > state wage -> risk of brain drain
Incentives to state employees to fulfil their state functions
Prioritisation proximity to beneficiaries means pressure to respond to all needs
67
What are the objectives of the humanitarian system
Save lives, alleviate suffering, and maintain human dignity during and in the aftermath of man made crises and natural disasters, as well as to prevent and strengthen preparedness for the occurrence of such situations
68
The humanitarian system comprises a multiplicity of international, national and locally based organisations deploying financial, material, and human resources to provide assistance and protection to those affected by conflict and natural disasters with the objective of saving lives, reducing suffering, and aiding recovery
Borton 2009
69
Humanitarian imperative says what
Aid is given regardless of the race, creed or nationality of the recipients and without adverse distinction of any kind
Aid priorities are calculated on the basis of need along
There’s lots more - but basically all about equality, respecting local cultures, not an instrument of government foreign policy, respect, etc
70
What is the sphere project
Launched 1997 to set minimum standards in core areas of humanitarian assistance
Aimed to improve the quality of assistance provided to people affected by disasters, and to enhance the accountability of the humanitarian system in disaster response
Major result - Humanitarian Charter and Minimum Standards in Disaster Response handbook
71
There are no clear rules [in the global health system] to stop powerful actors deciding the priorities more than less powerful actors e.g. Bill and Melinda Gates
Szlezák and Bloom 2010
72
What are the stages in creating an effective advocacy strategy?
```
Know the issues and know the solutions
Identify your stakeholders
Recognise, engage, and empower your networks
Identify appropriate strategies
Target your message
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73
Define Patient involvement
The active participation of patients and their carers in their own care and treatment. Patient involvement can be at the levels of service delivery, quality monitoring, and strategic planning (Kelson M 1997)
74
Define public involvement
The participation of members of the public or their representatives in decisions about the planning, design and development of their local health services (Kelson M 1997)
75
Define patient and public engagement
The active participation of patients, carers, community representatives, community groups, and the public in how services are planned, delivered and evaluated. It involves the ongoing process of developing and sustaining constructive relationships, building strong, active partnerships and holding a meaningful dialogue with stakeholders (PPE Toolkit for WCC 2009)
76
Define patient empowerment
The mechanisms enabling patients to gain control and make choices in their health and health interventions (O’Cathain 2005)
The act or process of conferring authority, ability or control (Farrel and Gilbert 1996)
77
Define patients' rights
A legal basis for claims on the system - a Patient Charter is a weak form of such rights, and may be supported by some form of ombudsperson
78
What are the effects of patient and public participation on health systems
Results in better responsiveness of the system to health consumers’ views and preferences
Participation is essential for patients in managing their own health
Public engagement in community organisations is essential to the community’s health and care provision (Lister 2007)
79
What are the 6 domains of patient engagement
(Picker Institute Europe 2010)
Improving patient experience
Building health literacy
Choosing appropriate treatment
Supporting people to manage their own conditions
Promoting health and reducing health inequalities
Engaging the public in services to make them responsive and accountable
80
involving patients:
Contributed to changes in services’ provision across a range of different settings
Can result in the production of new or improved sources of information for patients
Can result in new or more accessible services and prevent the withdrawal of existing provision
Crawford et al 2002
81
Effective strategies to strengthen patient engagement improve....?
