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

1. By: Adam Izzeldin, BPEH, MPH
Department of International Health,
TMDU
Martin Gulliford, Oxford Text Book of Public Health

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

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

4. Introduction
• A number of efficiencyoriented strategies have been
developed to increase the health gains from healthcare
(needs, cost, technology, research , organization, delivery).
• Estimates suggest that healthcare now adds about 5
years to life expectancy at birth in high-income
countries.
• About a quarter of the overall burden of disease in
middle- and low-income countries could be prevented
through implementation of packages of low-cost but
highly effective interventions.
• Pro-rich inequity exists in accessing preventive medical
interventions and specialist care for more serious
illnesses

5. Definition of healthcare
•
Health system: All the activities whose
primary purpose is to improve or maintain
health’ (Murray & Frenk 2000).
•
Healthcare: Services provided to individuals
or communities by agents of the health
services or professions to promote,
maintain, monitor, or restore health (Last
2001).
•
Health services: Services that are
performed by healthcare professionals, or
by others under their direction, for the
purpose of promoting, maintaining, or
restoring health(Last 2001).

6. Aspects of health
• Healthcare need: Capacity to benefit
from health care (Stevens et al. 2004)
• Health improvement: Population health
benefit associated with intervention on
the determinants of health.
• Health gain: Individual or population
health benefit associated with
healthcare intervention
• Health outcome: Change in individual
or population health status associated
with utilization of needed healthcare.

7. Concepts and values in healthcare
•
Healthcare represents a tangible
expression of the value placed on life and
health.
•
healthcare is valued as a private good
that can be utilized to preserve or
improve health
•
The risk of illness is unpredictable.
•
the costs of healthcare can be extremely
high.
•
Consumers may have limited information
on which to base choices.
•
Communities and national governments
are usually involved in arrangements for
the delivery of healthcare

8. Dimensions for evaluation of health services
•
Effectiveness: Extent to which a healthcare intervention
achieves the intended outcome (Last 2007)
•
Efficiency: Outcome achieved in relation to expenditure
of resources (Last 2007)
•
Equity: Fairness, or justice, in respect of treatment of
different individuals or groups (Last 2007)
•
Access: Extent to which services are available, can be
utilized, deliver needed services, and achieve
appropriate outcomes (Gulliford et al. 2002)
•
Appropriateness: Relevance to need (Maxwell 1984)
•
Responsiveness: Social acceptability (Maxwell 1984)

9. Health expenditures and health services indicators at different levels of
economic development around 2003-2004.source: world bank, 2006.
Country
Gross
national
income
per
capita
(2004)
Health
expenditu
re
(per cent
GDP)
Public
Health
expenditur
e
expenditur
e
(per cent
total)
Per capita
(US$)
Doctors
per 1000
populatio
n
Hospital
beds per
1000
populatio
n
Life
expectanc
y
at birth
years)
Low-income:
Kenya
480
4.3
38.7
20
0.1
1.6
48
Pakistan
600
2.4
27.7
13
0.7
0.7
65
Middle-income:
Albania
2120
6.5
41.7
118
1.3
3.1
74
Costa
Rica
4470
7.3
78.8
305
1.3
1.4
79
Indonesia
1140
3.1
35.9
30
0.1
0.7
67
High-income:
Japan
37050
7.9
81.0
2662
2.0
14.3
82
UK
33630
8.0
85.7
2428
2.2
4.2
79
USA

10. Ideological and philosophical drivers
•
Governments or externally funded health services may not be
available and families necessarily make out-of-pocket
payments to private providers or do not obtain healthcare.
•
According to utilitarian doctrine, society in general and health
services in particular should aim to maximize the health gains
obtained across all individuals.
•
Based on the concepts of human rights and social justice,
equity may be regarded as a moral value which health
services should strive to prompte (Braveman et al. 2001).
•
Equity of access is an objective, but this is only to the extent to
which it is considered acceptable to compromise efficiency.
•
In other systems, such as the United States or in middleincome countries, private financing of healthcare through
insurance or out-of-pocket payments may predominate.
•
governments may facilitate access to basic health services
for vulnerable groups such as the poor and elderly.

