Module 3 Flashcards
Age specific mortality declined between 1970 and 2010
Lozano et al 2013
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
Rajaratnam et al 2010
Adult mortality decreased 1970-2010 but period of no improvement in late 80s/early 90s (HIV and fall of Soviet Union caused drinking)
Wang et al 2012
Adult mortality is high in SSA, men in former soviet union, increased in these areas
Wang et al 2012
Adult mortality is higher in men because of RTAs, injuries, homicides, HIV/TB
Wang et al 2012
Ischaemic heart disease was top cause of death in 1990 and 2010, followed by stroke and then COPD & LRTIs (COPD now 3rd, was 4th)
Lozano et al 2013
HIV AIDS has massively increased as a cause of death
Lozano et al 2013
Protein energy malnutrition has decreased as a cause of death, but still relevant as a contributor to other causes
Lozano et al 2013
Chronic kidney disease and lung cancer have increased as causes of death globally
Lozano et al 2013
Not a lot of change in YLDs per person from 1990 to 2010 but absolute YLDs have increased due to ageing population
Vos et al 2012
Top YLD causes are lower back pain, major depressive disorder, and iron deficiency anaemia
Vos et al 2012
Top causes of DALYs are ischaemic heart disease, LRTIs, stroke
Murray et al 2013
DALYs per 1000 decreased globally 1990 to 2010, most noticeably in the developing world (but not Eastern Europe or Southern SSA)
Murray et al 2013
1990; biggest death risk factor was childhood underweight
Lim et al 2013
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
Lim et al 2013
Top 3 risk factors for women worldwide: high BP, household pollution from solid fuels, high BMI
Lim et al 2013
Top 3 risk factors for men worldwide: tobacco smoking, high BP, alcohol use
Lim et al 2013
Alcohol is a leading risk factor for young adult mortality
Lim et al 2013
Epidemiological transition has shifted risk factors e.g. higher bp
Lim et al 2013
Smoking now becoming more important in low and middle income countries
Lim et al 2013
Life expectancy in UK shows north-south gradient, varies with deprivation quintile (deprivation explains most of the variation)
Woods et al 2005
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
Ezzati et al 2008
Patterns in global mortality are mostly due to epidemiological transition, increase in the total population number, and increasing average age
Lozano et al 2013
MDG conditions only accounted for 42% years of life lost; the non-MDG deaths often affect young adults e.g. RTAs
Lozano et al 2013
Shift from ID risk factors to NCD risk factors globally
Lim et al 2013
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
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)
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
What are the 3 main goals of health systems
Promote good health
Responsive to expectations of the population
Fairness of financial contributions
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
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)
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)
Key features of primary care
First contact care
Longitudinal
Coordination of care
Comprehensiveness
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
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
Sharp reduction in premature mortality in countries with stronger primary health care
Macinko et al 2003
GPs didn’t order unnecessary gastroscopies/x-rays compared to private GPs or hospital doctors; therefore primary care is cost saving
WHO
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
Individuals reporting a good primary care experience are more likely to self report better health
Starfield et al 2005
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
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
Criticisms of Starfield’s research
Quality of primary care not well captured, mortality not morbidity, limited to OECD countries
Key challenges for health systems (WHO Now more than ever 2008/primary care)
Costs are growing
Health gains unevenly distributed
Increasing burden of NCDs
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
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
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
Programa Saude da familia has led to decreases in infant mortality rate, post-neonatal mortality, and diarrhoea mortality
Macinko et al 2007
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
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
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
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
What are the 3 main ways of doing a needs assessment
Epidemiological
Comparative
Corporate
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
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
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
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)
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)
Global health is collaborative transnational research and action for promoting health for all
Beaglehole et al
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
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)
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
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
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
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
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
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
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
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
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
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
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
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
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)
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)
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)
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)
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
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)
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
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
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