```
(Coulter and Ellins 2007)
Health literacy
Clinical decision making
Self care and self management in chronic diseases
Patient safety
```
82
Participation is generally seen to be good for society
Brodie et al 2009
83
What is disruptive innovation
innovations that may compromise performance, but in doing so significantly reduce price and/or improve access. May create entirely new markets and disrupt previous ones
84
What are sustaining innovations
improve the performance of existing technologies, products, or processes
85
What are frugal innovations
specifically designed to meet the needs of low-income users and extend access to the excluded
86
Features of a frugal innovation
Simple - low cost, easy maintenance, adaptable
Social - user centric, community-driven development
Clean - efficient re-use of existing resources and local materials
Lean - elimination of supply chain waste
87
technology for health e.g. sanitation, agricultural equipment, road safety technologies are more important and are likely to have a bigger impact than health technologies like drugs or devices
Howitt et al 2012
88
Why do we need innovation
Traditional models of healthcare delivery are poorly suited to modern diseases e.g. NCDs
In developing countries, extending access requires new ways of doing this
Financial resources are finite and, in most mature health systems, highly constrained
89
thinks that co-mingling business models has retarded progress, and that some things should be given over to algorithms and task shifting rather than trying to offer all services in one place
Christensen
90
How can organisations increase rates of diffusion
Alter individuals perceptions of innovations (reduce the psychological aversion to uncertainty)
Develop a permissive organisational culture (don’t penalise failure)
Deploy those who are predisposed to adopting innovation
91
Characteristics of people who do/don't adopt innovations
```
(Berwick 2003)
Innovators
Early adopters
Early majority
Late majority
Laggards
```
92
Innovation: There is often a ‘tipping point’ past which you can’t stop a change spreading
Berwick 2003
93
What is social epidemiology
Study of the social distribution and social determinants of states of health - explicitly investigates social determinants
Explores how social conditions give rise to patterns of health and disease in individuals and in populations
Aims to produce multi level models that interrelate key determinants at the individual, social group, network and population level - it produces a network as a real-world approach
94
How is social epidemiology different from traditional epidemiology
traditional epidemiology deals with biological characteristics and risk factors, with an individual focus - sociodemographic factors are treated as confounders rather than explanatory variables
Social epidemiology explores how social conditions give rise to patterns of health and disease in individuals and in populations
95
What is the ecosocial approach to health
Aims to integrate social and biological reasoning and a dynamic historical and economical prospective in multi level frameworks that explain population distributions of disease and social inequalities in health
96
What does the ecosocial approach develop concepts of
Embodiment
Pathways to embodiment:
Societal arrangements of power and property
Constraints and possibilities of our biology
Cumulative interplay of exposure, susceptibility and resistance
Accountability and agency
97
Give 3 examples of social factors leading to disease
High risk of hypertension in African Americans not explained by genetics/behaviour/standard risk factors - due to racism (Krieger 2001)
10 sociodemographic variables account for 71% of variation in syphilis rates between US counties - due to lack of minority representation, poor clinic/community links (Thomas et al 1999)
Microfinance for AIDS and gender equality (IMAGE)
98
What are the underlying 4 dimensions of food security
```
Lack of food
No availability
Lack of resources
No access
Barriers to utilisation
No ‘good’ use of the acquired food
Don’t know how to combine foods for optimum nutrition
Changes in time
No stability in availability, access and use
```
99
“Gender is a social norm, not a reflex of biology, though it’s a structure that relates to, and organises, human reproduction”
Connell 2012
100
Gender norms can lead to patterns of violence, which may determine access to services, and therefore HIV transmission (lots of interlinked pathways - this is just one)
STRIVE consortium 2013
101
Age differentials in partner selection and is related to power over condom use (HIV)
(Gregson et al Lancet 2002)
102
masculinity affects male and female access and adherence to ART
e.g. men diagnosed at lower CD4 counts and more likely o initiate ART at WHO stage IV disease
Skovdal et al 2011
103
Define patient centred medicine
Understanding the patient as a unique human being (Edith Balint 1968)
Represents a style of consulting where the doctor uses the patient’s knowledge and experience to guide the interaction (Byrne and Long 1976)
Where the physician tries to enter the patient’s world to see the illness through the patient’s eye (McWhinney 1989)
Closely congruent with and responsive to patient wants, needs, and preferences (Laine and Davidoff 1996)
104
Who introduced concept of patient centred medicine
Michael Balint
105
What are the benefits of patient centred medicine
Improves health outcomes as well as doctor and patient satisfaction
Greater efficiency of health care - fewer referrals and investigations (Stewart 1995)
Better self management (Little)
Better adherence to treatment (Mead and Bower 2000)
Fielding - shared decision making is especially important for long term conditions; they can improve their healthcare more than we can as doctors
106
What are the challenges to patient centred medicine
Regulation
Cost
Rationing
More guidelines, monitoring, and formal channels of complaint
107
What is globalisation?
