Health Care

Determinants
Dr Kameel Mungrue
MBBS MPH FRIPH MBA
Senior Lecturer
Primary Care and Public Health

What is medicine?

Art/Science/both
To laugh often and much; to win the respect of
intelligent people and the affection of children
to appreciate beauty, to find the best in others; to
leave the world a bit better, whether by a healthy
child, a garden patch, or a redeemed social
condition; to know even one life has breathed easier
because you have lived. This is to have succeeded.

- Ralph Waldo Emerson (1803 - 1882)

Diseases are
always generated
Defined

Symptoms & signs

x

Doctors
Define
Aetiology
pathophysiology

Measure the burden of

disease

determinants

It follows a course
(natural history)

Informs Therapeutic
practice

pay

Design
systems to
foster
health
Promote
Prevention

utility

outcomes

Experienced
by Pt
Different notion of
disease
Explication of their
symptoms

Health

What is health?

Public Resource
Commodity
A basic human right
Relative
Contingent on circumstances
Absence of disease

General aim is to promote, protect and restore

Health

Health is a state of complete physical,

mental and social well-being and not
merely the absence of disease.
WHO

Definition

A determinant of health is a factor or

characteristic that brings about a change in
health, either for the better or the worst.

May be diverse e.g.

Exercise
Arsenic in the water supply
Sun exposure too much or too little

Epidemiology:Porta 2008

Who what where when how

The study of the occurrence and distribution
of health-related states or events in
specified populations, including the study of
the determinants influencing such states,
and the
application of this knowledge to control the
health problems.

Determinants of Health

They are sometimes divided into:

Proximal
Distal

Or classified as:

Social
Environmental
Biological
genetic

A proximal determinant of health is one that is

near (time /distance) to the change in health
status

Readily and directly associated with change.

Also called downstream factors.

A distal determinant of health is one that is distant

in either time or place from the change in health.

Not readily identified because of other intervening events

and locations.
Upstream factors (e.g. globalization, government policies)

What are the determinants of health?

Social

Heredity (Genetic)
Environmental

Life sustaining elements: (sufficient)food,H2O,air,shelter.

Life threatening elements: (protection) natural & man made

Lifestyle (eating, drinking, smoking & sex)

Services & Policies: access, demand & supply focus
(prevention, Promotion)

WHY?

It attempts to identify causes of health

status change that are amenable to
intervention e.g.

Level of physical activity

Social isolation
Poor nutrition
But not age

Case Study
Kavita is a 6 yr child old girl from watapaharo in
Tabaquite.
she was playing with other children in the yard
when she got stuck with a nail.
Her mother washed the wound and bandaged it.
After several days the wound remained
oedematous, red and hot, with a purulent
discharge.
Kavita complained to her mother of a pain in the
groin and fever.

Next day her mother took her to the Tabaquite HC

and after several hours and much convincing of
the nurse in charge finally saw the doctor.
The doctor felt unsure of the diagnosis and
referred her to the Sangre Grande Hospital.
Again after several hours of waiting in the A & E
Dept of the SGH she was finally admitted.

She died several hours later.

List the possible determinants of Kavitas

death.

(possible) determinants of Kavitas

death

Septicaemia / septic
shock/DIC (x)
Gas gangrene
Tetanus
The nail (environmentalproximal)
The environment- no
playground with facilities
No shoes
poverty
immunization

Poor housing
Poor wound management
Poor knowledge about wound
management
Education
Gender
Poor health care facilities
Ethnicity
Social class
Prejudice
Rural/urban (access to HC)

While each factor may individually have an

effect on health, there is a complex
interaction between them, hence they do
not occur in isolation.
Hence ascribing health outcomes solely to
one factor or another provides an
incomplete picture
Ken Rothman calls it the web of causation

socioeconomic

Income, wealth & poverty

Level of education
Gender
ethnicity

gender

ethnicity

wealth

education

Diseases occurring in
groups/populations

Epidemiological model (triad)

