DEPARTMENT OF COMMUNITY MEDICINE

DEPARTMENT OF COMMUNITY MEDICINE

ASSESS

MEASURING:

1) Morbidity

2) Mortality

3) Burden of Disease

AND

UNDERSTAND WHAT MAKES PEOPLE UNHEALTHY

EXAMPLES OF MORBIDITY DATA

BURDEN OF DISEASE

MORBIDITY

EXAMPLES OF BURDEN OF DISEASE DATA

SOURCES OF MORBIDITY DATA

Impact of disease on a population

Amount of disease / how widespread it is

Measures of morbidity

• Incidence: Number and rate
• Prevalence: Number and rate

• Population-based sources
• Population-based surveys
• Facility or institution-based sources (clinics / hospitals)
• District health information system
• Surveillance
• Disease notification

• Measured by the Disability-adjusted-life-year (DALY).

• Time-based measure combines:
• YLL - years of life lost due to premature mortality

AND

• YLD - years of life lost due to time lived in states of less than full health (non-fatal ill-health)

• DALY = YLL + YLD
• Healthier population = lower DALY’s

The NEW cases of a disease occurring in a defined population at risk during a given period of time

The existing cases of disease in a defined population during a givenperiod of time

What are some of the limitations of using facility-based data sources for measuring population health?

Cure or Mortality

Deaths

MORTALITY

EXAMPLE OF MORTALITY DATA

Common ways of measuring mortality:

• Number of deaths
• Mortality rates (different types)
• Causes of death

Sources of mortality data

• Notification of deaths
• Health workers at health facilities (important role played by doctors)
• Mortuaries)
• Notification to Home Affairs => issue death certificate

DETERMINANTS OF HEALTH

BEHAVIOURAL AND SOCIAL DETERMINANTS OF HEALTH

BEHAVIOURAL DETERMINANTS OF HEALTH

SOCIAL DETERMINANTS OF HEALTH

Why is understanding behavioural risks important?

Not a new idea……..

The circumstances in which we grow, live, work, and age AND the systems put in place to deal with illness

Behaviours are responsible for significant BOD

• Sexual behaviour HIV
• Drunk / unsafe driving road traffic injuries
• Smoking, unhealthy diet, physical inactivity heart disease

What is a determinant?

• An influencing or determining element or factor
• A thing that controls or influences what happens

Merriam Webster Dictionary

• A determining or causal element or factor

The Free Online Dictionary

What are determinants of health

• Multiple and varied factors that
• Influence the health of a population
• Cause populations to be unhealthy

NB: Your behaviours are influenced by the social and physical environment in which you live and work

PUBLIC =HEALTH FOCUS

Biological Determinants

Social Determinants

Behavioural Determinants

Hippocrates: 460-377 BC

Distal To Patient

Proximal To Patient

Distal To Patient

MEASURE DISEASE AND DEATH

EXAMPLES OF THE EFFECTS OF SOCIAL DETERMINANTS OF HEALTH

WHY ARE THE SOCIAL DETERMINANTS OF HEALTH IMPORTANT?

Employment: mortality rates in manual vs. non-manual workers (deaths per 100 000 people)

Income inequality and child mortality rates

(deaths per 1000 children)

PERSONAL

SOCIETAL

Understanding the social determinants of health influences your practice as a doctor

Reduction in TB mortality in 19th-20th century had little to do with diagnosis and treatment

… according to HPCSA, all medical graduates in SA should have competencies to advocate for SDH

Social determinants of health lead to health inequities (unfair and unjust differences in health outcomes between groups)

SOCIETAL

Measuring the determinants with highest effect on health

• In clinical assessment: consider patient’s, family, environment and workplace (helps with understanding underlying causes of their health).

• Individual patients can take action on issues such as diet, alcohol intake, exercise and smoking, but they can only do so in the context of the socio-economic factors that affect their ability to take action.

• Need to understand the social barriers to a healthy lifestyle => so can provide more realistic, appropriate health advice and care.

• Health professionals can use this understanding to advocate for their patients, engage with their families

PERSONAL

COMPETENCIES OF A MEDICAL GRADUATE AS DETERMINED BY THE HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA (HPCSA) IN 2011

Improved living conditions => less overcrowding

Smaller family sizes => less spread of disease

Improved nutrition and thus immunity => less susceptible

CONCLUSION

ASSESS

AND

UNDERSTAND WHAT MAKES PEOPLE UNHEALTHY

MEASURE DISEASE AND DEATH

INTERVENE

Building Healthy Public Policy

Developing Personal Skills

DELIVER HEALTH SERVICES

PROMOTE HEALTH AND PREVENT DISEASE

AND

Primordial

Tertiary

Primordial

MONITOR

AND

PRIORITIES FOR IMPROVEMENT

PERFORMANCE

Distal To Patient

Proximal To Patient

Distal To Patient

INTERVENE

UPSTREAM

DOWNSTREAM

HEALTH PROMOTION

Develop Personal Skills

5 Pillars of Health Promotion

Strengthen Community Action

Build healthy public policy

Re-orient health services

Create supportive environments

Distal To Patient

Sometimes we use more than one pillar of health promotion to tackle a given public health problem

Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.