An elimination of barriers to trade, communication and cultural exchange. The theory: worldwide openness will promote the inherent wealth of all nations
Process in which economic markets, technologies, and communication patterns gradually exhibit more ‘global’ characteristics and less ‘national’ or ‘local’ ones (OECD 1997)
The closer integration of countries and peoples of the world which has been brought about by the enormous reduction of costs of transportation and communication, and the breaking down of artificial barriers to the flows of goods, services, capital, knowledge, and people across borders (Stiglitz 2003)
108
What are the different types of globalisation
Political
Environmental
Cultural
Economic and political
109
What was the washington consensus
John Williamson, 1989
Set of specific economic policy prescriptions
Macroeconomic stabilisation - austerity
Economic opening to trade and investment
Expansion of market forces within the domestic economy
Privatisation, trade liberalisation and deregulation
10 rules for developing countries: one size fits all
110
What are the mechanisms of globalisation
Liberalisation (neo-liberalism)
Relaxation of restrictions, deregulation, market reform, ‘freeing up’ markets
Privatisation
Of previous public services, state-run organisations and others
Macro-stability
Create a climate to attract investment which is supposed to create growth
Low inflation, unemployment
Ideology
Viability and legitimacy of the economic order
111
Define discrimination
The process by which a member, or members, of a socially defined group is, or are, treated differently (especially unfairly) because of his/her/their membership of that group
This unfair treatment arises from socially derived beliefs each group holds about the other and patterns of dominance and oppression, viewed as expressions of a struggle for power and privilege
112
Define embodiment
“A concept referring to how we literally incorporate, biologically, the material and social world in which we live, from in utero to death” Krieger 2001
113
Give 3 studies that show how discrimination affects health
Syphilis - Thomas et al 1999
Gender violence in Zimbabwe - Njovana and Watts 1996
Sexual risk in African American, Latino and white gay men and MSM Rhodes et al 2012
114
Define health
state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (WHO)
115
Define illness
psychological; the subjective state involving the experience of symptoms
116
Define disability
“an umbrella term for impairments, activity limitations, participation and effect of environment” (WHO)
UN Convention on the rights of people with disabilities:
Disability is an evolving concept… that results from the interaction between persons with impairments
And attitudinal
And environmental barriers
That hinders their full and effective participation in society on an equal basis with others
117
Define biomedicine
universality of biology and separation of body and mind
The model is:
Relatively recent
Identify abnormality and label disease
Treatment aims to cure
Regard body as a machine
Specialisation suggests a series of parts
Denotes a ‘set of procedures in which all doctors are trained’ which are applied to find the remedy and treat if this is possible (Laing 1971)
118
Why is the application of biomedicine not straightforward
people need to actually use it
85-90% citizens ‘self medicate’ even in countries claiming widespread primary care provision
Study in Madhya Pradesh, India
67% health care providers had no medical qualification (Wijesinghe et al 2012)
Adherence to checklists and related best practices differs little between trained and untrained doctors (Das 2011)
119
Ebola: In this village’s case, delays to seek care are not related to geographical isolation but ailments are believed to be self-righting, and risks/financial demands of seeking help
(SMAC Program, DFiD, 2015)
120
“Once Ebola is experienced, the true cause of infection readily becomes apparent, and people are ready to accept the constraints they and health workers deem necessary to remove the disease
(SMAC Program, DFiD, 2015)
121
Uganda: Once an illness is identified as a killer epidemic (gemo), the family is advised to quarantine or isolate the patient, survivor should feed and care for the patient if possible etc etc
Hewlett and Amola 2003 - Uganda)
122
Most persons involved in the outbreak were familiar with all three explanatory models [including biomedical] and did not see them as contradictory
(Hewlett and Amola 2003 - Uganda)
123
Effectiveness of techniques used to eradicate infections diseases, e.g. sleeping sickness, validated new biomedical theories about the microbial cases of epidemics but fed rumours that Europeans were cannibals using human samples to perform macabre experiments
(Lock and Nguyen 2013)
124
[Since publication of articles about menopause symptoms in Japan] took qualitative data, surveys, and biological samples in Japan - the prevalence of hot flushes had nearly doubled to 22%
Melby (2005)
125
“Differences in individual bodily experience at the end of menstruation are not adequately explained as due to cultural “beliefs” but rather must be understood as local entanglements among historical and cultural activities, techno-scientific interventions and the biology of individual ageing”
Lock & Nguyen 2013