Host
Time,
Place
person

environment

agent

Endogenous
Genetic
Immunity
Aging
Exogenous

Host

Organism (human or animal)

Host may or may not get the disease
Carrier

Contains, spreads,harbours an infectious

organism
Often absent clinical manifestations
Short/lifelong (typhoid), TB

6 types of carriers

Active: recovered from the disease but continues to harbour

the organism
Convalescent: in the recovery phase
Healthy: no illness or symptoms
Incubatory
Intermittant
Passive: no signs or symptoms same as healthy
A vector is a non-humancarrier of disease e.g. insect, rat.
Fomites are inanimate objects that server a ole in disease
transmission
Reservoir:living and inanimate where organisms live &
multiply

Host

Age
Sex
Ethnicity
Religion
Marital status

Host

Occupation
Socioeconomic status(income/living
conditions/education)
BMI
Behaviors eg diet, sex, recreation

Environment

Biologic (physiological) environment

Physical (ecological) environment
Social environment

Behavior
culture

Environment

Geographical distribution

Spatial epidemiology
Linking disease occurrence with nuclear plants, mining,
electric cables, emissions, floride , lead,.
Climate (rainfall, global warming, sahara dust,
altitude.)
Economic factors (income)
urban {drugs}, rural, housing, water supply, inhabitants
(Eskimos & CHD, american indians & DM, migration)

Agent

Pathogen (disease causing organism)

Bacteria
Viruses
Worms
Chemicals
Plant or animal substance

Time

Point (source) epidemic

Comparison of trends
Comparison of frequency at different periods
Cyclic/season variation
Linkage to social,biologic,physical or chemical
event or change that occurred with time
(clustering in time) eg polio & tonsillectomy

"A physician faced with a suffering patient

has an obligation to make things better. If
she sees 100 patients the obligation
extends to all of them. And if a society is
making people sick?" What then? Where
does the realm of clinical medicine stop and
the realm of public health begin?

Alma Ata

Primary health Care

On the whole, people are healthier, wealthier and

live longer today than 30 years ago. If children
were still dying at 1978 rates, there would have
been 16.2 million deaths globally in 2006. In fact,
there were only 9.5 million such deaths. This
difference of 6.7 million is equivalent to 18 329
childrens lives being saved every day

WHY?

The global health economy is growing

faster than gross domestic product (GDP).
Knowledge and understanding of health are
growing rapidly
Technological revolution
a better-educated and modernizing global
society

intensified exchanges between countries, often in

recognition of shared threats, challenges or
opportunities
BUT, there remains!
health inequalities
Ageing and the effects of ill-managed urbanization
and globalization accelerate worldwide
transmission of communicable diseases, and
increase the burden of chronic and
noncommunicable diseases.

Who will ensure ?

access
delivery
financing

citizens, professionals and politicians.

The governance of health is a major challenge for

ministries of health, that must provide health
leadership.
They can no longer be content with mere
administration of the system:
they have to become learning organizations which
requires inclusive leadership that engages with a
variety of stakeholders beyond the boundaries of
the public sector, from clinicians to civil society,
and from communities to researchers and
academia.

Primary health Care

primary care provides a place to which people

can bring a wide range of health problems it is
not acceptable that primary care would only deal
with a few priority diseases
primary care is a hub from which patients are
guided through the health system it is not
acceptable that, primary care would be reduced to
a stand-alone health post or isolated communityhealth worker

primary care facilitates ongoing relationships

between patients and clinicians, within which
patients participate in decision-making about their
health and health care

it builds bridges between personal health care and

patients families and communities

not acceptable that, primary care should be

restricted to a one-way delivery channel for
priority health interventions

primary care opens opportunities for

disease prevention and health promotion as
well as early detection of disease

it is not about treating common ailments

primary care requires teams of health

professionals: physicians, nurse
practitioners, and assistants with specific
and sophisticated biomedical and social
skills
it is not acceptable that primary care would
be synonymous with low-tech, nonprofessional care for the rural poor who
cannot afford any better

primary care requires adequate resources and

investment, and can then provide much better
value for money than its alternatives
it is not acceptable that primary care would
have to be financed through out-of-pocket
payments on
the erroneous assumption that it is cheap and the
poor should be able to afford it.

