A� I�TRODUCTIO�

to

SOCIAL MEDICI�E

Michaela Kostičová

Vojtech Ozorovský

Ladislav Badalík

Gregory Fabian

BRATISLAVA

2010

Editor Michaela Kostičová, MD, PhD Contributors Michaela Kostičová, MD, PhD assoc. prof. Vojtech Ozorovský, MD, PhD prof. Ladislav Badalík, MD, DSc Gregory Fabian, JD Language Subeditor Gregory Fabian, JD Peer Reviewers assoc. prof. Ivan Solovič, MD, PhD assoc. prof. Anna Volná, MD, PhD, MBA Darina Sedláková, MD, MPH

ISB� 978-80-7167-153-4

TABLE OF CO�TE�TS

PREFACE................................................................................................................................. 6 ACK�OWLEDGEME�TS..................................................................................................... 7 1 SOCIAL MEDICI�E (V. Ozorovský).............................................................................. 8

1.1 THE SCOPE OF SOCIAL MEDICINE..................................................................... 8 1.2 HISTORY................................................................................................................... 9

1.2.1 History of Social Medicine ................................................................................ 9 1.2.2 History of Public Health................................................................................... 12

2 HEALTH A�D DISEASE (V. Ozorovský, M. Kostičová)............................................. 14

2.1 HEALTH.................................................................................................................. 14 2.2 DISEASE ................................................................................................................. 14

2.2.1 Natural History of Disease ............................................................................... 15 2.2.1.1 The Agent...................................................................................................... 15 2.2.1.2 The Environment .......................................................................................... 15 2.2.1.3 The Host ....................................................................................................... 16

2.2.2 The Disease Process ......................................................................................... 16 2.2.2.1 Pre-pathogenesis .......................................................................................... 17 2.2.2.2 Pathogenesis................................................................................................. 17

2.2.3 Risk Factors for Disease................................................................................... 18 2.2.4 Disease Classification ...................................................................................... 20 2.2.5 Social and Economic Consequences of Disease .............................................. 22 2.2.6 Levels of Disease Prevention ........................................................................... 23

3 MEASURI�G THE HEALH OF THE POPULATIO� (M. Kostičová, V. Ozorovský)................................................................................................... 25

3.1 DEMOGRAPHY...................................................................................................... 26 3.1.1 Population Pyramid .......................................................................................... 28 3.1.2 Demographic Trends ........................................................................................ 29 3.1.3 Fertility ............................................................................................................. 30 3.1.4 Mortality........................................................................................................... 31

3.1.4.1 Life Tables .................................................................................................... 34 3.1.5 Migration.......................................................................................................... 35

3.2 EPIDEMIOLOGY.................................................................................................... 35 3.2.1 Definitions and Methods of Epidemiology ...................................................... 36 3.2.2 Measures of Morbidity ..................................................................................... 36 3.2.3 Screening.......................................................................................................... 37

3.2.3.1 Screening Tests vs. Diagnostic Tests............................................................ 38 3.2.3.2 Test Accuracy ............................................................................................... 38 3.2.3.3 Criteria for Screening Programs ................................................................. 39 3.2.3.4 The Individual Risks vs. Benefits.................................................................. 40

3.2.4 Epidemiologic Studies...................................................................................... 41 3.2.4.1 Observational Studies .................................................................................. 41 3.2.4.2 Experimental Epidemiology ......................................................................... 44

3.3 SUMMARY MEASURES OF POPULATION HEALTH...................................... 45 3.3.1 Healthy Life Expectancy.................................................................................. 45 3.3.2 The Burden of Disease ..................................................................................... 46

3.3.2.1 Disability-adjusted Life Year DALY............................................................. 47

3.3.2.2 Leading Causes of Morbidity and Mortality ................................................ 48

4 �O�-COMMU�ICABLE DISEASES (M. Kostičová)................................................ 50

4.1 CARDIOVASCULAR DISEASES ......................................................................... 51 4.1.1 Trends in Cardiovascular Disease Mortality.................................................... 51 4.1.2 Prevention of Cardiovascular Diseases ............................................................ 54

4.2 CANCER.................................................................................................................. 55 4.2.1 Trends in Cancer Mortality .............................................................................. 56 4.2.2 Prevention of Cancer ........................................................................................ 57

4.3 EXTERNAL INJURIES .......................................................................................... 58 4.3.1 Trends in External Causes of Mortality ........................................................... 58 4.3.2 Motor Vehicle Accidents ................................................................................. 59 4.3.3 Suicide and Suicide Attempts .......................................................................... 60 4.3.4 Domestic Violence ........................................................................................... 61 4.3.5 Homicide .......................................................................................................... 62 4.3.6 Prevention of Violence..................................................................................... 62

5 HEALTH OF VUL�ERABLE POPULATIO� GROUPS (M. Kostičová) ............... 63

5.1 FOCUS ON NON-DISCRIMINATION OF VULNERABLE GROUPS ............... 63 5.2 HEALTH OF WOMEN ........................................................................................... 64 5.3 HEALTH OF CHILDREN AND ADOLESCENTS ............................................... 65 5.4 HEALTH OF ELDERLY......................................................................................... 67 5.5 PERSONS WITH DISABILITIES .......................................................................... 71

6 ECO�OMY I� HEALTH CARE (M. Kostičová)........................................................ 74

6.1 BASIC CONCEPTS IN HEALTH ECONOMICS.................................................. 74 6.2 SUPPLY, NEED, DEMAND, AND UTILIZATION OF HEALTH CARE ........... 75

6.2.1 Need for Health Care........................................................................................ 76 6.2.2 Demand for Health Care .................................................................................. 77 6.2.3 Supply of Health Care ...................................................................................... 78

6.3 HEALTH CARE FINANCING ............................................................................... 79 6.3.1 The Macroeconomic Level of Health Care Financing ..................................... 79 6.3.2 The Microeconomic Level of Health Care Financing...................................... 83

6.4 COMPARING NATIONAL HEALTH SYSTEMS ................................................ 84 6.4.1 The Public-Integrated Model (Beveridge model) ............................................ 85 6.4.2 Public-Contract Model (Bismarckian model) .................................................. 86 6.4.3 The National Health Insurance Model ............................................................. 86 6.4.4 Mixed Private/Public System........................................................................... 86

6.5 THE HEALTH CARE SYSTEM IN SLOVAKIA .................................................. 88 6.5.1 Health Care Financing in Slovakia................................................................... 88 6.5.2 Health Care Reforms........................................................................................ 90

6.6 HUMAN RESOURCES FOR HEALTH CARE ..................................................... 91 6.6.1 Human Resources Planning ............................................................................. 91 6.6.2 Problems in Human Resources ........................................................................ 94

7 QUALITY I� HEALTH CARE (M. Kostičová) .......................................................... 96

7.1 INTRODUCTION.................................................................................................... 96 7.2 DEFINITIONS AND TERMS................................................................................. 96

7.2.1 Definition of Quality ........................................................................................ 96 7.2.2 Definition of Quality in Health Care................................................................ 97

7.2.3 Dimensions of Quality in Health Care ............................................................. 98 7.3 MEASUREMENT OF QUALITY IN HEALTH CARE....................................... 100 7.4 QUALITY ASSURANCE IN HEALTH CARE ................................................... 102

7.4.1 Models of Quality Assurance in Health Care................................................. 103 7.4.1.1 ISO model ................................................................................................... 103 7.4.1.2 EFQM model .............................................................................................. 104 7.4.1.3 Accreditation .............................................................................................. 105

7.5 CONCLUSION ...................................................................................................... 106 8 EQUITY I� HEALTH A�D HEALTH CARE (L. Badalík) .................................... 107

8.1 EQUITY IN HEALTH........................................................................................... 107 8.1.1 Equity in Health and the Social Determinants of Health ............................... 108

8.2 EQUITY IN HEALTH CARE ............................................................................... 109 8.2.1 Horizontal Equity ........................................................................................... 109 8.2.2 Vertical Equity ............................................................................................... 109

9 HEALTH A�D HUMA� RIGHTS (G. Fabian) ........................................................ 111

9.1 CONCEPT OF HUMAN RIGHTS........................................................................ 111 9.1.1 Difference Between Medical Ethics and Human Rights Obligations ............ 112 9.1.2 International Human Rights Laws and Norms............................................... 112

9.2 THE RIGHT TO HEALTH: A TOOLKIT FOR HEALTH PROFESSIONALS.. 113 9.2.1 The Aims of the Toolkit ................................................................................. 113 9.2.2 What is the Right to Health? .......................................................................... 114 9.2.3 What does the Right to Health Mean for Health Professionals and their Associations?.................................................................................................................. 115 9.2.4 What does the Right to Health Mean for Governments? ............................... 117 9.2.5 Summing up ................................................................................................... 119

10 TECH�IQUES A�D I�STRUME�TS I� SOCIAL MEDICI�E A�D PUBLIC HEALTH RESEARCH A�D PRACTICE (L. Badalík).................................................... 120

10.1 QESTIONNAIRES ................................................................................................ 120 10.1.1 Design of a Questionnaire .............................................................................. 120

10.1.1.1 Questionnaire Content ............................................................................... 120 10.1.1.2 The Construction of Questionnaire Items .................................................. 120

10.1.2 The Evaluation of a Questionnaire................................................................. 123 10.2 OBSERVATIONAL TECHNIQUES .................................................................... 124 10.3 INTERVIEW.......................................................................................................... 124

10.3.1 Interviewer ..................................................................................................... 125 10.3.2 Standardization of Interview Procedure......................................................... 126

REFERE�CES..................................................................................................................... 127 APPE�DICES ...................................................................................................................... 130

WORLD HEALTH ORGANIZATION............................................................................. 130 HEALTH21 - HEALTH FOR ALL POLICY FRAMEWORK FOR THE WHO EUROPEAN REGION ...................................................................................................... 132 EUROPEAN CHARTER OF PATIENTS RIGHTS ......................................................... 137 INTERNATIONAL RED CROSS..................................................................................... 142 UNITED NATIONS MILLENIUM DEVELOPMENT GOALS PRIORITIES IN GLOBAL HEALTH............................................................................... 145

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PREFACE

The textbook An Introduction to Social Medicine is based upon the authors’ courses

and covers the exam topics for medical students. The textbook is intended to serve the educational needs of English speaking undergraduate medical students by teaching them the basic fundamental concepts in Social Medicine. The aims of this textbook are to provide an understanding of Social Medicine as a scientific, medical and interdisciplinary subject focusing on health and health problems of human communities - their characteristics and determinants, and to promote students to apply this knowledge in their future medical practice to protect, maintain and increase the level of health in the communities they will serve.