11. Underlying problems of efficiencydriven approaches
• Lack of effectiveness :(environmental influence not
healthcare technology- medical errors and poor quality of
care).
• Quality of care and variations in practice: (in Brazil
72% of women giving birth in private clinics had Caesarean
sections, compared with 31 % in public hospitals).
• Iatrogenic illness and patient safety: (in US injuries
caused by medical management occurred in 3.7 per cent of
hospital admissions).
• Misallocation of resources and problems in service
organization and delivery

12. Proposed solutions of efficiencydriven approaches
• Clinical effectiveness and health technology
assessment :(evidence-based medicine-, technology assessment
,Cost-effectiveness analysis)
• Quality improvement, implementation research, and
patient safety: (standards of good clinical practice, guidelines,
invitations to educational meetings, provision of advice from
respected peers, or the inclusion of prompts in the medical
• Systems redesign and service organization and
delivery research: (workload, staffing levels, management
strategies, organizational culture, transferring care from hospital to
primary and community settings, utilizing staff with different types of
training, or integrating specialist skills into primary care service
delivery)

13. Healthcare and population health
•
Avoidable mortality: which known as a
given condition amenable to medical
intervention, then there should be few or no
deaths from the condition.
•
Time-series analysis: If a health service
intervention is implemented across a
population over a short space of time,
changes in trends in mortality or morbidity
occur
•
Modeling: concerning the incidence and
prevalence of disease, the effectiveness of
clinical interventions, and the expected
coverage and quality of services in the
population at risk

14. Healthcare and population health:
High-income countries
• Medical care, including preventive and treatment
services, contributed to add about 5 years
additional life expectancy in the United States
(Bunker et al. 1994)
• Cutler et al. (2006) estimated that cumulative
increase in life expectancy during the period 19602000 was 6.97 years with reduced mortality from
cardiovascular disease accounting for 4.88 years
(70%) and reduced rates of infant deaths
accounting for 1.35 years (19%).

15. Measuring the effects of medical care. Estimated increases in life expectancy for the
population from clinical preventive and curative services
Source: Bunker et al. (1994).
Examples:
Condition
treated
Relevant
population
Estimated gain in
Estimated gain in life expectancy
life years in those
distributed across the US pop.
receiving the service Current
Potential
Cervical cancer
screening
Adult women
96 days
2 weeks
1 week
Immunization for All children
diphtheria
10 months
10 months
0
Cervical cancer
treatment
Affected
women
21 years
2 weeks
1 week
Ischaemic heart
disease
Affected adults
14 years
1.2 years
6-8 months
Appendicitis
Affected
individuals
50 years
4 months
0
Trauma
Affected
individuals
24-38 years
1.5-2 months
3-4 months
5 years
1.5-2 years
Estimated overall gain from preventive and curative

16. More evidences from high-income countries
• In US the estimated median survival of incident HIV
cases after 25 years of age was 7.6 years in 1995-6,
22.5 years in 1997-1999, and 32.5 years in the period
2000-2005 attributed to (HAART) (Lohse et al. 2007)
• In UK evidence from randomized controlled trials to
reduce breast cancer mortality through screening
reported by (Gotzsche & Olsen 2000; Nystrom et al.
2002).
• About 53 % of the reduction in CHD mortality in
Finland between 1982 and 1997 could be attributed
to changes in risk factor levels, while 23% could be
attributed to more effective medical care(Laatikainen
et al. 2005

17. Healthcare and population health:
Middle- and low-income countries
•
Between 1967 and 1977, (WHO) organized a programme to
eradicate smallpox, based on systematic delivery of smallpox
vaccination.
•
In 1967, there were up to 2 million deaths from smallpox
annually, but there have been no naturally occurring cases
since 1977.
•
WHO established EPI programme which was estimated to
reduce the overall burden of disease among children under 5
by 20-25 per cent.
•
Between 1988 and 2005 an estimated 5 million people avoided
long-term disability from Polio as a result of Global Polio
Eradication Initiative.

18. Investing in Health
• A healthy population is a major resource that can
contribute to stronger economic growth and
improving standards of living (Bloom et al. 2004).
• On average, each 10% increase in life expectancy
at birth in a country is associated with an increase
in economic growth of 0.3-0.4% per year
(Commission on Macroeconomics and Health 2001).
• World Bank's World Development Report for 1993
applied the tools of needs assessment, health
technology assessment, and cost-effectiveness
analysis to modeling potential solutions to a wider
range of health problems in middle- and low-income
countries in term of DALLYs.

