Medical sociology, Social policy, and Health Economics Flashcards
Structural Functionalism
Durkheim
Macro approach
Objective reality
Balance within society lies with social structures.
Individuals have limited agency within this model.
This theory validates inequalities as they balance society.
Also validates actions to protect state health, but restrict individuals e.g lockdown.
Social conflict theory
Marx
Macro
Society bound by competition for resources and material wealth. Establishing industrialisation and social classes.
Establishing industrial sources of health concerns and inequality.
Interpretivism
Micro
Subjective
Individual behaviours and interactions determine how people interpret society
Sick role
Parsons
Temporary rights and responsibilities of people who are sick.
Rights:
Exempt from blame for illness
Exempt from normal responsibilities
Responsibilities:
Seek help
Desire to get better
Critically discuss the sick role model
+ Applies to all acute illnesses esp infection
- Some illness can have some level blame attributed e.g risky behaviours
- Some illness allow for normal duties
- Some illness mean patient lacks ability to seek care e.g lack of insight due to MH, also cultural definitions of “medical care”
- Duty to want to get better- definition of better? Defined by toxic societal physical attributes e.g obesity Also not possible for terminal illness.
Definitions of health
WHO 1948
“Not nearly absence of disease”
Ottawa Charter 1986
“Resource for everyday life, not object of living”
Canguilhem 1943
“Ability to adapt to environment”
Huber et al 2011
“Ability to adapt and self manage”
Critically discuss WHO/Ottawa definitions
+ Simple
+Multicultural appeal
+ Health as human right
+ Influences policy outwit disease
- Most people “unhealthy”
- Contributes to medicalisation of society
- Subjective
Critically discuss Canguilhem/Huber
+ More appropriate for current PH burden of chronic illness
+ Individuals can define health needs
- Individualistic
- No account for social structures
- Reactive to health status, not promoting health as human right.
Define deviance
Becker 1963
Behaviour seen as unacceptable within society
Audience is important in creating identity
Note different within different cultures.
Labelling theory
Becker 1963
Deviance is labelled as being abnormal.
Once recognised as abnormal deviant behaviour may be subject to sanctions, punishment, correction, or treatment.
Deviance in medicine
Parsons
Illness as deviant behaviour
Doctors agent of social control, restrict the sick role label by their definition of sickness.
Primary deviance
Deviant behaviour prior to labelling.
May only have minor implications for the individual
Secondary deviance
Individuals status once labelling of deviant behaviour occurs
Label could become self fulfilling prophesy
Label has greater implications for the individuals social role and self esteem than the behaviour.
Define stigma
Goffman 1963
An attribute that is discrediting within a particular social interaction.
Undesirable characteristic within a particular context.
Stigma as a consequence of labelling. Caused by inequalities, fear and misinformation.
Felt vs Enacted stigma
Felt stigma is the feeling experienced by those who are stigmatised
e.g Shame, guilt, depression, self stigmatisation, withdrawal from society
Enacted is actions from those with in the “normal’ group to the stigmatised group.
e.g Violence, loss of job opportunities, compulsory testing.
Ways to tackle stigma
Education/raising awareness e.g world aids day
Language e.g person with schizophrenia vs schizophrenic
Public acknowledgement of diagnosis by significant figures.
Public acknowledgement of exposure to disease, especially where deviant behaviours involved e.g STI
Treatment, Reducing burden of disease on patient
Legislation e.g Equality act
What is the virtuous cycle?
Helps reduce stigma through action.
Positive changes change attitudes and reduce felt stigma, which helps reduce enacted stigma perpetuating positive change.
How is disability assessed?
Barthel ADL index.
10 domains
Score out of 20
Bowels, Bladder, Feeding, Grooming, Dressing, Transfer, Toilet use, Walking, Stairs, Bathing.
Define impairment
Loss or abnormality of a body function.
e.g amputations
Define disability
Inability or restricted ability to perform an activity
e.g unable to walk due to impairment. wheelchair use
Define handicap
Disadvantage due to an impairment/disability that limits role in society
e.g difficulties accessing workplace
Iatrogenesis
Disease caused by medicine
Clinical - side effects/complications
Social- Widespread health service provision leading to people feeling “ill/abnormal” when previously would be well. e.g on demand C section/ cosmetic surgery
Structural - Reliance on medical care rather than use of previously used coping mechanisms or support networks.