This textbook specifically attempts to draw together all up-to-date strands of relevant information and to present that information in an easily accessible form to ensure efficient and comprehensive learning. Therefore, the core text is supplemented with numerous figures and tables, as well as with boxes highlighting key facts. In this way, the book provides information both at a foundation level, and at an advanced, more detailed level for the undergraduate students.

The structure of the textbook takes a balanced approach to cover many topics in a way that also provides a deeper understanding of the subject matter of a one-semester course. Although each chapter in the textbook could be expanded as indeed, there are entire books written on many of the topics we cover, we believe each chapter contains the essential material needed to introduce students to the issues related to Social Medicine. To enhance and facilitate learning, the chapters are organized in ten units. The first three chapters are an introduction to social medicine and its scope and methods. Two chapters (4 and 5) deal with the specific health problems of the population. Chapters 6 and 7 focus on economy and management in health care. Finally, the last three chapters are oriented on special topics based upon the authors’ courses.

To emphasize the importance of some international organizations, documents and programs in the process of strengthening the global population health, we provided five appendices to the textbook (World Health Organization, WHO Strategy Health 21, The European Charter of Patient Rights, International Red Cross, United Nations Millennium Development Goals). Bratislava, October 2010 Authors

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ACK�OWLEDGEME�TS

This work has been predominantly influenced by the book “The �ew Public Health”,

2nd edition from the authors Tulchinsky TH and Varavikova EA as well as by other books such as: Oxford Textbook of Public Health (Detels, Holland, McEwen, Omenn, 1997); Oxford

Handbook of Public Health Practice (Pencheon, Guest, Melzer, Gray, 2006); Epidemiology in

Health Care (Valanis, 1999); An Introduction to Quality Assurance in Health Care

(Donabedian, 2003); Applying quality management in healthcare: a systems approach (Kelly, 2007); Quality Management in Health Care. Principles and Methods (Lighter, Fair, 2004). The documents, publications and databases of World Health Organization, United Nations and Organization of Economic Cooperation and Development served also as important materials in creation of this textbook.

The authors are grateful to assoc. prof. Ivan Solovič, MD, PhD., assoc. prof. Anna Volná, MD, PhD., MBA and Darina Sedláková, MD, PhD. for reviewing and criticizing early drafts of the manuscript for this text and are also indebted to Gregory Fabian, JD for the language editing. Special thanks go to Mrs. Maria Hornisova for her dedicated clerical work which facilitated the final publication.

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1 SOCIAL MEDICI�E

1.1 THE SCOPE OF SOCIAL MEDICI�E

Social medicine is a scientific, medical and interdisciplinary subject, which deals with the health of the population and with the care of society. Social Medicine is a part of Public Health (Public Health Medicine or Community Medicine). They are orientated towards health

problems of human communities – characteristics and determinants – and the possibility of their control.

Social Medicine – is mainly concerned with the health situation, health needs and demands, the health care system and its components, health policy, evaluation of health services, health legislation, health economy, health insurance, and informatics and health management. Social Medicine, as a discipline is focused on human health (predominantly of populations and their components), its characteristics and determinants, and on health systems helping to protect, maintain and increase the level of population health.

W. Hobson, professor of Social and Industrial Medicine at the University of Sheffield in his article “What is social medicine?” published in British Medical Journal in 1949 said: “I

regard social medicine as a philosophy which should permeate all branches of medicine, for

its implications cannot be divorced from any branch of medical learning. It is a branch of

medicine also which provides a connecting link with the wider humanities. In the teaching of

medicine the accumulation of facts has been pursued, to the neglect of the study of man in his

environment. The liberal and intellectual structure of medicine and the humanism of medicine

are often lost in a welter of technical detail. It is well to remember that the great pioneers of

social medicine were men of liberal education and wide outside interests. They were

interested in men as part of humanity. If I were asked to define social medicine concisely I

should answer: The study of man within his environment, to give him life and to give it more

abundantly."

The scientific and methodological base of Social Medicine is first of all epidemiology

together with biostatistics as well as social psychology, sociology, law, economy, managerial

sciences, philosophy and history. The main differences between the scope of Social Medicine and Clinical Care are presented in Table 1.1.

Table 1.1 Comparison of the scope of Social Medicine and Clinical Care

Activity Social Medicine Clinical Care

Focus on: Community (population) Patient (individual) Care is: Continuous Episodic Diagnosis: Routine data

Special surveys Screening

History Examination Tests

Intervention: Health education Population intervention,

Therapy

Objective: Improvement of health status of community Improvement of health status of patient

Evaluation: Evaluation of changes in health status Follow up and assessment

Teaching Social Medicine helps to enlarge and enrich the understanding of students preparing for health related careers. Students today are preparing for medical practice and health field leadership in the years ahead. The task of teaching social medicine – along with other preventive and clinical subjects – is to build a set of concepts and skills for the students that will enable them to ask the right questions and to tackle the health problems of the population they serve.

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Public Health – is the process of mobilizing local state, national, and international resources to solve the major health problems affecting communities. Public health was defined by the American public health leader, Charles-Edward A. Winslow, in 1920 as, "the

science and art of preventing disease, prolonging life, and promoting physical health and

efficiency through organized community efforts for the sanitation of the environment, the

control of community infections, the education of the individual in principles of personal

hygiene, the organization of medical and nursing service for the early diagnosis and

preventive treatment of disease, and the development of the social machinery which will

ensure to every individual in the community a standard of living adequate for the

maintenance of health." Although a modern nosologist would add mental to physical aspects of health, Winslow's definition has not been superseded. It provided the basis for the World Health Organization's definition of health: "A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (1948).

Mission and essential services of Public Health are presented in Box 1.1.

Box 1.1 Mission and Essential Services of Public Health

Public health responsibilities or mission 1. Prevent epidemics and spread of disease 2. Protect against environmental hazards 3. Prevent injuries 4. Promote and encourage healthy behaviour 5. Respond to disasters and assist communities in recovery 6. Assure quality and accessibility of health services Essential public health services 1. Monitor health status to identify community health problems 2. Diagnose and investigate health problems and health hazards in the community 3. Inform, educate and empower people about health issues 4. Mobilize community partnerships and action to solve health problems 5. Develop policies and plans that support individual and community health efforts 6. Enforce laws and regulations that protect health and ensure safety 7. Link people to needed personal health services and assure provision of health care

when otherwise unavailable 8. Assure an expert public workforce of health professionals 9. Evaluate effectiveness, accessibility, and quality of health services 10. Research for insights and innovative solution to health problems

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

The Public Health movement focused attention on the environment while Social Medicine emphasised the relationship of persons to their environment, including the economic, nutritional, occupational, educational and psychological experiences of an individual or community. Social Medicine also accepts the need for social diagnosis, the organisation of after-care and readjustment of individuals or families due to illness. Social Medicine considers the diagnosis and the management of the condition in relation to the community rather than the individual.

1.2 HISTORY

1.2.1 History of Social Medicine

This history dates back (at least) to the early nineteenth century when the systematic study of the relationships between society, disease, and medicine began in earnest. Poor working conditions, periodic economic slumps, unemployment, lack of housing, and poverty and destitution all created an environment that had a significant impact upon people's health.

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This study—and the forms of medical practice derived from it—became known as “social medicine.”

In 1848, The French doctor orthopaedist Jules Guérin (1860-1910) published a new column in medical journal called Medicine Sociale.

Social Medicine as a scientific branch of medicine was established by Alfred

Grotjahn (1869-1931), a general practitioner in the workmen’s district of Berlin, who studied the relationship between diseases and social living conditions. The results of his studies formed the basis for a new scientific branch which was first termed Social Pathology, and later, Social Hygiene.

The great German pathologist Rudolf Virchow (1821–1902), together with his colleagues in the German Medical Reform movement of 1848, formulated the basic principles of Social Medicine (Waitzkin, 2006):

1. The health of the people is a matter of direct social concern. 2. Social and economic conditions have an important effect on health and disease, and

these relations must be subjected to scientific investigation. 3. Steps must be taken to promote health and to combat disease, and the measures

involved in such action must be social as well as medical.

Figure 1. 1 Rudolf Virchow

(1821-1902) the German doctor, pathologist,

politician - the founder of Social Medicine

Figure 1.2 Jules Guerin

(1860-1910) the French doctor who firstly used

the term Medicine Sociale

Figure 1.3 Alfred Grotjahn

(1869-1931) the founder of

Social Hygiene in Germany

Rudolf Virchow, is considered by many to be the founder of Social Medicine.

Virchow was one of the great pathologists of the nineteenth century, most notably contributing to the understanding of disease at the cellular level. He was also keenly aware of the social origins of illness. In 1848, while working as a staff physician at the Royal Charité Hospital in Berlin, he investigated an outbreak of typhus in the Prussian province of Upper Silesia. Virchow identified social factors, such as poverty and the lack of education and democracy, as key elements in the development of the epidemic. The experience led him to the concept of “artificial epidemics” arising in periods of social disruption: “Artificial epidemics...are attributes of society, products of a false culture or of a culture that

is not available to all classes. These are indicators of defects produced by political and social

organization, and therefore affect predominately those classes that do not participate in the

advantages of the culture” (Anderson, Smith, Sidel, 2005). Virchow's understanding of the social origins of illness comprised the source of the

broad scope that he defined for public health and the medical scientist. He attacked structures of oppression within medicine, particularly the policies of hospitals that required payment by the poor rather than assuming their care as a matter of social responsibility. Virchow envisioned the creation of a "public health service,” an integrated system of publicly owned and operated health-care facilities, staffed by health workers who were employed by the state. In this system, health care would be defined as a constitutional right of citizenship. Included

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within this right would be the enjoyment of material conditions of life that contributed to health rather than to illness (Waitzkin, 2006).

Nonetheless, organized medicine has traditionally been slow to accept the fact that social factors play an important role in disease. In the late nineteenth century the striking advances made in pathology and microbiology made social factors seem less germane in the etiology of disease. But humans are, in Aristotle’s words, “social animals” in whom the biological and social are inextricably linked (Anderson, Smith, Sidel, 2005).

Much of the early inspiration for Social Medicine came from European health statistics demonstrating major mortality differences between classes. Health and disease were correlated with wealth and poverty. Unfortunately, this remains true today and health inequalities are an active area of research and activism.

One of the basic sciences of Social Medicine is that of Social Pathology, just as the basic science of Clinical Medicine is Human Pathology. Its function is to study the disorders sand ills dependent upon a communal life. The idea, however, is certainly not new. One of the greatest accounts of Social Pathology was that written by Edwin Chadwick (1842). This was, however, largely concerned with the physical environment. Much of the information on the adverse effects of environment can be ascertained from the study of mortality statistics, first instituted by John Graunt and later developed by William Farr.

Inspired by the experiments in Social Medicine and Social Hygiene in revolutionary Soviet society in the 1920s, interwar sociomedical reformers on both sides of the Atlantic believed that the creation of a sociopolitical role for medicine could be achieved by turning it into a social science.