126
Overall, there is global variation in symptoms experienced at menopause that do not correlate with endocrine changes
Lock & Nguyen 2013
127
“Medicalisation describes a process by which non-medical problems have become defined and treated as medical problems, usually in terms of illness or disorders”
(Conrad 1993)
128
Irving Zola's view of medicalisation
focus of power in modern society
Institution of social control
“Nudging aside, if not incorporating, the more traditional institutions of religion and law”
“Making medicine and the labels “healthy” and “ill” relevant to an every increasing part of human existence”
129
Ivan Illich's view of medicalisation
a source of clinical, social and iatrogenesis
“The medical establishment is medicalising life itself”
Clinical iatrogenesis
Social and cultural iatrogenesis
Loss of capacity to accept death and suffering as meaningful aspects of life
Sense of being in a state of ‘total war’ against death at all stages of the life cycle
A crippling of personal and family care, and a devaluing of traditional rituals surrounding dying and death
A form of social control in which a rejection of “patienthood” by dying or bereaved people is labelled as a form of deviance
130
Foucault's view of medicalisation
thought of it not as a simple exercise of social control but as a set of relations, of power/knowledge
131
Disease mongering is the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments
(Moynihan R 2006)
132
69% of the 141 members of the DSM-5 task force report having ties to the pharmaceutical industry
(Cosgrove 2012)
133
Who are the migrants to the UK
Mostly non-EU (about double the EU migration)
12% of the total UK population
Students are the dominant incoming group
Dramatic drop in asylum applications
Sizeable and increasing population of irregular “illegal” migrants
Entered by avoiding immigration/using false documents, overstayers
Failed asylum seekers - no entitlement to support, no right to work
Poor health status and widespread destitution
75% applications refused in 2010; on appeal 27% are accepted
“Invisible people” - failed asylum seekers, those trafficked, etc - About 725,000 in the UK (>1%)
134
What is the burden of infectious disease in migrants
73% of TB cases
London has the highest rate among capital cities in Western Europe
Almost 60% of newly diagnosed cases of HIV (African/new migrants)
80% of hepatitis B and 50% hepatitis C cases
Most diagnosis of foreign-born active TB are in new migrants in their first 5 years after arrival; public health would say we should encourage people to come forward for screening and treatment ASAP but the government wants to tighten up access to the health system
The UK’s highest late diagnosis of HIV is in African migrants
135
What impact do migrants have on the health system
Charing Cross A&E - 64% of those walking in the door were ‘new migrants’ who were in their first 5 years
May be that low GP registration rates -> using A&E as a source of primary care
Hammersmith Hospital - again 64% migrants self referring through A&E, again with low GP registration rates
Low numbers of migrants in primary care
Some have complex health and social needs
Translation/interpreters and administrative burden
No evidence of large-scale health tourism
136
Findings from Newham about migrants?
the burden f overseas visitors was only about £3000/month on each practice, which may be more than the cost the chase people and up get the money back (about £30 pp); and Newham is the most ethically diverse borough in London so this may be much higher than the burden elsewhere
Some shortfalls of this evidence -relied on GP recall, didn’t talk about finances brought in by migrants, or GP vs A&E costs
137
Stats about health tourism to the UK
Conflicting figures on how much this costs the UK - estimates are between £70-£300 million
There are about 63,000 people per year in the UK who went abroad for health issues; 52,000 came into the UK
“Threat of health tourism is a myth” Hanefield et al BMJ 2013
Less than 2% of users at a London NGO clinic came to the UK for personal health reasons and 50% had no understanding or knowledge of the healthcare system
DOW clinic: 90% of 1450 patients not registered with a GP and 20% deterred because of fears of immigration control (DOW: The Truth About Health Tourism 2013)
Average time before accessing healthcare is >3 years
It is highly profitable - £219 million of income into the UK
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Financial impact of asylum seekers not on the health system
2012: pending asylum cases and stateless persons make up just 0.33% of the population
Only 0.5% of benefit applications
Often put in grotty, ‘hard to let’ properties
Cash support is £36.62 per person per week; this is £5.23 a day for fod, sanitation and clothing and most payment is in the form of vouchers
139
How many/what cost do British people think asylum seekers have
2009 poll: 44% of British people thought that 100,000 asylum seekers had been accepted
33% believed 25,000
Real figure was 4,175
2009 poll: 90% worried about abuses of the system and 71% believed too many people were accepted
However, 89% believed that providing refuge to those in danger was an important British tradition
140
Do GPs think there is enough provision for immigrants?
