DEPARTMENT OF COMMUNITY MEDICINE
MEASURING:
1) Morbidity
2) Mortality
3) Burden of Disease
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?
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
Social 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
UNDERSTAND WHAT MAKES PEOPLE UNHEALTHY
MEASURE DISEASE AND DEATH
Building Healthy Public Policy
Developing Personal Skills
PROMOTE HEALTH AND PREVENT DISEASE
Primordial
Tertiary
Primordial
PRIORITIES FOR IMPROVEMENT
Distal To Patient
Proximal To Patient
Distal To Patient
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
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
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
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
Complicated c/section – e.g. for premature labor.
Needs a general specialist (Obstetrician)
Uncomplicated caesarean section. Needs family physician or MO
Normal delivery – needs advanced midwife /midwife
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.
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
- 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
- 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