The interwar years witnessed a wide variety of international developments in Social Medicine as an academic discipline. Within international health organizations in the interwar years, supporters of Social Medicine as an academic discipline tried to undermine any exclusive focus on Clinical Medicine and pushed towards much broader social agendas. From the time of its establishment, the governing committee of the League of Fations Health

Organization prioritized the development of Social Medicine. The International Labor

Organization’s representatives on the committee persistently argued that issues of Social Medicine could not be separated from the question of access to services that fundamentally affected the health of workers.

The goals of Social Medicine as an academic discipline as it developed in the interwar years, therefore, were overtly linked to political programs of social reform. The international Social Medicine movement before the Second World War aimed to create a new social role for medicine in order to grapple with the epidemiological transition created by economic and social developments in the twentieth century. The interdisciplinary program between medicine and social science would provide medicine with the intellectual skills needed to analyze the social causes of health and illness (Porter, 2006).

After World War II, a strong movement for Social Medicine developed in the United Kingdom. In the United States, a broad concept of Social Medicine was developed by the economist and public health statistician Edgar Sydenstricker, the sociologist Bernhard J.

Stern, the public health scientist C.E. A. Winslow, and the medical historian Henry E.

Sigerist. However, the term was not adopted by American medical schools because of the conservative views of the medical profession (Waitzkin, 2006).

This conception of Social Medicine would not be complete if it did not indicate in some degree the emphasis to be placed on its various aspects. There are those who would place this emphasis on its application to the benefit of the patient in hospital, others on health and its communal aspects. John Ryle, himself a clinician of considerable experience and the first professor of Social Medicine in Great Britain, has elaborated the importance of Social Medicine in its clinical application. He has nevertheless indicated that the aspects associated

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with the community and their relations to health are possibly of even greater importance. It is clear that our conception of Social Medicine must include within its scope the realm of Preventive Medicine, Public Health, Occupational Medicine, and the application of those humanitarian principles so long practised by the good family physician (Hobson, 1949).

1.2.2 History of Public Health

In some ways, Public Health is a modern concept, although it has roots in antiquity. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread communicable diseases (theory of miasma). Early religions attempted to regulate behaviour that specifically related to health, from types of food eaten, to regulating certain indulgent behaviours, such as drinking alcohol or sexual relations. The establishment of governments placed responsibility on leaders to develop public health policies and programs in order to gain some understanding of the causes of disease and thus ensure social stability prosperity, and maintain order. Egyptian and Babylonian health practise

- community systems for collecting rain water and for disposing of sewage - Herodotus 5th century BC – described the hygienic customs of the Egyptians (personal

cleanliness, frequent baths, simple dress, earth closets) - Hammurabi a great king of Babylon around 1900 BC formulated a set of laws called the

Code of Hammurabi that governed the conduct of physicians and provided for good health practices. The code also regulated and defined unacceptable conduct in general

- Hebrew Mosaic law – defined conditions unacceptable for health and mobilized community forces against them (segregation of lepers, forbidden pork eating)

Greek era

- Classic Period 460 to 136 BC (games , gymnastics, personal cleanliness and dietetics); Hippocratic Oath; he also wrote the definitive treatise on environment and health with his trilogy, Airs, Waters, and Places

The Roman Empire

- the importance of the state; registration of citizens and slaves, periodic census, regulation of building construction, public baths, protected water supply, sewer system;

- Galen (130-291 AD) experimentation relating to health - Dark Ages (AD 476-1000)

The clergy were the only educated class, virtually the entire emphasis of the time was on the spiritual aspects of life (rejection of the body and glorification of the spirit became the accept pattern of behaviour). People seldom bathed and they wore dirty garments (era for perfumes).

During the 6th and 7th centuries, Mohammedanism arose. After the death of Mohammed, a series of pilgrimages to Mecca began. Each pilgrimage was followed by cholera epidemic. All through history migration has been a vehicle for a spread of disease. Leprosy spread from Egypt to Asia Minor. Lepers were decreed unacceptable and “civilly dead”, and were stripped of their civil rights (e.g. they were identified by clothing, and a bell or a horn was used to warn of their presence). The severe pandemics in Europe

During the 14th century Black Death in Europe, it was believed that removing bodies of the dead would further prevent the spread of the bacterial infection. This did little to stem the plague, however, which was most likely spread by rodent-borne fleas. Burning parts of cities resulted in much greater benefit, since it destroyed the rodent infestations. The development of quarantine in the medieval period helped mitigate the effects of other infectious diseases. However, according to Michel Foucault, the plague model of

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governmentality was later controverted by the cholera model. A Cholera pandemic devastated Europe between 1829 and 1851, and was first fought by the use of what Foucault called "social medicine", which focused on flux, circulation of air, location of cemeteries, etc. All those concerns, born of the miasma theory of disease, were mixed with urbanistic concerns for the management of populations, which Foucault designated as the concept of "biopower". Beginning of Epidemiology

The science of Epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. Although miasma theory correctly teaches that disease is a result of poor sanitation, it was based upon the prevailing theory of spontaneous generation. Germ theory developed slowly: despite Anton van Leeuwenhoek's observations of Microorganisms, (which are now known to cause many of the most common infectious diseases) in the year 1680; the modern era of public health did not begin until the 1880s, with Louis Pasteur's germ theory and production of artificial vaccines.

Other public health interventions include latrinization, the building of sewers, and the regular collection of garbage followed by incineration or disposal in a landfill, providing clean water and draining standing water to prevent the breeding of mosquitoes. This contribution was made by Edwin Chadwick in 1843 who published a report on the sanitation of the working class population in Great Britain at the time. So began the inception of the modern Public Health. The industrial revolution had initially caused the spread of disease through large conurbations around workhouses and factories. These settlements were cramped and primitive and there was no organised sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants.... Public Health in the 20

th century

As the prevalence of infectious diseases in the developed world decreased through the 20th century, Public Health began to put more focus on chronic diseases such as cancer and heart disease. During the 20th century, the dramatic increase in average life span is widely credited to Public Health achievements, such as vaccination programs and control of infectious diseases, effective safety policies such as motor-vehicle and occupational safety, improved family planning, chlorination of drinking water, smoke-free measures, and programs designed to decrease chronic disease.

Meanwhile, the developing world remained plagued by largely preventable infectious

diseases, exacerbated by malnutrition and poverty. Front-page headlines continue to present society with public health issues on a daily basis: emerging infectious diseases such as SARS; the increase of HIV-AIDS among young heterosexual women and its spread in South Africa; the increase of childhood obesity and the concomitant increase in type II diabetes among children; the impact of adolescent pregnancy; and the ongoing social, economic and health disasters. These are all ongoing public health challenges.

Since the 1980s, the growing field of population health has broadened the focus of Public Health from individual behaviours and risk factors to population-level issues such as inequality, poverty, and education. Modern Public Health is often concerned with addressing determinants of health across a population, rather than advocating for individual behaviour change. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships - these are known as "social determinants of health." A social gradient in health runs through society, with those that are poorest generally suffering the worst health. However even those in the middle classes will generally have worse health outcomes than those of a higher social stratum. The new Public Health seeks to address these health inequalities by advocating for population-based policies that improve health in an equitable manner.

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2 HEALTH A�D DISEASE

2.1 HEALTH

Health is a state of complete physical, mental and social wellbeing, and not merely

the absence of disease or infirmity. Health should be comprehended as a process not only a state, and as the ability of an organism to adapt itself to the requirements of changeable environment without impairment of the functions of body organs and social roles.

According to the World Health Organization (WHO), health is the extent to which an individual or group is able:

• to satisfy their needs, • to realize their aspirations, • to change or cope with their environment. Health is a resource for everyday life, not the objective for living: it is a positive concept

emphasizing social and personal resources as well as physical capabilities. The determinants of health may be endogenous and exogenous. They include:

• susceptibilities: markers, genetic factors (e.g. prevalence of sickle cell trait, apoE4 gene), or endogenous susceptibilities,

• physical, emotional, social, economic, and environmental influences, • health attitudes and health-related behaviour, • health protection, collective prevention, health promotion, • health and social care, both somatic and mental.

Health and disease are two endings of the continuous spectrum whose intensity can be measured on the scale. On the continuum health - illness, there are a series of qualitatively distinct states from good health, through many transient conditions, to full ill health culminating in death. This concept allows not only to measure illness by degrees, but also to gradate the level of health. Implicit in the concept is the possibility of increasing physical and psychic efficiency by means of exercise and sports

2.2 DISEASE

Disease is objective ascertainable set of symptoms creating a settled clinical entity. Some physical or mental disturbances are termed disability or handicap or impairment. Criteria for disease:

• Manifestation: precursors, symptoms, syndromes – disease • Type: organic, functional, psycho-social • Dynamism: acute, chronic • Development: latent – asymptomatic, unapparent, subclinical;

manifest – apparent • Prognosis: good (favorable), unchangeable, unfavorable (bad)

Causes of disease: • Biological (microorganism, etc.) • Chemical (chemicals, poisons, venoms) • Physical (cold, hot, ionizing radiation, noise, etc.) • Psycho-social (stress, inter-personal trouble, etc.) Causes of diseases need some circumstances (conditions) to evoke disease. In many cases,

it is impossible to distinguish among causes and conditions, so the terms “factors” and “determinants of health and disease” are used instead causes.

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2.2.1 �atural History of Disease

Natural history of disease is the process by which diseases occur and progresses in the human host. This process involves the interaction of three different kinds of factors: the causative agent(s), a susceptible host (human), and the environment. As long as a state of equilibrium exists between host, agent, and environment a state of health is maintained. A lack of equilibrium, such as an increase in the amount of the agent resulting from a change in environmental conditions, increases the likelihood that a susceptible host will be exposed. An increase in host susceptibility because of lack of sleep, malnutrition, extensive stress, aging, or a variety of other factors also increases the risk of disease. Changes in the environment contribute to changes in host susceptibility as well as to the conditions for variability of the agent (Valanis, 1999). AGENT HOST ----------------------------------------------------------------------------- = DISEASE/HEALTH ENVIRONMENT

2.2.1.1 The Agent

An agent is a factor whose presence causes a disease or one whose absence causes disease. An example for the former is Salmonella, which causes salmonella’s poisoning; an example of the latter is lack of vitamin D, which leads to rickets. Categories of agents include physical, chemical, nutrient, biological, genetic, and psychological agents. Physical agents include mechanical forces or frictions that may produce injury or atmospheric conditions such as extremes of temperature and excessive radiation. Chemical agents are those that affect human physiology through chemical action and include substances such as dusts, gases, vapours, fumes, or liquids. �utrient agents are chemical in nature but refer specifically to basic components of the diet. Agents transmitted from parent to child through the genes are genetic agents. Psychological agents are those stressful factors in the environment, such as social circumstances, that affect physiology by psychosomatic means. The category of biological agents encompasses all living organisms, including insects, worms, protozoa, fungi, bacteria, Rickettsial diseases, and viruses. Biological agents are infectious in nature. Certain characteristics of agents affect their ability to produce disease in the host. For infectious agents, the characteristics are infectivity, pathogenesis, and virulence. These characteristics are measured by the infection or attack rate, pathogenesis rate, and case fatality rate, respectively. These rates provide a means of population surveillance, allowing public health officials to assess the nature of the problem they are confronting and to plan an appropriate intervention. Important characteristics of non-infectious agents include concentration and toxicity for chemical agents, size, shape, and intensity for physical agents, chronic nature or suddenness for psychological agents, and homo- or heterozygocity of genetic material for genetic agents.