>50% of GPs think provision for immigrants is too generous (Pulse survey 2013)
141
Human rights arguments for treating migrants
UK violates the International Covenant on Economic, Social and Cultural Rights guaranteeing everyone to the highest attainable health (International Bill for Human Rights ratified by the UK in 1976 and Human Rights Act 2000)
Other rights:
To life
Not to be subjected to torture (many live in squalor)
Right to privacy and family life
Right to dignity, fair treatment
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“We need to ensure that steps taken to defend the NHS against malicious misuse do not deprive the vulnerable of the help that they need - arguably to do so would be to kill the spirit of the NHS whilst striving to defend it”
“Furthermore it runs the very real risk of putting doctors and other medical staff in danger of feeling obliged to ignore their Hippocratic Oath - we cannot allow doctors to feel morally and legally compromised when faced with vulnerable people in need of treatment”
DEMOS Do No Harm Document (2014)
143
Professional codes encouraging treatment for migrants
GMC: duty not to discriminate on any grounds
RCGP: Based on the principle that GPs should not be expected to police access to healthcare and turn people away when they are at their most vulnerable
WMA declaration on the rights of the patient: “Every person is entitled without discrimination to appropriate medical care… physicians and other persons or bodies involved in the provision of healthcare have a joint responsibility to recognise and uphold these rights. Whenever legislation, government action, or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or restore them”
144
“We know that the first duty of health professionals is to treat the individual patient in front of them but they also have a responsibility to protect the NHS for the future and ensure best use of its resources”
- Sir Keith Pearson DoH Independent Advisor for recovery of NHS costs from overseas visitors and migrants (2013)
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Vulnerable migrants:
Physical health needs tend to reflect endemic spectrum of disease in their home country
Psychosocial distress may cause somatising presentations
Psychological health: depression, anxiety, agoraphobia, exacerbated by conditions in the host country
Most impoverished on arrival, and social isolation is common
Taylor 2009
146
Vulnerable migrants: “Children face a double burden of lack of provision of current basic needs and future loss of opportunity through lack of education, socialisation, and normal development”
(Taylor 2009)
147
Asylum process can be highly stressful and bewildering/traumatic for children
Children’s Society report 2012)
148
“The evidence that so many refused asylum seekers risk destitution, rather than going back to their place of origin, reveals both the desperateness of the situations they have fled, and sometimes lack of knowledge about accessing section 4 support”
British Red Cross 2010 Not Gone, but Forgotten report
149
What did classical economists believe about poverty
Social phenomenon - lack of ‘historical societal subsistence’ = a basic bundle of goods and services that allow people to actively participate in the society in which they live
150
What did Adam Smith think about poverty
Different societies, different subsistence; each society has a different ‘minimum bundle’ even in the same time period
151
What did neoclassical economists think about poverty
Individual circumstances and behaviour matter - poverty is identified with a shortfall in consumption (or income, wealth, or assets) from a given poverty line which can be fixed in various ways
This is the standard conceptualisation of poverty used by the World Bank’s estimates of the world’s poor and National Statistical Offices
152
Why does poverty matter?
Intrinsic
Matter of basic human rights and social justice
Instrumental
Less likely to accumulate ‘human capital’ i.e. education, health that is key for advancing countries’ economies
Less likely to invest in higher risk/more remunerative activities i.e. poverty traps
Intrinsic and instrumental:
Intergenerational transmission of poverty - children born in poor households are more likely to be poor themselves, perpetuating the poverty cycle across generations
153
Poverty measures
focus on the part of a population that falls short of some minimum level (often called the poverty line, in one or several indicators) and provides a value that summarises deprivation in the society
154
Inequality measures
consider the entire distribution (in one or several indicators) and provide a value that summarises the inequalities between every person/group and the rest of the population/groups
155
Wellbeing measures
consider the entire distribution of achievements (in one or several indicators) and provide a value that summarises the well-being of the entire population
156
Difference between poverty measures and poverty models?
Poverty measures assess the extent of poverty in population
| Poverty models model the socioeconomic factors that are associated to a higher risk of poverty
157
“It is clear that without solid information we cannot measure where we are and what needs to be done with respect to the MDGs or in other domains. If the world cannot get the right numbers, it cannot come up with the right solutions” -
Paul Cheung
158
If you can’t measure it, you can’t improve it
(Lord Kelvin)
159
Measurement and policy issues are inseparable
(Ravallion 1992)
160
What were Sen's 3 steps to measuring poverty
Choice of the space of the analysis
Identification
Aggregation
161
What is the headcount ratio
q/n (q = number of people under the poverty line, n = total population)
What is the proportion of poor people in the population?
162
What is the poverty gap
I = (z - µp)/z (z = poverty line, µp = average income of the poor)
What is the average depth of poverty amongst the poor in the population?