Modify the environments to make it more difficult for people to adopt unhealthy behaviours

Examples:

• Taxes on unhealthy food, tobacco, alcohol
• Subsidise healthy food
• Laws to ban tobacco smoking in public places
• Laws to ban tobacco advertisin
• Road safety laws

The Ottowa Charter on Health Promotion

• Changing the built and natural environments (such that healthier choices are easier for people to make
• Health promotion takes place in settings where people live, learn, work, play) – e.g. cities, schools, neighborhoods, workplaces, prisons, hospitals, etc
• Workplace safety
• Measurement of number of accidents deaths in the workplace
• Identification of risk
• Legislation to protect workers

• Re-orient means shifting focus of the health sector.

• Health sector’s role should include health promotion => move beyond merely diagnosing and treating disease

• Health sector should work with other sectors to improve health (advocacy)

• Health professional training including health promotion

Examples:

The health sector focusing on healthy eating rather than on surgery to reduce the impact of heart disease

Doctors prescribing physical activity before the development of conditions such as diabetes

Setting up self-help groups in health facilities

Health professionals working with schools to support road safety education

Collective efforts by communities directed at increasing community control over the determinants of health

…..empowering communities to play an active role in: setting priorities, planning, and implementing strategies for their better health

Build healthy public policy

Create supportive environments

Re-orient health services

Strengthen community action

Develop personal skills

WHO 1986

HOW WOULD YOU ADDRESS DIABETES USING THE 5 PILLARS OF HEALTH PROMOTION?

World Health Organization: Ottawa Charter, 1986

Proximal To Patient

PROMOTE HEALTH AND PREVENT DISEASE

PREVENTION OF DISEASE

UPSTREAM

DOWNSTREAM

Various actions aiming to:

• Prevent exposure to risks
• Preserve health
• Restore health when it is impaired
• Minimize disability, death

These goals altogether => what we refer to as the “levels of prevention”

ASSESSING THE HEALTH OF POPULATIONS, PROMOTING HEALTH AND PREVENTING DISEASE, DELIVERING HEALTH SERVICES AND HEALTH SYSTEM PERFORMANCE

INTERVENE

UPSTREAM

DOWNSTREAM

HEALTH SYSTEM BUILDING BLOCKS

INTERMEDIATE OUTCOMES

HEALTH WORKFORCE

HEALTH FINANCING

HEALTH SYSTEMS

DELIVERY OF HEALTH SERVICES

Delivering the needed interventions through facilities

A System for Delivering Health Services

The services cater for patient’s non-medical needs and expectations

No. of health facilities, conveniently located, equipped, staffed

Patients are able to pay for service (income and ability to pay)

Produce enough SKILLED health workers, place them where they are needed, retain them

Delivering health services means making sure facilities are available where people can receive the services (e.g. clinics, hospitals)

A system for producing data on population health and determinants

• A high % of people who need the interventions actually receive them.

• Services provided according to standards

A system for buying and delivering the right quantities of drugs, vaccines, equipment to where needed

Despite health promotion and prevention, people do develop disease and need clinical care....

How do we deliver health services so those who need curative care can get it?

And….how do we deliver “re-oriented” health services that also focus on prevention?

Public health is concerned with making sure people get the health services they need

WHAT DO WE MEAN BY HEALTH SERVICES?

Personal health services (provided to people)

promotive, preventive, curative, rehabilitative interventions What personal health services would a diabetic need?

Non-personal health services (environmental health services)

E.g.: water, air quality; sanitation; food safety

WHAT ELSE IS NEEDED TO DELIVER HEALTH SERVICES?

• Not cause harm to those who provide and use the services

A system for raising money from different sources, and using the funds to pay health service providers

Competent leaders / management to oversee system

DELIVER HEALTH SERVICES

SOUTH AFRICAN HEALTH SYSTEM

PUBLIC SECTOR

SOUTH AFRICAN HEALTH SYSTEM

NATIONAL DEPARTMENT OF HEALTH

NIOH /

NICD /

NHLS

Services are provided NOT FREE OF CHARGE

PUBLIC SECTOR

PUBLIC SECTOR

PROVINCIAL DEPARTMENTS OF HEALTH

PRIVATE FOR PROFIT SECTOR

PRIVATE NOT FOR PROFIT (NON-GOVERNMENTAL)

24-hour service

Family physicians, MOs

Includes trauma, emergency, out-patients, paediatrics, obstetric care.