2.2.1.2 The Environment

Environment refers to all external conditions and influences affecting the life of living things. Physical, biological, and socio-economic environments provide reservoirs, places where agents can reside or reproduce, or both, or modes of transmission for transporting agents from the reservoir to a human host. The physical environment includes the geological structure of an area and the availability of resources, such as weather and flora that influence the number and variety of animal reservoirs and certain insects that function as vectors to

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carry an agent from the reservoir to the host. Weather, climate, and season are important influences in the physical environment. The socio-economic environment contributes to the types of infectious agents in a locality because social and economic conditions relate both to the extent of environmental sanitation practices, such as disposal of garbage and excreta, and to the availability of medical facilities for immunization and medical care. The socio-economic environment may also influence non-infectious agents. More psychological stressors may be found in poorer socio-economic environments than in more affluent ones. Poor socio-economic neighbourhoods are more likely to be located near industrial plants, which may produce dangerous chemicals or emit physical particles of agents such as asbestos or coal tar. Finally, there is the biologic environment, which includes living plants and animals that may serve as either the reservoir or the vector (living carrier that transports an infectious agent from an infected individual or its wastes to a susceptible individual or its food or immediate surroundings). Brucellosis is a disease in which animals, particularly cattle, swine, sheep, goats, horses, and reindeer, serve as reservoirs for human infection. The disease is transmitted from these animals to humans by contact with tissue, blood, urine, vaginal discharges aborted foetuses or placentas, or by ingestion of milk or dairy products from infected animals. Special animal inspection and disposal procedures and education of farmers, animal handlers, and slaughterhouse workers help to control the spread of this disease among these groups. Pasteurization of milk is an effective control measure for protecting the general population. In the case of plague, wild rodents are the usual reservoir, although infective fleas serve as the mode of transmission of the disease to humans.

2.2.1.3 The Host

A host is the individual human in whom an agent produces disease. Disease can occur only in a host who is susceptible. Lack of susceptibility may be due to immunity or to inherent resistance. Immunity is the resistance on the part of a host to a specific infectious agent. Immunity can be humeral (antibodies in the blood) or cellular (specific to each type of cell), and of short-term or long-term duration. The role of immunity varies with the type of infectious agent. In contrast to immunity, the term inherent resistance refers to the ability to resist disease independently of antibodies or of specifically development tissue response. Inherent resistance commonly rests in the anatomical or physiological characteristics of the host; it may be genetic or acquired, permanent or temporary. The concept of inherent resistance is useful in understanding host resistance both to infectious agents as well as to other types of agents. Factors such as general health status or nutrition, for example, may affect resistance to disease. Someone in good health who maintains good nutrition and a regular schedule of rest and exercise may be exposed to the common cold virus and resist infection even though the person is not immune to the organism. Similarly, this same individual, if exposed to psychological stress, may be resist ulcers better than would someone in poorer general health. 2.2.2 The Disease Process

Occurrence of disease in a human host is not a single event at one point in time. Rather it is a process occurring over a period of time – the natural history of the disease. This natural history may be divided into two periods; pre-pathogenesis and pathogenesis. Stages in pre-pathogenesis are susceptibility and adaptation. Pathogenesis can also be broken down into two stages: early pathogenesis and clinical disease (Figure 2.1). These stages are discussed in the following paragraphs. The subsequent section in this chapter, “Levels of Prevention”, describes how the events that occur at each stage of a disease process can be used as a basis for determining intervention measures.

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Prepathogenesis Pathogenesis Susceptibility Adaptation Early

pathogenesis Clinical disease

Exposure Early clinical stage

Late clinical stage

Latency

Early detection

possible Diagnosis

occurs

Symptom onset

Figure 2.1 �atural history of disease Source: Valanis B. Epidemiology in Health Care. 2nd edition. 1999.

2.2.2.1 Pre-pathogenesis

Exposure of the host to an agent occurs during the stage of susceptibility. In this first stage of pre-pathogenesis, disease has not yet developed, although the groundwork has been laid through the presence of factors that favour its occurrence. For example, poor eating habits and fatigue resulting from lack of sleep often present among college students during exam week, present risk factors that favour the occurrence of the common cold. If exposure to an agent occurs at this time, a response will take place. Initial responses reflect the Norman adaptation response of the cell or functional system (e.g. the immune system). If these adaptation responses are successful, then no disease occurs and the process is arrested in the second stage pre-pathogenesis, adaptation.

In the case of infectious agents, exposure is followed by an incubation period, a time when the organism multiplies to sufficient numbers to produce a host reaction and clinical symptoms. This time period is relatively short, usually hours to months. For diseases caused by non-infectious agents, however, this time period from exposure to onset symptoms, called the induction period or latency period, is often years to decades, although shorter induction periods may occur. Accidents resulting from a severe psychological stress may occur shortly after initial exposure to the stressor. Elevated blood pressure, as a consequence of psychological stress, may require years of exposure to stress. One of the shorter known latency periods for cancer is the 5-year latency period for leukaemia in children exposed to radiation. Lung cancer resulting from asbestos exposure may have a latency period of 40 years between exposure and detection of the disease. Some chemical agents cause almost instantaneous, acute episodes of poisoning. The end of the incubation or induction period is the point of disease detection, whether by screening or by appearance of clinical signs and symptoms, although the time of clinically observable illness has conventionally been used.

2.2.2.2 Pathogenesis

The next stage in the natural history of a disease is the stage of pre-symptomatic

disease, sometimes called early pathogenesis. At this stage, the individual has no symptoms indicating the presence of illness. Adaptation, however, has been unsuccessful and pathogenic changes have begun. This happens during the incubation or latency period. These changes, which may be detectable by sophisticated laboratory tests, are called subclinical because they are below the level of the clinical horizon, an imaginary line dividing the point where there are detectable signs and symptoms from that where there are not. Pre-malignant changes or

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early malignant tissue changes in the cervix, for example, may be detected by a Papanicolaou (Pap) smear long before a woman experiences symptoms and before signs are visible to a gynaecologist on visual examination. Such tests that can detect disease during the preclinical stage of early pathogenesis are used for screening to detect disease earlier than it would normally be discovered through the clinical presentation of symptoms. The end of the incubation or induction period is the point of disease detection. This is stage four in natural history, clinical disease. Clinical disease is defined as a disease which is detectable because of symptoms experienced by the patient or signs apparent to a clinician during a physical examination. By this stage, sufficient anatomical or functional changes have occurred to produce recognizable signs and symptoms. This stage includes a range of disease severity from early clinical disease to that so advanced that death is inevitable. Possible outcomes, once a patient has entered this stage, may be complete recovery, residual defect that produces some degree of disability, or death. In an attempt to further understand this stage, clinicians and researchers have developed classification schemes for degrees of disease severity, including the staging systems used for malignancies, and the functional and therapeutic classifications used for cardiac disease. Another difference between diseases caused by infectious agents and those caused by non-infectious agents or by still unidentified agents, is the likelihood for the latter to be conditions of a chronic nature. Most, but not all, diseases with infectious causes are of relatively short duration. The patient is usually ill for a period ranging from a few days to several months and generally recovers, without any residual disability or, if the illness was severe, may die from illness. The patient who has recovered rarely requires long-term follow up, although there are exceptions. Rheumatic heart disease, which results from a staphylococcal infection, is a disease caused by an infectious agent that is chronic in nature. The herpes virus may produce a single acute infection or may become chronic with repeated outbreaks of the infection following periods of remission. In case of non-infectious agents, residual disability requiring prolonged medical treatment and rehabilitation programs in common. Patients with cardiovascular disease, for example, are likely to require ongoing supervision with prescribed medications, control of diet and indefinite modifications of lifestyle. Pathogenesis is the mechanism by which an etiological agent produces disease. Pathogenesis elucidates the patho-physiological processes of development of the disease. 2.2.3 Risk Factors for Disease

For non-communicable diseases, causation is multi-factorial, and risk factor for one disease may also be a contributor to increased risk for another disease. Diet has been established as a major risk for coronary heart disease, as well as diabetes and hypertension. Risk factors for disease are those aspects of personal behaviour or lifestyle, occupational or environmental exposure, social and economic conditions, and inborn or inherited characteristics which, on the basis of epidemiologic evidence, are known to be associated with health-related conditions considered important to prevent. Noninfectious diseases are often related to and exacerbated by a number of risk factors, so that measurement of prevalence of risk factors, or intervening variables, is important to epidemiologic assessment of the future risk of such diseases. The prevalence of smoking, as an example, may serve as an indicator of the future potential of lung cancer and cardiovascular diseases. Identification of risk

Risk refers to the probability of an unfavourable event. In epidemiology, the term generally refers to the likelihood that people who are without a disease, but who come in contact with certain factors thought to increase disease risk, will acquire the disease. Factors associated with an increased risk of acquiring disease are called risk factors. These factors

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may be part of the physical environment, such as stressful life events, divorce, or death of a spouse. They may also be behavioural, such as smoking and lack of exercise, or inherited, such as haemoglobin S, which increases risk for infection. In general, the risk to an individual of developing a disease can be estimated only on the basis of the experience of whole populations of individuals. Once this experience is known, the relevant risks can be calculated for persons who are similar to those in that population. Further, population data on disease occurrence can be used for estimating the effect of a public health intervention on disease rates. A measure called the relative risk ratio, estimates how much the risk of acquiring a disease increases with exposure to a particular causal agent or known risk factor. This ratio is derived by comparing the occurrence of disease in a population exposed to the causal agent to the occurrence of disease in a non exposed population. Thus a relative risk ratio of 5 implies that the risk of acquiring that disease is five times greater for someone exposed to an etiological agent than for someone not exposed. Relative risk ratios are a useful tool for identifying factors that represent increased risk for development of a disease. Diabetes, obesity, hypertension, and smoking are considered risk factors for cardiovascular disease because populations with these characteristics show several times the rate of that disease as opposed to population without those conditions or behaviour. Once risk factors are identified, public health programs can be instituted to change high-risk behaviour, such as smoking, and to identify high-risk individuals through comprehensive screening programs that ensure medical treatment to reduce risk. In addition, nurses and other clinicians can counsel high-risk individuals on how they can reduce their risk by adopting healthier lifestyles. A measure called attributable risk estimates the effect on disease occurrence of public health intervention(s) that eliminate exposure to a causal agent.