163
What are the World Bank's poverty measures
$1.25 and $2 a day measure
Headcount ratios, defining extreme and moderate poverty
Measured in international dollars that are adjusted for the fact that people in different countries face different price levels (Purchasing Power Parity)
164
What is the HPI
Developed by Anand and Sen in 1997
Measures the deprivations in the there basic dimensions of human development captured in the HDI
Long and health life
Probability at birth of not surviving to age 40*100
Knowledge
Adult literacy rates
Lack of access to overall economic provisioning
% population not using an improved water source
% under 5 that are below weight for age
HPI has ‘weights’ for the different indicators which you can adjust; as a increases towards infinity, the HPI tends towards the value of the dimension in which deprivation is greatest
However, only macro data - no decomposability in sub-regions/groups of interest
165
What is the MPI
Developed by Alkire and Santos (2010) to replace the HPI
Aim was to measure deprivations in “rudimentary services and core human functionings”
Captures the number of households which experience multiple deprivations at the same time (acute poverty)
Portrays the composition of poverty for these households i.e. in which dimensions or indicators they are deprived
Also decomposable by geographic location (in order to show variation in poverty within countries) and subgroups of the population
There are 10 indicators of poverty with equal weights between and within indicators; a household is considered poor if it is deprived in 30% of weighted indicators:
Education
Years of schooling
School attendance
Health
Child mortality
Nutrition
Standard of living
Electricity
Drinking water
Sanitation
Flooring
Cooking fuel
Assets
166
Outline the SAPs
Loans granted to developing countries, but with conditions of structural economic reforms attached, known as ‘conditionalities’
Based on free market principles
Short-term stabilisation measures e.g. public sector wage freezes
Long-term adjustment measures e.g. export promotion
167
What was wrong with SAPs
Contributing to dependence and only addressing economic problems superficially
Women and children bore disproportionate burdens from SAPs
Poverty increased after SAP implementation
SAPs were then replaced by poverty reduction strategies as part of the HIPC initiative
168
Outline the HIPC initiative
Replaced the SAPs
Provides debt relief and low interest loans to cancel or reduce external debt repayments to sustainable levels to countries with high levels of debt and poverty
Assistance is conditional on national governments of the countries meeting a range of economic management and performance targets
Country driven
Meant to recognise the multidimensional nature of poverty, and to take a long-term perspective
Results- and partnership-oriented
169
What is wrong with the HIPC approach
The debt-to-export and debt-to-government-revenues criteria were said to be arbitrary and restrictive; as evidence some people said it took too long for countries to actually get debt relief
6 year program too long and too inflexible to meet the needs of debtor nations
IMF and World Bank didn’t cancel any debt until the completion point, so countries were still under the burden of their debt payments while they struggled to institute structural reforms
ESAF conditions often undermined poverty reduction efforts e.g. privatisation of utilities meant poor people couldn’t pay
Said to be designed by creditors to protect creditor interests, leaving countries with unsustainable debt burdens even upon reaching the decision point
Some say it is a cosmetic change only
Fundamental principles of neoliberal lending haven’t altered
170
What are PRSPs
Invented by the World Bank and the IMF to ensure that debt relief money would go to poverty reduction and to respond to evidence of weaknesses in relations between poor countries and the Bretton Woods institutions - especially a lack of poverty focus and no country ownership of reforms
Five core principles:
Country driven - involving broad based participation by civil society and the private sector in all operational steps
Results oriented - focusing on outcomes that would benefit the poor
Comprehensive in recognising the multidimensional nature of poverty
Partnerships oriented - involving coordinated participation of development partners (bilateral, multilateral, and non-governmental)
Based on a long term perspective for poverty reduction
Should build on existing national plans when possible
Intended to be the basis for all foreign aid to poor countries - HIPC countries have to produce a PRSP as a basis for concessional lending
Conditions still attached to loans
171
What's wrong with PRSPs
Even with an approved PRSP, some countries have difficulty following through with the intended policies and so don’t reach the outcomes - large factor in this is the misallocation of budgetary funds that were intended to go towards the PRS
Increases aid conditionality even though it was supposed to undo the imposition of policy conditions from the outside by increasing country ownership
It is a process conditionality and not a content conditionality - donors are only monitoring if they have made a PRSP and if it was in a participatory way
However, donors couldn’t impose content effectively before so why would they be able to impose process now
Donor’s attempts to influence domestic policies have been shown not to be successful int he past
International financial institutions do evaluate PRSP content, not just the process
Clear definition of what civil participation means hasn’t been laid out by the IMF or the World Bank
Participation that involves the population working with the government to develop specific strategies to reduce poverty doesn’t exist in any developing country, which seems to suggest that the WB and IMF approve PRSPs regardless of fulfilling this condition
172
What are the 6 WHO building blocks of a health system
```
Service delivery
Health workforce
Information
Medical products, vaccines and technologies
Financing
Leadership/governance
```
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What comes under the 'service delivery' building block
Deliver effective, safe, quality person and non-personal health interventions
When and where needed
Minimum waste of resources
174
What comes under the 'health workforce' building block
responsive, fair and efficient to achieve the best health outcomes (given available resources and circumstances)
sufficient numbers and mix of staff
fairly distributed
competent, responsive & productive.