MAY employ specialists (PAED, O&G, general surgery)

• Sub-specialist care only. These hospitals use high level technology and highly trained staff (sub-specialists)
• Very high specialized services = high cost . Specialised referral units for the other hospitals.

LOCAL GOVERNMENT HEALTH SERVICES

PRIVATE HEALTH CARE SERVICES

DISTRICT HEALTH SERVICES

DISTRICT HOSPITALS

CENTRAL HOSPITALS

HOSPITALS

ENVIRON-MENTAL HEALTH SERVICES

24-hour service

Nurses, maybe MOs

• General specialist and some sub-specialist care.
• Receive referrals from regional hospitals.

Government providers

• Provincial and local government

Key service delivery platforms: clinics, CHCs, hospitals

Promotive, preventive, curative and rehabilitative services

TERTIARY HOSPITALS

GENERAL PRACTITIONERS

/ PRIMARY HEALTH CARE PRACTICES

COMMUNITY HEALTH CENTRES

There are laws (the Constitution and National Health Act) that define the health service delivery responsibilities of different levels of government:

• National: makes policy
• Provincial: delivers personal health services
• Local: delivers environmental health services

Private providers

• Independent general practitioners
• Hospitals: three major hospital groups

Traditional health practitioners

Mostly curative services

Mainly target specific issues (e.g. HIV) or groups (pregnant women)

Preventive, some curative

Advocacy and social mobilization

8-12 hour service

Nurses, rarely doctors

• General specialist and some sub-specialist care.
• Receive referrals from regional hospitals.

REGIONAL HOSPITALS

CLINICS

Services are provided FREE

Each province has several District Health Departments, each with it's own management team

COMMUNITY BASED HEALTH SERVICES

9 Provincial Departments of Health

SPECIALIST HOSPITALS

8 hour service

Nurses (public) + community health workers (NGOs)

• Psychiatric hospitals, TB hospitals, Rehabilitation facilities

MATERNAL SERVICES

CENTRAL HOSPITAL

Caesarian section in a woman with heart disease. May needs intensive care and cardiac care.

Caesarian section in a diabetic woman carrying twins. Needs obstetrician & neonatologist

TERTIARY HOSPITAL

REGIONAL HOSPITAL

Complicated c/section – e.g. for premature labor.

Needs a general specialist (Obstetrician)

DISTRICT HOSPITAL

Uncomplicated caesarean section. Needs family physician or MO

COMMUNITY HEALTH CENTRE

Normal delivery – needs advanced midwife /midwife

CLINIC

Antenatal care – needs professional nurse

SOUTH AFRICAN HEALTH SYSTEM

PRIMARY HEALTH CARE

DISTRICT HEALTH SERVICES

PHC SERVICES IN SA: Range of services for women and children: maternal and child health, immunizations, family planning, TB, HIV services, etc.

• Provides a way of decentralising the administration of health services
• Decisions would be made locally (closer to where services are provided)
• Allows people who would use the services to be involved – easier to set up structures for engaging them in the delivery of services (e.g. clinic committees)
• District health system created for delivering Primary Health Care

“Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain…… it forms an integral part of the country's health care system ..... and of the social and economic development of the community. .....

• District health services within each district make up the district health system
• Each district is a geographically-defined area that includes a well-defined population.
• Each district has ONE district health management team (DHMT) responsible for the planning and delivery of public sector health services for the people living in that district.
• Within the district health system there are other providers of health services (but not under the DHMT):
• Local government: environmental health services
• Private sector services (for-profit and NGOs)

In South Africa, district health services = primary health care services

PHC services are …

……..the first level of contact with individuals, the family and the community …. bringing health care as close as possible to where people live and work and constitutes the first element in the continuing health care process

PHC includes promotive and preventive services

ELEMENTS OF ESSENTIAL HEALTH CARE

• Education concerning prevailing health problems and methods of preventing them
• Promotion of food supply and proper nutrition
• Maternal and child health, including family planning
• Immunisation
• Prevention and control of endemic diseases
• Appropriate treatment
• Water and sanitation
• Provision of essential drugs

Primary Care 101

• A package of PHC services for adults with HIV, diabetes, and other common conditions needing primary care level
• Guided by national policy and guidelines
• Comprehensive services – curative, preventive and rehabilitation
• All clinics, CHCs , district hospitals should have equipment and drugs to provide this package of services

