Society, Culture & Health Care system
Dr. Babar T Shaikh
The Aga Khan University, Karachi
1
“ New doctors advise that colostrum should be given. It is essential.
Our elders say that colostrum should be disposed off, therefore, we practice what our elders advise us to do”.
Mothers‟ focus group
Rural Sindh, Pakistan.
2
Health System
• a set of cultural beliefs and practices;
• the institutional arrangements; and • the socio-economic, political & physical context Health system includes environmental conditions, nutrition, water supply, education, housing, status of women, social structures, economic and political system
3
Factors influencing health service utilization
Socio-demographic factors
•Age/sex of child •Family size/ parity •Education •Occupation
4
Economic factors
•Possession of household items •Possession of cattle •Possession of agriculture land •Type of residential house
5
Physical accessibility factor
•Availability of the transport •Physical distance for Health Facility/Health Care Provider •Time taken to reach Health Facility/Health Care Provider
6
Financial accessibility factors
•Fare spent for one round trip to Health Facility/Health Care Provider •Total amount spent for treatment of last illness (excluding fare)
7
Health service factors
•Attitudes of health provider
•Satisfaction with the treatment •Received medicines from Health Facility/Health Care Provider •Received prescription for medicines to be purchased from bazaar
8
Mother‟s autonomy
•Freedom to visit HF alone •Permission to spend money on health •Decision power in emergency situation
9
Conceptual framework of Kroeger
Socio-demographic factors
•Age/sex of child •Family size/ parity
Financial accessibility factors
•Fare spent for one round trip to HF/HCP •Total amount spent for treatment of last illness (excluding fare) Mother‟s autonomy •Freedom to visit HF alone
•Education •Occupation
Economic factors •Possession of household items •Possession of cattle •Possession of agriculture land
Govt./ Private HF/HCP
•Permission to spend money on health •Decision power in emergency situation Health service factors •Attitudes of health provider •Satisfaction with the treatment •Received medicines from HF/HCP
•Type of residential house
Physical accessibility factor
•Availability of the transport •Physical distance for HF/HCP
•Time taken to reach HF/HCP
•Received prescription for medicines to be purchased from bazaar 10
Challenges
Knowledge of illness/wellness and of services available Perceptions of services/service providers Risk/symptoms assessment Cultural “prescriptions” Social barriers/social pathways to care Etc…
11
Changing disease patters
Advances in biomedical/ clinical sciences Health Sector Reform
Health Sector Change Agents
Global perspectives on health and health care New specializations/ professions Ethical issues: New dimensions Information/ Communication revolution Globalization
12
PROVISION OF HEALTH CARE
Focus on Life-styles
Focus on the Environment Shift focus from individuals to populations Cost-effective health care
PRODUCING HEALTH
Evidence-based decision/ policy
Resources to sector that contribute to health
13
HEALTH CARE SYSTEM: TYPES AND COMPONENTS
T R A D I T I O N A L
PRIMARY
Physicians‟ office Dispensaries NGO/Community Groups BHU/RHC
SECONDARY
P R I V A T E
M O D E R N
Clinics/Maternity homes Tehsil Hospitals NGO-run clinics/hospitals
TERTIARY Distric Hospitals Large Urban Hospitals
P U B L I C
14
Outreach/Communitybased activities [Immunization, malaria control, MCH, FP]
GOVT. (PUBLIC) HEALTH DELIVERY SYSTEM (4 TIERS)
PHC Facilities (OPD)
TEHSIL & DISTRICT HQ. Hospitals
Tertiary Care Hospitals
15
1 - 2 Million Pop
DISTRICT HQ HOSPITAL (80 - 100 Beds)
50,000-1 ml. Pop
PUBLIC HEALTH DELIVERY SYSTEM
25-50,000 Pop
TEHSIL HQ HOSPITAL (40 - 50 Beds)
RURAL HEALTH CLINICS (Extensive OPD; 10-20 Beds)
10-20,000 Pop
BASIC HEALTH UNITS (Preventive & Curative; mostly OPD)
16
IMMUNIZATION PROGRAM
MCH SERVICES
PREVENTIVE HEALTH SERVICES
FP SERVICES
LHW PROGRAM [45,000 LHW /2000; Target 1:1,000 Pop]
17
Insufficient focus on Prevention/Promotion
Gender Imbalances Excessive centralization of management Political Interference
Lack of openness Weak human resource development Lack of integration
GOVT. HEALTH SERVICES: WEAKNESSES
Lack of Healthy Public Policy
18
Problem areas
POVERTY
ILLITERACY
PROBLEM AREAS
LOW STATUS OF WOMEN
INADEQUATE SANITATION & WATER SUPPLIES
POOR QUALITY OF HEALTH SERVICES
19
Income influences health
• People
in the top income bracket are healthier than middle income earners • Middle income earners are, in turn, healthier than people with low income
• This means that the poorer people are, the less healthy they are likely to be.
20
Social status affects health
• It affects health by determining the
degree of control people have over life circumstances • It affects their capacity to act and make choices for themselves • Higher social position and income somehow act as a shield against disease.
21
Gender influences health
Gender is linked more to the roles, power and influence society gives to men and women, than it is to their biological differences.
22
Culture influences health
Culture and ethnicity influence how people link with health system, their access to health information and their lifestyle choices.
„Dominant‟ cultural values largely determine the social and economic environment of communities.
Result:
Marginalization Loss/devaluation of culture and language Lack of access to culturally appropriate health services
23
Health Care system 25%
Biological endowment 15% Physical environment 10%
Socio-economic environment 50%
Estimated Health Impact of Determinants of Health on Population health Status: CIAR 1997
24
Population Health Approach
• Focuses
on the entire range of individual and collective factors (income and social status, education, employment and working conditions, social environment, physical environment, gender, culture, personal health and coping skills, healthy child development, health services) • The interaction among these factors
25
Population Health Approach
• Health is determined by the complex
interactions between individual characteristics, social and economic
• Strategies to improve population health must
address the entire range of factors that determine health
• Important health gains can be achieved by
focusing interventions on the health of the entire population/significant sub-populations rather than individuals
26
Population Health Approach
• Improving health is shared responsibility
that requires the development of healthy public policies in areas outside the traditional health system
• The health of a population is closely
linked to the distribution of wealth across the population
27
Creating a Healthy Community
Community Economy
Environment
Based on a model from: Hancock, Trevor. 1993, “heath, human development and community ecosystem: three ecological models”
28
Health Services
towards „broader resources‟ to support well-being • the design: services to maintain and promote health, to prevent disease, and to restore health system functioning to contribute towards population health.
• move
29
30