Health seeking behaviour
Zola 1973
Triggers- concomitant crisis, sanctioning by others, interference with normal activity (work/social), temporising deadlines.
Black report
1980
Found social class gradient across all ages, major diseases, increasing over time.
Possible explanations for health inequalities
Artefact
Social selection- Health determine social class “drift”
Behavioural/cultural - social class determines health through promoting or damaging behaviours
Materialistic- social class determines health through material circumstances
Social epidemiology
The study of the social determinants of the distribution of disease within a population.
Micro/meso/macro level assessment
Surveillance of HI, Investigation of social determinants, evaluating interventions.
Implications of the clinical iceberg
Underestimate of burden of ill health if only interactions with healthcare are the measure
Value of healthcare enhanced by understanding informal care systems
Self care is the commonest form of care- e.g with chronic illness. DM on average 3h of healthcare interaction annually.
Kaiser pyramid
Depicts proportion of selfceare in relation to the complexity of long term conditions.
How do hospitals influence society
+ Employer
+ Purchases
+ Community resource
+ Research facility
+ Education and training
- Polluter
- Isolation/exclusion
Aspects of medical profession (Parsons)
- Defined knowledge base
- Patients expected to defer to authority
- Self governing
- Potential to exploit power
- Commitment to public service
- Protection for patients
Factors that balance clinical autonomy
Management, Costs, Guidelines, revalidation, competition.
Illness behaviours
Mechanic 1968
Disability
Perceived seriousness
Disruption
Frequency/persistence of symptoms
Tolerance
Knowledge
Denial
Competition of needs with illness
interpretations of symptoms
Availability of treatment
Definitions of need
Doyal and Gough - physical health as a basic objective need, but healthcare doesn’t automatically follow on from this need for health.
Culyer and Wagstaff Need is equal to a persons capacity to benefit from healthcare.
Bradshaw - Felt, expressed, normative and comparative needs.
Bradshaw categories of need
Felt- Subjective experience of being unwell, doesn’t necessarily correlate to service use.
Measured by surveys and census.
Expressed- Seeking of healthcare. Measured with waiting lists
Normative- Professional judgement of an individuals/groups health status. Measured through HNA
Comparative- comparing services in areas with similar prevalence.
Distributive justice
The fair distribution of the burdens and benefits of social cooperation among diverse persons
Interpretations:
Utilitarianism - greatest good for the greatest number.
Can marginalise groups.
Justice as fairness-
basic liberties for all, difference principle (resources distributed equally but social and economic inequalities should benefit the most)
Maximising individual capabilities-
Define and criteria of procedural justice
Fairness in the process rather than the outcome.
- Consistent
- Neutral
- Evidenced based
- Potential to be corrected
- Takes account of all parties
- Ethical
Types of social justice (5)
Distributive- fair distribution of goods
Procedural- Fair process/decisions
Interactional- treating people fairly
Retributive- fair punishment of injustice
Restorative- restore justice after harm
Macro level rationing
Government level
+ Save duplication of work at local level
- No scope for local decision making
Meso level rationing
Organisation level
+ respond locally
- Can’t dress individual needs
- risk of duplication if similar issues in near by areas
Micro level rationing
Individual clinical decision making
+ Individualised response
- Vulnerable to inconsistencies
- Lack of accountability
Rationing criteria
Need- Individual/societal
Cost effectiveness
Fairness- equal access to care
Pareto optimal
Efficiency has reached a point where no further improvement can be made to one part of a system without disadvantaging another part.
Efficiency vs Equity
Conflict:
Efficiency = greatest good, but this may marginalise or increase inequality.
Alignment:
Externalities- beneficial by products
E.g vaccination, resources spent on reaching hard to reach groups benefit the whole of society through herd immunity.