19. Actual and proposed allocation of public expenditure on health in developing
countries and potential health gains, 1990
Sources: World Bank (1993) and World Health Organization (2000).
Propos
ed
spendin
g ($
per
capita)
Estimat
ed
actual
spendin
g
1990
Reduction in
disease
burden
Pe ｒ
cent
Million
s of
DALYs
5
1
6
77
‘Essential’ clinical services:
Treatment of TB, maternal health and safe
motherhood, FP, IMCI, treatment of STDs,
malaria treatment, NCDs and injuries (selected
early screening and secondary prevention)
10
4-6
19
225
‘Discretionary’ clinical services:
All other services including low-cost-effectiveness
6
13-15
Package component
Public health:
Immunization (EPI), school health interventions,
HIV/AIDS prevention, tobacco and alcohol
control, nutrition and family planning
education, STDs control, malaria prevention

20. Criticisms of Investing in Health
• Technical criticisms of the methods used in
estimating the costs and outcomes of intervention
in different conditions (no cases of wild-type
poliomyelitis in the US since 1979, but polio control
costs US$230 million annually).
• The lack of a well-developed strategy for
implementation of essential packages of care (Costeffectiveness analysis is useful in defining the set of
interventions but has a more limited role in defining
the systems that should be developed to implement
them).

21. Equity-driven approaches
• The unequal distribution of
determinants, especially income and
education, fosters the development of
inequalities in health
• Gini coefficients for countries
generally fall in the range 0.2-0.6.
• Health systems should be organized
so as to minimize inequalities in health
and improve the health status of all
groups in a population

22. Aspects of equity in health and healthcare
Parameter
Definition
Equity)
Fairness, or justice, in respect of treatment of different
individuals or groups
Horizontal
equity
The extent to which equals are treated in proportion to their
equality
Vertical equity
The extent to which unequals are treated in proportion to their
inequality
Equity in
financial
contribution
The extent to which individual or household contributions are
consistent with their capacity to pay
Equity in
access to
healthcare
The extent to which there is a fair distribution of access to
healthcare in relation to need, including equal access for equal
need (horizontal) and unequal access for unequal need
(vertical)
Equity in
health
The extent to which there is a fair or just distribution of health
among individuals and groups in a population
Effective
coverage
The proportion of the population in need of an intervention that
has received an effective intervention

23. Access to healthcare
• In general terms, ‘access to healthcare’
is said to exist when individuals or
families can mobilize the resources they
need to preserve or improve their
health.
• Accessibility of healthcare judged by
the availability and supply of health
services, needs, obstacles to utilization
include financial; physical; personal; or
organizational barriers, as well as
relevant to need and effective in
addressing people's health problems.

24. primary healthcare
•
The Alma Ata Declaration 1978 promoted access to primary
care, with an emphasis on community participation and
universality, as a means of facilitating equity in health.
•
Institute of Medicine (1994) defined PHC as `Care which
provides integrated, accessible healthcare services by
clinicians who are accountable for addressing a large majority
of personal healthcare needs, developing a sustained
partnership with patients, and practicing in the context of
family and community`.
•
The Cuban health system is frequently cited as one that has
successfully adopted the primary care approach. In 2001, life
expectancy at birth in Cuba was 76.3 years compared with
77.4 years in the United States, and the infant mortality rate
was 7.2 per 1000 in both countries in spite of the great
disparity in economic conditions .

25. Stop asking this but you could ask
those.

26. Conclusion
• Modern healthcare offers a wide range of
interventions of proven effectiveness that
when implemented widely can be shown, at
least indirectly, to contribute to improving
trends in population health status in
countries at different levels of economic
development.
• Population health gains can be increased by
investing resources in the most cost-effective
interventions, by increasing effective
coverage of the population, increasing
quality of care, and optimizing systems for
organizing and delivering care.
• Public health specialists should advocate
principles of efficiency and equity through
participation in processes of needs
assessment, health technology assessment,
quality improvement, and facilitating access

27. Thank you for
lisTening