What is a health care system?

Comprises all institutions, organizations and

resources that are devoted to producing health
actions, health actions is defined as any effort,
whether in personal health care, public health
services or intersectorial initiatives whose
primary purpose is to improve health.

Health transition

Encompasses 3 specific and interrelated

shifts

demographic

epidemiological

fertility, mortality, aging of the population

changes in the pattern of diseases

social

rise in knowledge and expectations of the health

system

Total deaths f r om i nf ectious di seases f or the per i od, 1950-60.

1400

1200

1000
T otal deaths f r ominf ectious disaeases
TB

800

T yphoid Fever
tetanus
600

Diphter ia
Malar ia

400

200

Y ear

di str i buti on of deaths f r om chr oni c di seases

4000

3500

3000
Malignant neoplasms

2500

DM
2000

CVA
AMI

1500

total no of deaths (chr onic diseases)

1000

500

ti me ( year 0

Di str i buti on of deaths f r om chr onic di seases and i nf ectious di seases over the per i od 1944-1979

4000
3500
3000
2500
2000
1500
1000
500
0

T i me (year )

352 315 351 367 398 411 469 493 530 1183 1312 1606 1559 1697 1682 1747 1680 1599 1646 1749 1935 1851 1948 1933 2052 2930 3140 2819 3321 3449 3208 3350 3688 3581 3509 3621 3455 3167
3790 4030 4005 4378 4298 4348 4590 4428 4604
total deaths selected inf ectious diseases

SDR and change i n % popul ati on 1953-77

18
16
14
12
10
8
6
4
2
0
1953 1954

1955 1956 1957 1958

1959 1960 1961 1962

1963 1964 1965 1966 1967

y ear

1968 1969 1970 1971

1972 1973 1974 1975

1976 1977

Maj or di seases contr i buti ng to IMR

c hanges i n I M R ov er the per i od 1953- 92

IMR

100
50
0
IMR Year

E nter itis/ DD
congenital malf or mations
CHD
1980

1981

1982

1983

P neumonia
spina bifi da

y ear

Vital functions

Service provision
Resource generation
Financing
Stewardship

Fundamental objectives

Improving the health status of the people they serve

Responding to peoples expectations, demands & needs
Providing financial protection against the cost of ill-health

Why do health care systems matter?

Provide interventions against particular diseases

Promotion of healthy lifestyles
Insecticide spraying
Anti-tobacco campaigns
Protection of food and water
Urban sanitation
Personal hygiene

Non-health interventions

Per capita income

Female education

What is the perfect health care system ?

Free at the time of need

High class system of primary care with
gatekeeper role into the secondary system
Equal access to primary and secondary care
universality (available to all & all health services)
Comprehensiveness

Millennium Development Goals

Sept 2000, United Nations Millennium
summit.
189 countries adopted a set of timebound and
measurable goals and targets for combating:

poverty, illiteracy, environmental degradation

hunger, discrimination against women, Human
rights, good governance, democracy
disease

8 Goals

Goal 4: reduce child mortality

Goal 5: improve maternal health

reduce by 2/3 1990-2015 maternal mortality ratio

Goal 6: Combat HIV/AIDS, malaria & other

reduce by 2/3 1990-2015 <5 mortality rate

halt the spread of HIV

Goal 7: ensure environmental sustainability

IMR

Maternal Mortality

Canada 5.3 per 1000 live births

Haiti 80.3
T & T 15
Haiti 523 per 100 000 live births

HIV prevalence 1% (average)

Measles vaccination coverage

malaria transmission
tuberculosis
concept of essential drugs