Prioritisation frameworks
Programme budgeting and marginal analysis
Save to invest
Multi criteria decision analysis
Programme budgeting and marginal analysis
Priority setting approach
Plan and allocate expenditure across health programmes/primary, secondary and tertiary.
Aim is to balance spending across disease areas.
+ manages finite resources/ resources in competing demands
+ assumes rational behaviour
+ can address both technical and allocative efficiency
- variable coding of healthcare data to work with
- changes in year on year budget info so hard to compare yearly trends
Bartleys explanations of inequalities
Individual: risky behaviours
Materialist: living in deprived conditions
Psychosocial: effects of social circumstances on psychology and physiology
Life course: cumulative effect of social circumstances through life
Solutions to inequalities: Acheson inquiry 1998
Focus on evaluating gov policies affecting family and children
Reduce income inequalities, Improve housing standards
Solutions to inequalities: Marmot 2010
Best start in life,
Take control of lives
Fair employment
Healthy standard of living
Healthy and sustainable places and communities
Strengthen prevention
Factors that affect migrant health
Reason for migration, rights of the migrant, Geography/understanding systems and rights, genetics, culture, language
Health risks for forced migrants
Communicable disease- poor sanitation/living conditions in camps
Sexual violence
PTSD
Transit risks
Hostility on arrival
Dental
Screening
Direct and indirect impacts of trade on health
Direct :
Availability of medical technologies
Infection risks
Food safety
Indirect:
economic and environmental determinants
Issues with economic evaluation of health promotion interventions
- Multiple objectives
- Clients heather so benefits are broader
- QUALY doesn’t capture the full benefits
- RCTs are useful to confirm observed benefits but don’t suit the time frame of health promotion
Health economics
Healthcare always in a position of scarcity, resources spent could be infinite. Such decisions must be made.
Health economic is the science of making these decisions.
Scarcity
More resource is wanted than available
Opportunity cost
Benefits that are forgone by making a choice.
Important in finite resource setting for evaluation.
Calculated via CEA/CUA
Microeconomics
Elements within the economy e.g People, households, buyers, sellers, markets
Macroeconomics
Entire economy e.g unemployment, inflation, economic growth, policy
Economics definition of need
A capacity to benefit from healthcare
E.g Bradshaws needs
Economics definition of demand
A request for healthcare. the amount of good/services that consumers are willing and ale to purchase.
E.g attending a service, waiting for a service, paying for a service.
Determinants of demand
- Price elasticity of demand
- Income
- Preferences
- Price/availability of alternatives
Define substitutes
Products where increased price of one item increases the demand for an alternative item.
E.g vaccine brands
Define Complements
Increase in price of one, causes decreased demand in another.
e.g needles and syringes - increase cost of leur lock may decrease demand for complimentary needles
Define and explain price elasticity of demand
Measure of how much swing in demand there is based on changes in price.
PED = % change in demand / % change in price
PED > 1 Large response in demand on changes of price
PED= 1 proportionate demand response
PED < 1 Small response in demand
PED = 0 No response in demand to price change
Changes to the demand curve : Rise and fall in price
Rise in price : less product demanded, move left along curve
Fall in Price : More product demanded, move right along curve
Changes to demand curve : Left shift
Due to decreased income
Changes to demand curve : Right shift
Due to increased income, population size or change in preference in favour of the item
Define and explain Income elasticity of demand
Measure of how much swing in demand there is with changes in income
IED = % change in demand / % change in income
IED>1 Large demand for luxury goods as income rise
IED > 0 Proportionate changes, normal good demanded alongside income
IED<0 Goods demanded are inferior as income has fallen
Define supply in healthcare context
Supply is how much of a good/service can be supplied at a given price and depends on cost of material, cost of production etc
For health care services it is the capacity of services to meet need. Defined by costs of staff, beds, equipment etc.
Changes to the supply curve : Rise and fall in price
Rise in price : More product is supplied, move right along curve
Fall in price: Less product is supplied, move left along the curve.