175
What comes under the 'health information' building block
production, analysis, dissemination & use of reliable and timely information on health determinants, health systems performance and health status.
176
What comes under the 'medical products, vaccines, and technologies' building block
equitable access
assured quality, safety, efficacy and cost-effectiveness
scientifically sound and cost-effective use.
177
What comes under the 'financing' building block
adequate funds for health
ensure people can use needed services
protected from financial catastrophe or impoverishment associated with having to pay for them.
178
What comes under the 'leadership/governance' building block
strategic policy frameworks exist
combined with effective oversight, coalition building, the provision of appropriate regulations and incentives, attention to system-design, and accountability
179
"People with mental disorders are subject to serious human rights violations e.g. chaining, caging, incarceration – this is a global emergency requiring sustained action"
Patel and Saxena 2014
180
“In no country is the financial allocation for mental health care proportionate to the contribution of mental disorders to the burden of disease”
Patel and Saxena 2014
181
”One-size-fits-all approach is not appropriate for scaling up mental health care globally” – need to consider the local social, economic and cultural conditions including resource availability and adapt policy accordingly
Patel and Saxena 2014
182
"Characteristic of Fragile States:
Weak government unable to provide security and services whilst lacking legitimacy.
Population split into ethnic, religious or class based groups with history of grievance and conflict"
Brinkerhoff
183
What are the transition challenges for a health system after a conflict (Brinkerhoff)
Bypassing government for emergency aid
| Specific donor behaviour and funding mechanisms can create problems
184
How can bypassing government for emergency aid in a conflict setting create problems
(Brinkerhoff)
Creates many different uncoordinated projects
Takes scarce resources away from the government as NGOs may offer better salaries
Can cause vertical programs to dominate inhibiting development of integrated health system
185
How can specific donor behaviour and funding mechanisms in a conflict setting create problems
(Brinkerhoff)
Corruption concerns can prevent inclusion of local government
Desire for measurable results leads to discrete project funding making coordination difficult
Separation of humanitarian aid and development aid can cause timing issues for transition
186
What should transitional programming (after a conflict) take into account?
(Brinkerhoff)
Need for health system to build legitimacy amongst population
Need to rebuild health system capacity including financing, operation and governance
Any existing sources of capacity that can be built on to create health system
Structure relief effort as integral components of plan that can be transitioned to country actors
187
What are some suggested contract activities to support transition after a conflict for a health system (Brinkerhoff)
Planning: Develop annual plans including NGOs together with host Government
Information: Share information and data with Government to build basis for planning
Training: Develop a plan for training host-government workers
Basic Services Package: Define which basic service provision is to be prioritized.
Supervision: Have a supervision plan jointly with host government.
188
What are the negative effects of conflict on public health (Waters et al 2007)
Direct effects: mortality and morbidity from conflict, injuries due to landmines. Effects are both physical and emotional and can result in long-term disability
Indirect effects: displacing populations (who are particularly susceptible to other health problems – infectious diseases, nutritional deficiencies etc.), damaging the infrastructure needed to supply food, clean water, sanitation as well as the health system itself (thus resulting increase in preventable communicable diseases e.g. diarrhoea).
189
What are the negative effects of conflict on health systems (Waters et al 2007)
Financial due to weak economy and diversion of resources to military
Human Resources as health professionals are killed or fled during conflicts
Infrastructure such as health care clinics and hospitals are destroyed and
Policy making structures are severely weakened
190
What are some country examples/lessons of health systems rehabilitating after a conflict
(Waters et al 2007)
Uganda: example where lack of priority for health system led to poor planning and resource allocation. Large capital-intensive programs proved unsustainable.
Afghanistan: performance based partnerships between government and NGOs delivered a Basic Health Services Package where previously the health system was almost non-existent.
Mozambique: example where long term planning eventually managed to build health system where previously under 5 mortality has reached 473 per 1000 although after 10 years this was still high at 270.
East Timor: at start of program only 20 health professionals left in country. Multi phase plan built a new Department of Health through cooperation of government and NGOs.