Define people in the district

Decide on how to deliver services to meet needs

Determine their health needs

One team to manage all services

WHO: Declaration of Alma Ata, 1978

SOUTH AFRICAN HEALTH SYSTEM

PRIMARY HEALTH CARE: Participation of Communities

PRIMARY HEALTH CARE: Intersectoral Collaboration

PRIMARY HEALTH CARE: Universally Accessible Services

PRIMARY HEALTH CARE:

Sustainable Cost for Community and Country

• PHC requires and promotes maximum community and individual self reliance.
• Community participation is about ensuring meaningful engagement with communities.
• People have the right – and duty – to participate, individually and collectively, in the planning and implementation of their services.
• Participation important so that health services are accountable to communities.
• Mechanisms to ensure that this happens. – e.g. clinic committees

• PHC emphasises addressing the social determinants of health

• So, delivering PHC needs the health sector

AND

• Also other sectors (e.g. education, agriculture, water) = need inter-sectoral action

Appropriate Technology

• Technology which is scientifically sound, adaptable to local needs, and acceptable to those who apply it and for whom it is used.
• Suitable for the particular area and situation it is used in, i.e. it is sensitive to that area’s environmental, cultural, social and economic concerns.

Equity in access to health services

• Those who need the services should be able to use them when needed (according to need and not ability to pay);
• Also, the quality of health services is good enough; and
• The cost of using care does not put people at risk of financial hardship.

PERFORMANCE

HEALTH SYSTEM PERFORMANCE

HOW DO WE MEASURE HEALTH SYSTEM PERFORMANCE?

HEALTH SYSTEM PERFORMANCE

Responsiveness

Improved Health

Efficiency

Financial Risk Protection

Is the health system meeting health service users’ expectations of how they should be treated by health providers?

Level: are morbidity, mortality and BOD improving?

Equity: are differences in morbidity/mortality between richest and poorest communities getting smaller/bigger?

Delivering services with minimal waste of resources.

HEALTH EQUITY

LEVEL OF HEALTH

HEALTH EQUITY

Over spending of health budgets

Managers do not know what money is spent on

E.g.:

SA: doing better with improving level of health…

Than with reducing health inequities

Some communities are affected more than others – due to differences in e.g. socio-economic status

Health systems should monitor:

are there differences between groups?

are these differences unjust or unfair?

BOD reducing and some improvements in morbidity and mortality

E.g. improved IMR

2000 – 2011

BUT: BOD still high relative to other LMICs

ALSO:

Average IMR does not show (in)equity in health

Need to also measure health (in)equity

People can access the quality health services they need without experiencing financial hardship.

SA: PHC services are free, but hospitals not free and private services not free. People spend significant amount of money on health.

SA: problems with meeting expectations of service users

• Not much choice
• Service not prompt: long waiting times
• Amenities unclean
• Patients complain no respect - dignity, privacy, confidentiality

Maternal Mortality Ratio by district

Wide differences between districts

Key:

• White = Unqualified
• Blue = Qualified
• Black = Adverse/disclaimer

Performance is managed against goals/outcomes

WHY IS THE PERFORMANCE OF THE SA HEALTH SYSTEM SO POOR?

Weakness in Building Blocks AND Access and Quality

PRIORITIES FOR IMPROVEMENT

WORKFORCE

SERVICE DELIVERY

WHAT SHOULD CHANGE?

CHALLENGES

FOCUS ON INTERVENTIONS THAT WILL MAKE A DIFFERENCE

PRIMARY HEALTH CARE

RE-ENGINEERING:

ENVISIONED MODEL

Many focus on prevention, some address “upstream factors”

CHALLENGES

• Services remain focused on hospital services > district health services
• Less focus on PHC strengthening
• Limited clinical staff at PHC facilities
• Greater focus on curative vs. prevention

IMPROVING THE WORKFORCE

IMPROVING SERVICE DELIVERY

Ideal Clinic Initiative

Policy on Re-engineering of Primary Health Care

ENTRY

• Too few health workers – not producing enough; not able to retain them
• Wrong skills or poor skills => poor patient care
• Distribution not equitable - not working where the need is greatest
• Private vs. public
• PHC vs. tertiary facilities
• Urban vs. rural
• Poor staff morale => high absenteeism, emigrate

PERFORMANCE

To improve service delivery and access (availability)

WARD BASED OUTREACH TEAMS

• Managing performance - accountability
• Remuneration

Teams of trained community health care workers who would provide “outreach” to households

Each team is supervised and supported by a nurse (Outreach team leader).