Changes to the supply curve : Left shift
Less product supplied for same price point
Due to less land/resource
Reasons for increased price- war, cross, climate change etc
Changes to the supply curve : Right shift
More product supplied for same price point
Due to - Better technology, more land/labour
Market equilibrium
The price reaches equilibrium at the intersection of the supply and demand curve.
Characteristics of a free market
Atomicity- Many buyers and sellers
Homogeneity- identical products
Free entry/exit - sellers are free to come and go
Equal access- production technology is available to all sellers
Perfect information- All buyers/sellers know price and product info for all products
No externalities- benefit or disbenefit to someone other than the buyer.
Causes of market failure
Failure to meet characteristics of a free market.
Externality- benefits/dis-benefits to others e.g in health herd immunity
Public goods- publicly available good e.g health promotion posters.
Market control - Monopoly (single seller), monopsony (single buyer)
Imperfect information-
Agency: relying on doctors for information
Uncertainty
Moral hazard: no price to consumer at time of use
Adverse selection: people opting out of paying health insurance.
Merit goods- belief that certain goods are special in someway
Characteristics of perfect agency
Balance between Patient health status, patient preference and utility to society.
Imperfect agents
Supplier induced demand- recommendations for treatment where in a perfect scenario treatment isn’t necessary
Supplier reduced demand- not recommending a treatment, especially where resources are scarce. Making it look like demand is lower.
Policy can counter this by linking payment to quality indicators.
Define margin
incremental variation in inputs that is required to have corresponding outputs.
Marginal cost- cost of producing one extra unit of service.
Marginal benefit- benefit gained from increased unit of service.
Marginal analysis
Process of examining the effect of small changes in expenditure.
- Help to identify-
where resources should be targeted - Where reductions should be made if expenditure must be cut.
- How resources can be reallocated to achieve an overall gain.
Efficiency
Measure of how much good is achieved with available resources
Technical- max output to input
Economic- Max output to expenditure
Allocative - level of production that marginal benefit is greater than marginal cost.
Discounting
Discounting is used to deal with positive time preference.
Where the preference is for the benefit to come early and the cost later.
But in PH cost often comes first with benefits later. As such discounting is applied.
“Adjusting the value of costs/benifits that occur in the future such that they can be compared as if they occurred in the short term”
Distinguishing features of healthcare in economics
Supply and demand: not truly independent
Imperfect markets
Immediacy: short time scales in urgent health situations
Agency
Uncertainty
Necessity
WHO dimensions for assessing a healthcare system
Social goals
Resource use
Efficiency
Review - How the system influences outcomes and efficiency
Feedback- improve outcomes and monitoring the effect
Healthcare funding systems: Private insurance
Private purchase of insurance by individuals/ workplaces
+ Competitive insurance/ patient choice
+ incentivise providers to increase quality/ decrease cost
- Adverse selection: low risk people don’t want to pay in, doesn’t subsidies higher risk people.
- providers compete on perceived rather than actual quality
- generally inefficient
- exacerbate inequalities
- Moral hazard
Healthcare funding systems: Social insurance
Contributions made by employees, employers, and government to provide healthcare
+ generally lower cost than private insurance
+ Government is a strong partner
+ fewer inequalities due to better coverage
- Only provides insurance for employed, another government scheme is required for others
- consumer and provider moral hazard
Healthcare funding systems: Public funding
+ lower cost/ efficient
+ Government strong partner can influence costs
+ fewer inequalities due to high coverage
- Less competitive pressure
-consumer and provider moral hazard
Incentives used in healthcare
Quality and outcome frameworks (QOFs) - incentives for improved quality to target
Payment by results/ activity- payment of average cost nationally, incentive to reduce cost and increase coverage
Delayed discharge - hospitals crane social care the cost of IP care, incentivising provision of care upon discharge.