Box 2.1 Criteria for Causation in Chronic Disease – Evans’ Postulates

1. Prevalence of the disease should be significantly higher in those exposed to the hypothesized cause than in controls not so exposed.

2. Exposure to the hypothesized cause should be more frequent among those with the disease than in controls without the disease, when all other risk factors are held constant.

3. Incidence of the disease should be significantly higher in those exposed to the hypothesized cause than in controls not so exposed, as shown by prospective studies.

4. The disease should follow exposure to the hypothesized causative agent with a normal or log-normal distribution of incubation periods.

5. A spectrum of host responses should follow exposure to the hypothesized agent along a logical biological gradient from mild to severe.

6. Experimental reproduction of the disease should occur more frequently in animals or humans appropriately exposed to the hypothesized cause than in those not so exposed; this exposure may be deliberate in volunteers, experimentally induced in the laboratory, or may represent a regulation of natural exposure.

7. Elimination or medication of the hypothesized cause should decrease the incidence of the disease (e.g., attenuation of a virus, removal of tar from cigarettes).

8. Prevention or modification of the host’s response on exposure to the hypothesized cause should decrease or eliminate the disease (e.g., immunization, drugs to lower cholesterol, specific lymphocyte transfer factor in cancer).

9. All of the relationship and findings should make biological and epidemiologic sense. Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

Risk factors in non-communicable diseases have been identifies by important epidemiologic studies over the past four decades. The famous longitudinal heart study in Framingham, Massachusetts (1948) provided important epidemiologic data showing that hypertension, smoking, and elevated cholesterol are associated with increased risk of cardiovascular diseases. The Framingham study pioneered the epidemiologic approach to gain insight into causes of cardiovascular diseases. This was a prospective cohort study to quantify risk for these diseases, both in terms of absolute and relative risk. Its observations have led to causal inferences (e.g., elevated blood pressure with increased risk of stroke).

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Cardiovascular disease is still the leading cause of death worldwide. An important portion of the total number of cases of this disease can be attributed to behavioural factors, such as those that can often be modified, including cigarette smoking, physical inactivity, and unhealthy diet. The global risk for cardiovascular disease includes many risk factors and is therefore difficult to assess. WHO organized the MONICA project (Multinational Monitoring of Trends and Determinants in cardiovascular disease) as an epidemiologic investigation system to assess trends and determinants of cardiovascular mortality, incidence and case fatality from the mid- 1980s to the mid 1990s. The study included 38 population centers in 21 countries worldwide. Altogether some 13 million people were monitored over a 10-year period. In western countries where the CHD mortality declined on average 2-3 percent annually, two-thirds of this decline could be explained by a decline in CHD incidence and one-third by a decline in CHD case fatality. The greatest contribution to the observed decline was decreased smoking. 2.2.4 Disease Classification

Because comparative statistics are vital in monitoring the health status of a population, it has been essential to develop internationally accepted standard nomenclature and a coding system in order to minimize differences in classification. The Bills of mortality used in the seventeenth century defined 17 categories. Classification of disease by anatomic sites or body system was initiated by William Farr at the Second International Statistic Congress in Paris in 1855 when he stated: “Classification is a method of generalization. Several classifications

may, therefore, be used with advantage; and the physician, the pathologist, or the jurist, each

from his own point of view, may legitimately classify the diseases and the causes of death in

the way that he thinks best adapted to facilitate his inquires, and to yield general results.”

After World War I, the League of Nations supervised revisions of the International

Classification of Diseases (ICD), and since the 1948 sixth revision, the ICD has been updated at about 10-year intervals by the WHO. The tenth revision of the International Classification

of Diseases (ICD-10) came into many subcategories with coding to indicate precise disease and procedure groups.ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States in 1994.

The ICD is the international standard diagnostic classification for all general epidemiological and many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines.

It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States.

A statistical classification of diseases must be confined to a limited number of mutually exclusive categories which can encompass the whole range of morbid conditions. The categories have to be chosen to facilitate the statistical study of disease phenomena. A specific disease entity that is of particular public health importance or that occurs frequently should have its own category. Otherwise, categories will be assigned to groups of separate but related conditions. Every disease or morbid condition must have a well defined place in the list of categories. Consequently, throughout the classification, there will be residual categories for other and miscellaneous conditions that cannot be allocated to the more specific categories.

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The “core” classification of ICD-10 is the three-character code, which is the mandatory level of coding international reporting to the WHO mortality database and for general international comparisons. The four-character subcategories, while not mandatory for reporting at the international level, are recommended for many purposes and form an integral part of the ICD. In place of the purely numeric coding system of previous revisions, the 10th Revision uses and alphanumeric code with a letter in the first position and a number in the second, third and fourth positions. The fourth character follows a decimal point. Possible code numbers therefore range from A00.0 to Z99.9 The letter U is not used. The classification is divided into 21 chapters. The first character of the ICD code is a letter, and each letter is associated with a particular chapter:

• Chapters I to XVII relate to diseases and other morbid conditions (e.g. I10 Hypertension, K74 Cirrhosis of liver, J18.1 Lobar pneumonia, C56 Malignant neoplasm of ovary)

• Chapter XVIII covers Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.

• Chapter XIX relates to injuries, poisoning and certain other consequences of external causes.

• Chapter XX - External causes of morbidity and mortality. • Chapter XI - Factors explaining the reason for contact with health care services of a

person not currently sick. The concept of a “family” of disease and health-related classifications

Although the ICD is suitable for many different applications, it does not always allow the inclusion of sufficient detail for some specialties, and sometimes information on different attributes of the classified conditions may be needed. It was felt that the main ICD (the three- and four-character classification), covered by the three volumes of ICD-10, could not incorporate all this additional information and remain accessible and relevant to its traditional users, so the idea arose of a “family” of disease and health-related classifications, including volumes published separately from the main ICD, to be used as required. The various members of the family of classifications are:

• Specialty-based adaptations - bring together in a single, compact volume the sections or categories of the ICD that are relevant to a particular specialty

o International Classification of Diseases for Oncology, Dermatology, Dentistry

and Stomatology, Feurology, Rheumatology and Orthopaedics, Pediatrics,

Mental and Behavioural Disorders.

• Non-diagnostic classification

o International Classification of Procedures in Medicine

o International Classification of Functioning, Disability and Health

• International Nomenclature of Diseases - to provide for each morbid entity, a single recommended name.

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2.2.5 Social and Economic Consequences of Disease

Social inequalities in morbidity and mortality have become a major field of interest in epidemiologic studies for many years. A study of late-stage diagnosis of colorectal cancer in New York State showed women and African-Americans as more likely to have late-stage cancer than men and whites. Individuals living in areas of low socio-economic status were significantly more likely to be diagnosed at a later stage than those living in higher socio-economic status areas. Poor having three times greater rates of mortality than the wealthy minority. Social inequities in health occur in virtually all societies with differences in physical access to care; differences in lifestyle and risk factors; socio-economic status; and knowledge, attitudes, and practices related to health and health care.

Health of populations is largely determined by environmental factors of society, and that to understand causation of disease, it is essential to understand its historical and social context.

Disease breaks social relationship, disturb social role and in many cases isolates the sick people from society (changes in physical, social and emotional function).

Economic consequences of ill-health are direct costs (organizing and operating costs within the health sector, e.g. health professionals’ time, supplies, equipment etc.; costs born by patients and their families: out-of-pocket expenses, patient input into treatment), indirect costs ( time lost from work, psychic cost), and costs borne externally to the health sector, patients, and their families (societal assessment).

Governments are most concerned about the impact of health care programs and treatments on their revenues and expenditures. To a more limited extent the government may be interested in the indirect costs (benefits), since these relate both to the productivity of the country and to the government’s own revenues and expenditures in taxation and welfare payments.

Community diagnosis consists of information acquired by talking with community + data from records (vital statistics, health statistics and health care services statistics) + surveys. Community diagnosis make possible to identify the health needs of a community, to know what the major problems of that community are and which subgroups in it are most affected. Having some factors increase the probability that individuals will develop disease. This “risk-factors” may be:

• social – smoking, drinking • genetic – ethnicity • dietary – saturated fats, vitamin deficiencies • occupational – pollutants, trace chemicals, vibration, noise • behavioural and socio-economic and cultural factors Limited expenditure on health care and health services and scarce resources must be

carefully considered before deciding on the priorities for developing health care strategies. Choices must be made:

• Which population groups, diseases or underlying health problems should be given priority?

• Which health programs should receive more attention and more resources? Good epidemiological health information is necessary to help answer these questions. The

analysis should identify the following: • Main health problems • High-risk groups • Access to and coverage by health programs • Organization and management of these programs

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Priorities should be developed in terms of the activities that will have the greatest impact on improving the health status of the population; Task requiring epidemiological and planning skills are presented in Figure 5. District population Improvements in health status ↓ ↑ Defining population Evaluating groups effectiveness ↓ ↑ Assessing health and Increasing access health problems and coverage ↓ ↑ Collecting health data Implementing programs ↓ ↑ Producing health Choosing alternative information interventions ↓ ↑ Assessing health Deciding on priority status health problems ↓ ↑ Figure 2.2 Activities required in process of improving health status of population 2.2.6 Levels of Disease Prevention

An ultimate goal of public health is to improve health and to prevent widespread disease occurrence in the population and in the individual. The methods of achieving this are wide and varied. When an objective has been defined in preventing disease, the next step is to identify suitable and feasible methods of achieving it, i.e. a strategy with tactical objectives. The methods of public health are categorized as health promotion and primary, secondary and tertiary prevention (Box 2.2).

Box 2.2 Modes of Prevention

Health promotion. Fostering national community, and individual knowledge, attitudes, policies, and standards conducive to good health; promoting legislative, social, or environmental conditions and individual self-care that reduce individual and community risk; and creating a healthful environment. It is directed toward action on the determinants of health. Primary prevention. Preventing a disease from occurring .

Secondary prevention. Making an early diagnosis and giving prompt and effective treatment to stop progress or shorten the duration and prevent complications form an already existing disease process. Tertiary prevention. Preventing long-term impairments or disabilities as sequels; restoring and maintaining optimal function once the disease process has stabilized for instance promoting functional rehabilitation.

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

Health promotion (HP) is the process of enabling people and communities to increase control over factors that influence their health, and thereby to improve their health. HP involves activities intended:

• to enhance individual and community health and well-being, • to increase involvement and control of the individual and the community in their

own health, • to improve health and social welfare, • to reduce specific determinants of disease and risk factors, • to set up targets based on the size of the problem, • to propose successful interventions in a cost-effective way.