191
" Compared to substantial funding for disease-specific programs, health care infrastructure is relatively underfunded"
Mills 2014
192
“On average, almost 50% of health care financing in LICs comes from out-of-pocket payments, as compared with 30% in MICs and 14% in HICs.”
38% of health care financing in LICs is combined in funding pools compared with approximately 60% in MICs and 80% in HICs
Mills 2014
193
"There is no ‘magic bullet’ or ‘blueprint’ of the ideal health system – they are social systems that depend on the system they work within as well as local ideologies"
Mills 2014
194
" 3 strategic pathways for WHO to achieve coherence and coordination in GH:
Provide mechanisms and instruments which link new global health actors to the system of multilateral intergovernmental institutions
Engage in new ways with the many non-health actors that influence health e.g. geopolitics, security, trade, and foreign policy
Improve coordination function in relation to the development on legal instruments e.g. International Health Regulations"
Kickbusch et al 2010
195
"However new consensus emerging that the success of new health initiatives and actors was achieved “at the cost of fragmentation, created ineffective parallel activities, neglected the need to strengthen health systems, and increased problems of transparency and accountability”"
Kickbusch et al 2010
196
" Large numbers of disparate NGOs with individual agendas make co-ordination difficult.(100 working in Mozambique)"
Pfeiffer 2003
197
Mozambique:
Funding of actors: NGOs had greater funding than local Health Service (DPS) making it difficult for DPS to control process
Expatriate workers did not integrate into community building walled compounds to live in creating separation from local population.
Many aid workers were on short contracts (2 years or less) and displayed no interest in host country.
NGOs driven by short-term goals which were difficult to achieve if work had to be co-ordinated through DPS incentivising them to bypass DPS.
Different donor priorities led NGOs to compete for resources rather than co-operate
Pfeiffer 2003
198
Mozambique after NGOs arrived:
Local health workers pay fell (Nurses $110 to $40 Doctors $350 to $100 per month) This led to:
Demoralisation of local workers
Supplementing salaries by private work, corruption and theft of medicines
Health workers moving to NGOs who paid far better.
Ability for NGOs to offer favours (contract work, travel, paid training) to obtain approval for programs.
Daily pay (per diems) by NGOs becoming a distorting effect in the health system. Daily pay in 1998 was $25 attracting workers away from routine duties.
Pfeiffer 2003
199
Somalia Food security assessment found:
1) prolonged absence of a central government
2) dispersed inter-clan nature of the conflict
3) high degree of agro-ecological, economic and socio-cultural diversity within the country
4) The central role of remittances in food security in Somalia
5) degradation of common property resources
6) well-established external assistance community network
Somalia Food Security Assessment Unit
200
Most 20th century famines were triggered by:
1) natural disasters
2) malevolent exercise of state power
3) conflict
NEW FAMINES
201
"· India supplies 20% of the global market for generic medicine
· From 2002-2008 more than 4 million people were started on ART
· Indian manufacturers can provide low-priced high quality anti-retroviral therapy
· Leading to ‘accelerated global scale-up of HIV/AIDs treatment’"
Waning et al 2010
202
Consequences of barriers to healthcare for migrants:
Self medicate = prescription drugs may be ordered from home country. Wrong dosages, duration and interactions with other drugs can lead to ineffective treatment.
Alternative therapies = traditional healers (which are cheaper too, can bring pain relief/ease some health conditions).
Using fake identities = Not uncommon. Often by relatives/friends. Risk of exploitation by people who service their identities as a business.
Reliance on A&E = A&E ask fewer qs, can’t charge on the spot in the dept. People delay seeking treatment until very ill (e.g. need an ambulance) so given treatment straight away and no qs asked. Treatment in A&E more expensive than primary care, so strain on NHS and individual afterwards when they get billed.
Thomas 2010
203
Prostitution in Ecuador:
"Increased enforcement increases street prices, reducing the overall number of street clients and decreasing the probability of sex workers choosing this sector by 40 percent.
Increasing enforcement in the brothel sector has the potential to exacerbate public health problems as it induces unlicensed sex workers to either comply with health regulations or shift to the risky street sector. If more sex workers choose the street, then increasing enforcement in the brothel sector will only aggravate public health outcomes."
Gertler and Shah 2011
204
" Ethics: ‘inverse care law applies to refugees in UK, where disproportionate needs are met by insufficient access, empowerment and provision.’ This debate highlights the modern tension between a libertarian and egalitarian perspective of health care. Within primary care, there is a tension between ‘utilitarian gatekeeper’ and ‘consumer-provider’ roles."
Taylor 2009