Re admissions - Trusts are accountable for readmissions
Vaccinations - Fee for service e.g flu vaccines
Case mix - payment based on average costs so mix of complex and non complex balances out
Types of economic evaluation : CBA
Cost benefit analysis
Calc costs and benefits in monetary terms and the difference - Result - net benefit
Costs £
Outcomes £
+ Can compare the value across different sectors
+ Also examines allocative efficiency
- Requires a monetary value to be places on life/health
Types of economic evaluation : CEA
Cost effectiveness analysis
Compares costs of different interventions that produce the same outcome
Result- Incremental cost effectiveness ratio (ICER)
Cost £
Outcome - clinical
+ Useful to compare difference interventions that produce the same outcome
- Can’t compare across areas/diseases
Types of economic evaluation : CUA
Cost utility analysis
Measures outcomes in terms of DALYs/QUALYs to compare across disease areas.
Result - ICER
Costs £
Outcome DALY/QUALY
+ Can compare interventions for different medical conditions
+ some assessment of allocative efficiency
- Can’t be used to compare interventions across sectors
Types of economic evaluation : CMA
Cost minimisation analysis
Compares interventions who produce the same outcome (e.g clinical)
just compares which is cheaper for the same outcome.
Types of economic evaluation : CCA
Cost consequence analysis
Consequence are listed but not aggregated into same units
Disaggregated approach
Types of costs used in economic evaluation
Direct: Exclusive for that output
Indirect: Shared costs across several outputs, productivity, community costs
Overhead: Shared across the organisation
Tangible: easily measured in £
Intangible : Difficult to measure in £
Fixed: don’t change with volume of activity
Variable: Vary with activity/proportion produced.
Monetary and non monetary valuation on health
Monetary-
Easy to compare across sectors e.g education and non health outcomes e.g income
Use : Human capital, Revealed preference, and stated preference to calculate
Non monetary-
Difficult to give accurate monetary value for health. QUALY/DALY
QUALY
Commonly used unit of utility
Combines quality and duration of life
QUALY= Utility value in health state x Years in that state.
Utility value is 0- death –> 1 perfect health.
+ Combine QoL and mortality
Compare outcomes across specialities
+ can be specific to the population of interest
- Not necessarily equal/ comparable as depends on creation of utility value
- Not weighted
- may not be generalisable
Methods to calculate utility for QUALY
Rating scales-
patient rates health state
* poor interval properties
Time trade off - patients state how many years os diseased life they would trade for 1 year of health
* time preference
Standard gamble -
respondents imagine they have a disease and decide on a treatment that can cure/cause death at set probabilities
* biased by participants attitude to risk.
Person trade off -
comparing treatments that cure many/few until stand off is reached.
* respondents may consider more than the health question e.g moral/personal
DALY
DALY = YLL + YLD (age weighting and discounting of 3%)
YLL- Years life lost = (75- av age of death) x Number of deaths
YLD- Years lived with disability=
No of cases x Disability weight x average years lived in that state
+ Combine morbidity and mortality
+ international comparisons
+ Good for MH
+ Discounting applied
- Based on expert opinions
- Age weighting could be discriminatory
- requires good morbidity and mortality data
Approaches to valuing life in monetary terms: Human capital
Expected value of individuals productivity is calc, and adjusted for life expectancy.
Productivity - market and household, e.g via wages
+ Objective
- Hard to identify changes in productivity
- the value of children, older ages appears lower than working age
- Doesn’t reflect what we are willing to pay for treatment
- Improvements in health are only valued for their improvement in productivity
Approaches to valuing life in monetary terms: Revealed preference
Individual preference of risk/benefit are traded against income
+ Based on actual choices
+ Provides insight into individuals valuation on their life
- Focus on immediate accidental death rather than through chronic exposures
- Biased toward working age males
- Ignores imperfect labour markets
- Limited generalisability
Approaches to valuing life in monetary terms: Stated preferences
Individuals state what they would choose in hypothetical situations. Two types:
Contingent valuation
Understand max willingness to pay to avoid a risk or improve health
Discrete choice
choose between different interventions based on cost.
Decision analysis
Economic decision process the involved breaking down components into decision trees, attaching probabilities.
Sensitivity analysis
Testing assumptions made during an economic evaluation.
Deterministic: model different parameter values (where assumptions have been made) to see the effect on ICER. One way or multi way.
Probabilistic: Uses parameter distributions rather than distinct parameters.
Displayed as cost effectiveness acceptability curve.