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HP is practiced by organizations and persons with many professional backgrounds. Initiative may come from government with dedicated allocation of funds to address specific health issues, from donors, or from advocacy or community groups or individuals to promote a specific or general cause in health. HP endeavors to create a climate of knowledge, attitudes, beliefs, and practices that are associated with better health conditions.

Primary prevention (PP) means that new cases of disease are really prevented and do not occur, because the new cause(s) of a disease has (have) been eliminated. PP is only feasible if the cases (determinants, risk factors, risk indicators) of certain forms of morbidity and premature mortality are known and can be tackled. Therefore, lung cancer is suitable for PP and breast cancer is not. Well-known methods of PP are health education – e.g. against smoking, an in safe sexual practices, hygiene – e.g. safe drinking water and adequate sewage disposal, malaria prophylaxis and vaccination. PP often calls for intersectoral cooperation, i.e. participation of others sectors such a finance, agriculture, social welfare, employment, environment, etc. This cooperation is essential if health objectives such as less smoking, better nutrition or fewer accidents are to be achieved (Valanis, 1999). It may be directed at the host to increase resistance to the agent (immunization, cessation of smoking), or may be directed at environmental activities to reduce conditions favorable to the vector for a biological agent.

Secondary prevention is the detection and treatment of a disease before the patient becomes aware of it, by preventing the disease from becoming manifest. Well-known examples are screening for phenylketonuria, hypercholesterolaemia or breast cancer and the periodic examination of school children or workers in certain occupations (Valanis, 1999). Health care providers have a role in secondary prevention; for example, in preventing strokes by early and adequate care of hypertension. In the case of injury, competent emergency care, safe transportation, and good trauma care may reduce the chance of death and/or permanent handicap. Screening is also the method of secondary prevention (Tulchinsky, Varavikova, 2009).

Tertiary prevention is not really a form of disease prevention, it is instead an attempt to limit the damage caused by manifest disease and mitigate its effects. TP focuses especially on preventing permanent invalidity, e.g. after an injury or due to chronic diseases (Valanis, 1999). Tertiary prevention involves activities directed at the host or patient, but also at the social and physical environment in order to promote rehabilitation, restoration, and maintenance of maximum function after the disease and its complications have stabilized. The public health system has a direct role in promotion of disability-friendly legislation and standards of building, housing, and support services for the chronically ill, the handicapped, and the elderly persons. This also involves working not only with many governmental social and educational departments, but also with advocacy groups, nongovernmental organizations, and families. It may include promotion of disability-friendly workplaces, and social service centers (Tulchinsky, Varavikova, 2009).

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3 MEASURI�G THE HEALH OF THE POPULATIO�

Measuring the health of the population is fundamental to improving their health status.

The public health professional working with individual and community health needs to acquire the knowledge and skills necessary to measure and interpret the factors that relate to disease and health. An assessment of the health status of the community, based on information about health problems and diseases, is necessary for planning and evaluating the health services. The concept of the “iceberg phenomenon” emphasizes that the mass of health problems lies below the surface and is frequently not fully recognized. The common purposes of the health assessment include (Gentle, Pencheon, Flowers, 2006):

• comparing findings for the population with other similar populations or larger populations, or comparing health status observed with that expected for the type of population

• describing the relative health of parts of the population (areas or social groups), identifying inequalities

• comparing health trends over time • estimating the extent of potentially preventable health problems • describing the likely health impact of environmental and social factors • describing the impact of health problems in terms of people's experience of health

problems. Information about the health of a population can cover (Tenisson, 2006): 1. Demography: the basic characteristics of the population, such as age, sex, geographic

distribution, and mobility. 2. Health-related characteristics or risk factors, such as measures of deprivation, living

conditions, employment, housing, or more medical factors or physiologic measurements (e.g. blood glucose levels).

3. Health need data, such as the distribution of the indications for an intervention such as hip replacement or the distribution of different thresholds for intervention.

4. Mortality: the death experience of the population, including causes of death and variation according to the dimensions of person, place, and time.

5. Morbidity: the health or illness experience of the population, including prevalence and incidence of diseases.

6. Health service use data, such as diagnoses, interventions and procedures, and health outcomes of interventions; it may be useful to distinguish patient interactions with agents such as nurses or doctors from their use of settings such as hospital, day hospital, health centre, or home in using the health service.

7. Health economic data, often concerning the costs of interventions, and the distribution of activity and costs at marginal or average levels.

In terms of how it is collected, assembled, and made available, information can be either: • Routine: collected, assembled, and made available repeatedly, according to well-

defined protocols and standards; such data are usually part of a system of data collection by which information is:

o made available at regular intervals o intended to allow tracking over time o codified according to national or international standards (for example, using

the International Classification of Diseases . The iceberg phenomenon – routine health information comes mainly from people who attend the health services, they are not covering people who did not ask for health care.

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• Specially collected: for a particular purpose, without the intention of regular repetition or adherence to standards (other than those needed for the specific study or task). Such data are usually:

o aimed at a specific, time-limited study or task o codified according to the task at hand and the wishes of the investigators

(sometimes in ignorance of the availability of suitable standard codes and methods)

o difficult to compare (between times, places, and people) with routine data and other specially collected data.

A great deal of useful data is recorded as part of clinical care or collected by health-care providers. However, very great care is needed in using such data: not all people with a health condition receive treatment (or they may be treated by other providers). Clinicians usually record information just for clinical purposes rather than for analytic purposes. The absence of a positive record (e.g. of smoking) may mean a true negative or that the information was not sought. The definition of a condition (and whether to treat it) may vary substantially from clinician to clinician, causing large differences between areas. Issues of confidentiality must be addressed.

At first sight there seems to be so much data available that assessing health should not be much of a challenge. However, Finagle's law of information is usually proven to be correct in public health work: ‘The information you have is not what you want; the information you want is not what you

need; the information you need is not what you can get; the information you can get costs

more than you want to pay’

Demography and epidemiology are the basis of health information systems. Demography deals with the recording of the characteristics and trends of a population and its characteristics over time. Epidemiology measures the distribution, causes, control, and outcomes of disease in population groups. It provides the basic tools for quantification of the extent of disease, its patterns of change, and associated risk factors. Epidemiology also provides basic information needed for planning, evaluating, and managing health services. Other disciplines provide additional information.

3.1 DEMOGRAPHY

The health and health care needs of a population cannot be measured or met without knowledge of its size and characteristic. Defining the population of interest is critical. Population size, structure, and the period of observation covered can have powerful effects on the numbers of cases of disease or disability: data are therefore usually expressed as proportions (e.g. the number of people with diabetes per thousand population at a particular point in time) or rates (the number of new cases per thousand population per year). For certain purposes such rates may need adjustment for potential confounding variables (e.g. age, sex, socio-economic status, or ethnicity) to allow valid comparison with other populations.

Demography is concerned with this essential “numbering of the people” and with understanding population dynamics–how populations change in response to the interplay between fertility, mortality and migration. Demography is “the study of populations, especially with reference to size and density, fertility, mortality, growth, age distribution, migration, and vital statistics and interaction of all these with social and economic conditions”. Demography is based on vital statistics reporting and special surveys of population size and density; it measures trends over time. Data on demographic events are needed, as well as data on population characteristics. In the developed world this data is usually drawn from vital registration systems. Vital

statistics include births, deaths, and population by age, sex, location or residence, marital

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status, socio-economics status, and migration. Birth data are derived from mandatory reporting of births and mortality data from compulsory death certificates. Other sources of data are population registries as well as economic and labor force statistics, census data and data from special household surveys.

Most developed countries now have well-established registration systems with complete, or very nearly complete, coverage. In the less developed world, however, many people have no need for certificates of birth or marriage and vital registration systems are frequently seriously incomplete or non-existent, although there are some exceptions. A census is an enumeration of the population, recording the identity of all persons in every residence at a specified time. The census provides important information on all members of the household.

The first modern censuses were undertaken in Scandinavia in the eighteen century. During the nineteenth century censuses spread throughout Europe and are now almost universal. As well as basic questions about age, sex, marital status, and place of residence, data on other characteristics such as employment, education, and housing are often collected. The United Nations recommends that censuses be conducted at least decennially in years

ending 0 or 1. Censuses have much strengths. They have been used as ways of discovering vital events in order to provide data on recent internal migration. Against the strengths of censuses must be set the huge costs of collecting and processing census data and the major problems involved in ensuring that it is of reasonable quality. Young geographically mobile adults, members of minority ethnic groups, infants, and the very old are the groups most likely to be under-enumerated. Groups such as seasonal migrants (including students), seamen, military personnel, and people temporarily away from home present particular problem. Assessment of the extent of under-enumeration is usually achieved through census validation surveys. Age misreporting is one of the most serious problems that must be estimated and allowed for in analyses of census and similar data. In many populations, people may not always know their exact age and some approximation is reported or made by an enumerator. Overstatement of age by elderly people (particularly older men) is common. Other characteristics may be “mis-stated” because individual’s perceptions of their status do not match official classification systems (e.g. quite high proportions of divorced men in England revert to describing themselves as single - never married). Usually inter-census surveys are carried out to determine trends in important economic or demographic data such as individual and family incomes, nutrition, employment, and other social indicators. Despite its limitations, the census is accepted as the basis of a “statistics” definition of a population. Sample surveys now represent a major addition, or in some cases an alternative, to conventional demographic data sources. Most developed countries have a range of government-sponsored surveys which provide far more detailed information on, for example health-related behaviour, family-building strategies, or reasons for migration than it would be possible to collect in a census. Data quality is potentially much better in a survey than in a census, as it is more likely that well-trained interviewers can be used. The enormous potential complications arising from people’s uncertainties about age or other ‘basic’ characteristics, uncertain recollections of prior events, and the vast scope for administrative errors of various kinds have to be considered. There are organizations that produce international sources of data on health status of the population. These include the World Health Organization (WHO), the World Bank, the United Nations, the Organization of Economic Cooperation and Development (OECD), the Council of Europe, and Euro stat.

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3.1.1 Population Pyramid

Population pyramid is a very popular presentation of the age-sex distribution of the human population of a particular region. It gives a picture of a population’s age-sex structure, and can also be used to display historical and future trends. Generally, there are three main pyramid shapes: expansive, constrictive, and stationary (Figure 3.1).

Figure 3.1 Three main shapes of population pyramids. Source: Korenjak-Černe, Kejžar, Batagelj, 2008

1. The expansive shape (with a wide population base) is typical for fast-growing populations where each birth cohort (a group of people born in the same year or year’s period) is larger than the previous one (Latin America, Africa). A country or region has a high birth rate and a large percentage of its population under age 15;

2. Constrictive shape (a narrow base) displays lower percentages of younger population (United States). Growing elderly population will have a smaller workforce to provide the economic base for the “dependent age” population.