Focus on prevention and promotion

Main activities of WBOTs

• Assess health status of individuals in households
• Provide health education
• Identify those in need of preventive, curative or rehabilitative services (e.g. those in need of immunization or antenatal care)
• Refer those in need to PHC facility

DISTRICT CLINICAL SPECIALIST TEAMS

Team members

• Family physician
• Obstetrician
• Paediatrician
• PHC nurse
• Advanced midwife
• Advanced paediatric nurse
• Anaesthetist

Roles

• Strengthen clinical governance
• Provide treatment guidelines (and make sure that they are used)
• Ensure that essential equipment available
• Ensure that mortality review meetings take place
• Monitor health outcomes
• Support clinicians

4 streams

• PHC Ward Based Outreach teams

• District Clinical Specialist Teams

• Integrated school health programme

• Contracting private health practitioners (non specialists) to work in public sector

EXIT

INTEGRATED SCHOOL HEALTH SERVICES

Production of health workers

• Number (how many?)
• Increasing numbers each year – doctors in medical schools
• Medical school in Limpopo, UJ, Mpumalanga
• Cuban Programme
• New cadres of health workers
• Mid-level workers – clinical associates
• Community health workers
• School health nurses
• Curriculum => appropriate skills / type

Distribution of health workers

• Training location

• Provided by teams of nurses to school-going children (learners)

• Outreach from clinics to schools (nurses not stationed at schools- HR shortage)

• Focus on Quintile 1 and 2 schools (resource-poor schools)

• Focus is prevention and health promotion: health education, identifying barriers to learning, screening

• An Ideal Clinic is defined as a clinic (or CHC) with good infrastructure, adequate staff, adequate medicine and supplies, good administrative processes, and sufficient adequate bulk supplies. It uses applicable clinical policies, protocols and guidelines, and it harnesses partner and stakeholder support.

• An Ideal Clinic also collaborates with other government departments, the private sector and non-governmental organisations to address the social determinants of health.

CONTRACTING PRIVATE GPs FOR PUBLIC SECTOR PHC

• Have always contracted doctors to provide hospital services

• Extending this to PHC level

• AIM = improve accessibility of primary care srevices

• Improve outcomes

• Could be extended to other providers

• Managing attrition
• Retention in public sector - financial incentives (occupation specific dispensation)
• Retention in rural areas (rural allowance)

National priorities for improving health system performance

FINANCING

QUALITY

IMPROVING FUNDING

FINANCING FLOWS

IMPROVING QUALITY

CHALLENGES

Health care that:

• takes into account the preferences and expectations of users and cultures of their communities
• does not vary in quality because of user characteristics (sex, race, geographical location, socio-economic status;

• Office for Health Standards Compliance (OHSC) established

• Sets standards to which all facilities must comply

• Facilities are inspected and reports generated.

• OHSC to inspect facilities and assess against core standards; accredit health facilities that comply.

CHALLENGES

IMPROVING FUNDING

SERVICE PROVISION

SERVICES COVERED

• The NHI Fund will decide on a defined package of services to be delivered to all South Africans.
• Package (and criteria for choice of package) has not been defined but likely to be comprehensive.
• May include all currently available services.
• May exclude some high cost, low volume services (highly specialised services).
• All South Africans will have an NHI card which will entitle them to use the defined package of services

• NHIF will fund certified and accredited public and private providers to deliver services.
• NHI providers will be certified and accredited by the Office for Health Standards and Compliance (to ensure funded providers meet the quality standards).
• All public sector providers will be funded – how much will be determined by the NHIF.
• Public sector hospitals likely to be funded according to the number of patients in a particular diagnostic related group (importance of ICD 10 coding)
• Districts likely to be funded on a per capita basis – every person in their district / catchment population

PROGRESS

COSTS OF SERVICES PROVIDED AND COVERED

• Long waiting times
• Long queues
• Poor staff attitudes towards users

• Fairly slow
• White Paper published end 2015, final policy July 2017
• Implementation to take place over 14 years
• Three phases
• Phase 1 (5 years)
• Strengthening the delivery and quality of services
• Defining service packages
• Delegations and accountability
• Financial management
• Re-engineering PHC
• Ideal clinic initiative
• Office for health standards and compliance established

• All accredited providers participating in the NHI will be free (no user fees)
• All primary care services (public and private) will be free
• All public sector hospital services will be free
• Point of entry will be primary care level (public sector primary care facilities or GPs) and patients will need to be referred to hospital
• Services provided on a uniform basis (standardised) in all facilities.
• Guidelines for the management of disease will be used.

PUBLIC HEALTH BLOCK: 23 October 2017