3. Stationary shape present somehow similar percentages for almost all age groups. The population pyramids of the Scandinavian countries tend to fall in this group. Although fertility has the greatest potential impact on age structure and population

growth, in some circumstances mortality may become a more important influence. Many factors may affect the population pyramid; such as the loss of a large number of people during wartime. With aging of the population in many countries due to low birth rates and increasing longevity, the concepts of “dependent” population groups of those under age 15 and those over 65 as a percentage of the total population is increasingly relevant to social and economic planning. In these demographic conditions, further improvements in mortality have the greatest impact at old ages, and further population ageing occurs from the apex rather than, or as well as, from the base, of the population pyramid. Mortality changes are now the main motor of the further ageing of the population of a number of developed countries with already old age structures.

Expansive Constrictive Stationary

men women men men women women

age

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3.1.2 Demographic Trends

There are very substantial differences between regions of the world in population characteristics and trends and predominant public health issues. The size of the world’s population is growing at an unprecedented rate. Most of the recent growth has been in the less developed world. In many countries of sub Saharan Africa, nearly half the population is aged 15 or under. In contrast, some European countries are expected to experience real falls in population size between 2010 an 2025, with almost a quarter of their population being aged 65 or more.

China implemented a “one child per family policy and with male preference now faces a major gender imbalance with excess males and a deficit in the female population. Developing countries with high birth rates are experiencing population growth exceeding economic growth capacity. The United States has the benefit of steadily improving life expectancy and high immigration rates to offset low birth rates. Japan and many European countries with very high life expectancy and low birth rates face declining and aging populations. These variations have enormous implications for the health and health care priorities of the populations concerned. In the less developed countries of the world a third of all deaths occur among infants and children aged under five. In the most developed world in contrast, deaths of elderly people aged 65 or more account for 72 per cent of the total and those of children under five accounts for less than 3 per cent. The watershed that separates populations with high fertility, relatively high mortality, young age structures, and rapid growth from those with low vital rates, older age structures, and slow or no growth is conceptualized as the demographic transition. Demographic transition is a long-term trend of declining birth and death rates, resulting in substantive change the age distribution of a population. Demographic transition may be characterized by the following stages:

1. Traditional: high and balanced birth and death rates; 2. Transitional: falling death rates and sustained birth rates; 3. Low stationary: low and balanced birth and death rates; 4. Graying of the population: increased proportion of elderly as a result of decreasing

birth and death rates, and increasing life expectancy; 5. Regression: migration or increasing death rates among young adults due to trauma,

AIDS, early cardiovascular disease mortality, or war resulting in steady or declining longevity (i.e., demographic regression).

Birth rates in the industrialized countries have fallen over the past half-century with economic prosperity, efficient and easily available methods of birth control, and greater opportunities for women in the workforce. Nowadays potential parents must think it acceptable to balance the advantages and disadvantages of another child and some advantage must be gained from reduced fertility. In some countries, access to prenatal diagnosis of the gender of the fetus has resulted in wide-scale abortion of females because of birth policies, with parental preference for male children in China and India as examples. This has resulted in a major lack of young women in the population with the attendant social and political effects. Factors influencing the fertility decline and the increase in longevity are presented in Box 3.1.

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Box 3.1 Factors in Fertility Decline and Increasing Longevity

Factors in fertility decline 1. Education, especially of women; 2. Decreasing infant and child mortality reduces pressure for more children to ensure survivors; 3. Economic development, improved standards of living, expectations, and income levels; 4. Urbanization – changes family needs compared to rural society; 5. Birth control, supply, accessibility, and knowledge; 6. Government policy promoting fertility control as a health measure; 7. Mass media increases awareness of birth control, and aspiration to higher standards of living; 8. Health system development and improved access to medical care; 9. Changing economic status, social role, and self-image of women; 10. Changing social, religious, and political and ideological values. Factors in increasing longevity 1. Increasing family income and standards of living; 2. Improved nutrition including improved food supply, distribution, quality, and nutritional knowledge; 3. Control of infectious diseases; 4. Reduction in noninfectious disease mortality; 5. Safe water, sewage and garbage disposal, and adequate housing conditions; 6. Disease prevention, reducing risk factors, promoting healthy lifestyle; 7. Clinical care services with improved access and quality; 8. Health promotion and education activities of the society, community, and individual; 9. Social security systems; for example, child allowances, pensions, national health insurance; 10. Improved conditions of employment and recreation, economic and social well-being. Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

3.1.3 Fertility

Fertility is the bearing of living children. Fertility is a complex issue influenced by cultural, social, economic, religious, and even political factors.

In developed societies a total fertility rate of 2.1 is taken to indicate replacement level fertility as, under this regime, a cohort of women would be succeeded by a cohort of daughters of the same size. Fertility levels in much of the developed world have been below this level. Total fertility rates are highest in sub-Saharan Africa.

Marriage patterns have a major influence on fertility and upsurges and downturns in marriages are associated with upsurges and downturns in births. Where possible, demographers have often preferred to calculate age-specific marital fertility rates on the grounds that the unmarried population is not ‘at risk’ (or at a very reduced risk) of child-bearing. Changes in marital fertility indicative of deliberate attempts to limit family size are regarded as one of the defining features of the fertility ‘transition’. In the long term populations will grow if mothers replace themselves with one or more (surviving) daughters and decline if they fail to achieve this. Reproduction rates thus relate only to female fertility, i.e. births of daughters. A huge range of social, economic, cultural, and psychological factors may influence decisions about family-building strategies and family size. The biological and behavioural factors have a direct influence. Three elements chiefly responsible for observed fertility variations were identified:

• The proportion of women married (exposed to risk) • Contraceptive use • Induced abortion

In modern populations, fertility decisions are normally couple (or woman) based, and ia implemented through contraception and abortion. In non-contraception populations, biosocial factors, notably marriage patterns, breast feeding-practices, sexual frequency, and, in some populations, the prevalence of infertility have been, or are, of major importance. Entry into

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marriage, or more generally, any sexual union, is important because it marks entry to the social reproductive span.

In the developed world there have been substantial variations in post-transition fertility levels and trends. Many developed countries experienced a post-war ‘baby boom’ which was followed by a ‘baby bust’ period in which fertility declined to very low levels during the 1970s. Since 1970 fertility has continued to decline in southern Europe which now has the lowest fertility in the world. The reasons for these recent trends and for the very low fertility now prevalent in much of the developed world remain a matter of lively debate. Economic changes, particularly the increased participation of women in the labor force, attitudinal shifts, and advances in the availability of effective birth control, have all been proposed as predominant influences. The very low fertility in most of Europe and the rest of the developed world and the continued ageing of the population, cause concerns in a number of countries about the implications of these demographic trends. On one hand a group deemed to have substantial support needs (the elderly) is growing, while on the other hand it is feared that the ability or willingness of younger generations to meet their needs may be diminishing. Increases in divorce, single parenthood, and the participation of married women in the labor force are frequently cited as constraints on the availability of younger generations to provide support for their elders. Recent changes in patterns of family formation and dissolution have been interpreted by some as indicative of a major reorientation from familial to individual goals. If current low levels of fertility persist, the populations of more developed countries will start to decline in size unless the negative natural increase is offset by immigration. However, fertility levels are still high, the population is young, and population growth is rapid in regions of the less developed world.

Box 3.2 Commonly Used Fertility Rates

Crude birth rate (CBR) is the number of live births in a population over a given period, usually one calendar year, divided by the midyear population of the same jurisdiction, multiplied by 1 000. Total fertility rate (TFR) is the average number of children that a woman would bear if all women live to the end of their child-bearing years, and bear children according to age-specific fertility rates; most accurately answering the question “how many children does a woman have, on average?”

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009

3.1.4 Mortality

A death rate (mortality rate) is the incidence rate that measures the frequency of deaths over a given period of time in a defined population. Mortality rates may be standardized to allow comparability and may be specific to define diseases or conditions.

Mortality data are based on the mandatory reporting of all deaths. A standard national death certificate is vital for public health as it provides basic information needed for demographic and epidemiologic purposes.

Death certificates are mandatory in most countries and must be signed by a licensed physician before the body can be buried or cremated and before insurance payments or inheritance can occur. The contents of the death certificate are important because the medically certified cause of death is the basis for mortality statistics.

Completeness of reporting, accuracy of diagnosis, coding of causes of death and the extent to which autopsies are used may limit the conclusions that can be drawn from such data. Standardization of reporting causes of death is far from simple. Doctors who fill in the form may vary in their perception of diagnosis and the difference between immediate and underlying cause of death.

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Causes of death recorded on the death certificate include the immediate cause of death; the second and third lines include contributing conditions (e.g., acute myocardial infarction and congestive heart failure); with the fourth line being the underlying cause (e.g., coronary heart disease). Medical diagnoses are coded, according to the 10th International Classification of Disease (ICD-10), adopted by the World Health Organization (WHO) in the 1990s.

Epidemiologic analysis of mortality data depends on the registration of deaths with basic demographic data and causation of death as recorded by the physician certifying it. Total, age, and sex-specific mortality are usually calculated on an annual basis, with the midyear population as the denominator. This provides crude, age-specific, cause-specific, and proportional mortality rates from which standardized mortality rates are calculated.

Change in mortality may reflect a change in incidence of the disease or CFRs related to treatment methods and access to care, or changes in definition or classification of diseases.

Mortality is strongly influenced by age structure, and age-specific (and sex-specific) rates, or measures based on them, are much to be preferred if data are available to calculate them. Both direct and indirect standardization are sometimes used to make comparisons between populations with different age and sex structures. Most commonly used mortality rates are shown in Box 3.3.

Box 3.3 Commonly Used Mortality Rates and Ratios

Crude Death Rate (CDR) = number of deaths all causes per 1 000 population in a given year = A/B x 1 000 (total deaths/average population x 1 000); Age-Specific Mortality Rate = Number of deaths of person in the specified age group per 1000 live population in that age group over a period of time, usually a year; Cause-Specific Mortality rate = number of deaths from a specific cause per 100,000 live population (estimated on July 1 of the given year); for example, annual number of deaths from lung cancer in a given year = 400 in a population of 1 million = 400/1,000,000= 40 lung cancer deaths per 100,000 population; Case Fatality rate (CFR) = number of deaths from a specified cause during a given time period over the number of diagnosed cases of that disease during the same time period x 100; for example, 10 deaths from measles among 5000 cases is a CFR of 10/5000x100 = 0,2%; Standardized Mortality Rate or Ratio (SMR) = the ratio of the number of deaths from a specified condition observed in a study population over the number that would be expected if the study population had the same specific rates as the standard population x 100;

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009

Concerning the age-specific mortality rates infant mortality is calculated as the number of deaths to infants aged less than one year age per 1000 live births. Infant mortality has attracted particular research interest because of observed links with fertility behaviour and as an indicator of public health standards and conditions. Infant mortality in contemporary developed countries is extremely low - less than 6 per 1000 live births in some cases. There also have been huge falls in infant mortality in much of the less developed world, but rates remain high.

Mortality is a robust indicator of a population’s health situation that is widely used in the European Region. The overall mortality rate from all causes of death in the Region gradually declined during the past decade to reach an average age-standardized death rate (SDR) of 888.2 per 100 000 population in 2006. The rates vary significantly, increasing from the countries in the western part of the Region to the eastern countries (EHR 2009).

The decline in death rates from infectious and parasitic diseases and maternal mortality, from which the young benefited more than the old and women more than men, meant that deaths of older persons accounted for a larger share of all deaths. Chronic degenerative diseases, notably, circulatory diseases and cancers, are the predominant cases of death in low-mortality populations, in all of which women live longer than men.

Improved nutrition, better housing and living conditions, public sanitation schemes, and specific public health initiatives (vaccination) as well as development of medical

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technology, all have their particular adherents. One result of increasing scientific knowledge is the greater potential importance of public policy and education. Historical research suggests that in the nineteenth century differences in child mortality by level of mother’s education or income were slight, whereas they are marked in contemporary less developed countries. In the developed world differentials in health-related behaviour are also strongly associated with income and education. It has also been argued that societal factors, such as the extent of income inequalities and degree of social cohesion, may account for some of the differences between developed countries in the overall level of mortality. Causes of death - situation in European Region

Non-communicable diseases produce the largest burden of mortality in the European Region accounting for more than 85% of the 9 million estimated deaths between 2003 and 2007 in the Region. Diseases of the circulatory system continue to be the main cause of death. They account for 48% of all deaths in the Region. Cancer (malignant neoplasms) is the second most important cause of death, accounting for more than 20% of total deaths in the Region. External causes of injury and poisoning, and respiratory diseases are the two other major causes of death, accounting for 8% and 6% of deaths in the Region. These four groups of causes account for almost three quarters of all deaths (Figure 3.2). Infectious and parasitic diseases cause 16% of deaths globally but less than 2% in the European Region.

Mortality profiles in the Region differ greatly by cause of death, age and sex. For example, external causes of injury and poisoning account for more than 70% of deaths among adolescents and young adults (especially men). Diseases of the circulatory system and cancer become leading causes as age increases. In early childhood, diseases of the respiratory system and “other diseases” comprise the largest share (nearly 90% of deaths), affecting boys and girls similarly. Infectious and parasitic diseases have declined among young children, accounting for less than 5% of deaths, but are becoming increasingly important among adults.

Figure 3.2 Causes of death in European region. Source: The European health report. WHO, 2009a. Notes: EU 15 - EU members before May 2004, EU 12 - EU members after May 2004, CIS - Commonwealth of Independent States, CARK - Central Asian Republic and Kazakhstan.

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3.1.4.1 Life Tables

Life table analysis is a core demographic technique and life tables provide one of the most powerful tools for analyzing mortality. Life tables are derived from age-specific mortality rates and show the probability of dying (and surviving) between specified ages. With regard to the level of mortality, death rates tend to be higher in infancy than in later childhood and rise with age from around the age of puberty. Life tables are an essential part of much demographic analysis (including, for example, making population projections). They allow the calculation of a variety of other indicators, including life expectation and are also widely used to analyze events other than death.

Life expectancy

Life expectancy is an important health status indicator based on average number of years a

person at a given age may be expected to live given current mortality rates. Life expectancy

can be measured at age 0, or any other specific age. Life expectancy either at birth (e0) or further life expectancy at a particular age, say 65 (e65) is calculated from life tables by dividing total person years lived after age zero or 65 and dividing it by the number of survivors aged zero or 65. The level of infant mortality is a powerful influence on e0 as so many potential person years are lost though an infant death.

Life expectancy at birth is a common measure used to compare health status in and between countries. Life expectancy roughly but comprehensively measures overall population health, as it summarizes, in a standardized format, current information on the health situation of all age and sex groups of populations. As such, it reliably indicates overall health performance in a society at a specific time (EHR 2009).

The female life expectancy is now greater than that of males, but there is considerable variation in the extent of this difference. Low-mortality countries generally have larger sex differences in life expectancy than high-mortality populations, reflecting the association between falls in mortality and an increasing female advantage. This is the result of declines in causes of death specifically or primarily affecting women (such as maternal mortality and respiratory tuberculosis), gender differences in health-related behaviour and in exposure to occupational hazards, and the possibly greater susceptibility of men to stresses associated with socio-economic changes as casual factors. In Western developed countries a large proportion of the sex differential in life expectancy at birth is due to differences in ischemic heart disease, lung cancer and accidents and violence. The epidemic of smoking and attendant smoking-related diseases is undoubtedly a major cause of gender differences in death. Alcohol is also a factor in gender differentials in mortality particularly in Eastern Europe.

The elderly population in nearly all countries of the world is predominantly female. Older women experience more disability than older men. This seems to reflect women’s greater risk of disability from musculoskeletal disorders and longer survival than men after the onset of disability. Estimating the relative contributions of the numerous health-related and other, mainly socio-economic factors that might affect the variation in life expectancy over time and across countries is difficult. In general, higher national income is associated with higher life expectancy at birth. Expenditure on health services is also important in improving health. The highest life expectancy at birth in the European Region was 82.0 years in Switzerland (2006) and the lowest, 66.4 years in Kazakhstan (2007), (EHR 2009). Life expectancy is also used in chronic disease epidemiology to summarize patterns of mortality and survival in a population, such as a population with breast cancer. This is important in clinical epidemiology where studies of effectiveness of specific interventions are assessed. Life expectancy is quite different for male and female genders.

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3.1.5 Migration

In many countries migration is the predominant influence on the spatial distribution of the population. In the less-developed and newly industrialized world recent rural-to-urban migration has resulted in the phenomenal growth of cities, which often lack the infrastructure to meet the needs of the expanding population for basic services such as sanitation and power. In contrast in the old developed world urbanization has been succeeded by ‘counter-urbanization’ involving migration from cities to suburbs or beyond. One result has been a growing concentration of those unable to move (the old and the disadvantaged) in inner-city areas. Measuring migration represents particular difficulties. In the absence of direct census data, estimates of migration can be made indirectly. Differences in the size of a population at two points in time (censuses) not accounted for by natural increase or depletion must be due to migration (or errors in data).

Surveys are also used to measure migration in terms of the reasons for, and consequences of migration. Tourists and business travelers comprise the vast bulk of people entering or leaving a country, and so surveys are and inefficient way of identifying immigrants and emigrants. Unfortunately, other data are often lacking as legal and administrative record systems are frequently concerned with citizenship.

At the local level, migration flows may be the predominant influence on population size. Migrants differ from non-migrants, and so migration has a potentially strong impact on population structure and characteristics. Migration is an important element to take account of in health planning.

3.2 EPIDEMIOLOGY

Health care providers are generally oriented toward individual patient assessment and care. However, even the specialized clinician must have a basic understanding that disease is not an event isolated to an individual, but instead affects population groups and communities alike. The clinician must be aware of the potential of non-communicable diseases that affect the individual patient.

Epidemiology is the study of health events in a population. The distribution and determinants of health-related states are important to identification of potential interventions and priorities to control health problems. This includes surveillance, observation, and hypothesis generation and testing in analytic research and experiments. Epidemiologic studies include descriptive studies of routinely collected and reported data on mortality, morbidity, and related factors. They focus on the distribution of a disease or risk factor by time, place, and person characteristics. Analytic epidemiologic studies are based on hypothesis testing and include observational studies such as cross-sectional, case control, and cohort studies as well as intervention studies, including clinical program trials. They focus on exposures and outcomes attempting to determine their associations. Classically, the clinician examines a patient who presents himself for medical care, including preventive action, while the epidemiologist studies a defined population. Epidemiology studies a particular disease in population. Clinicians and epidemiologists depend on each other, and need the work of others fields, such as health economics and management. This also relies on interaction with the various disciplines within public health, health systems management, and clinical medicine.

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3.2.1 Definitions and Methods of Epidemiology

Measuring the extent of a disease (or a risk factor) in a population relates known cases to a population base, expressed as a rate or a risk. Comparing the extent of a disease or a risk factor among population groups can be expressed as a ratio (or a relative risk).

Relative risk is the probability that individuals in one group will develop a certain condition within a defined time period as compared to people in another group. As a probability, it therefore ranges from 0 to 1. It is usually calculated as the cumulative incidence of a certain disease condition. Cumulative incidence implies that a defined population group is followed during a certain time period to allow the identification of incidence of new cases. When including new and preexisting cases the term used is prevalence. The denominator is a fixed population about which information is available.Because the study population is often dynamic it is often impossible to correctly calculate risk.

Rates are measures of frequency of a phenomenon, such as occurrence of a health event (A), in a defined population (B), in a given time period. A multiplier to covert the fraction to a decimal number may be used for convenient comparisons between the frequency of the event in different population groups. Defining the number of cases of a disease or the risk factors being studied is essential to provide the numerator of the rate or ratio. This is also difficult because not all cases of a disease may be reported. The same applies in chronic diseases (e.g., diabetes mellitus) for many reasons, including non-presentation to the medical system of asymptomatic cases, unclear case definition.

Crude rates are summary based on the actual number of events reported in a total population in a given time period. Cause-specific rates measure for specified condition occurring in the total population or in a designated population group in a specified time period.

Odds ratios are fractions (A,B), where A and B are two separate and distinct quantities. A ratio may compare mortality rates from a specific disease in two population groups, one group exposed to a risk factor compared to the mortality rate in an unexposed population. This is called a relative risk (RR).

3.2.2 Measures of Morbidity

Morbidity is a departure, subjective or objective, from a state of physiological and psychological well-being or normal function. It can be measured as the number of persons who are ill, periods or spells of illness, or duration of illness. Morbidity is also described in terms of frequency or severity. Disability or incapacity rates measure the extent of long-term reduction of a person ´s capacity to function in society (Box 3.4).

Box 3.4 Measures of Frequency of Disease in Population Groups

The number of cases in a given time period

Rate = x Nth

The population at risk in same time period

Were Nth = 100, 1000, 100,000 or 1,000,000; Period: Usually = 1 year; Population: mid-year (July 1) estimate.

Incidence rate defines the rate at which new health-related events occur in a population. The numerator is the number of new events occurring in a defined period (usually 1 year); the denominator is the population at risk of experiencing the event during this period. Prevalence is the total number of all individuals who have an attribute or a given disease or condition at a point in time or a designated time period. The prevalence rate is the number of individuals with the attribute divided by the population at risk, at that point in time (point prevalence), or midway through the period (period prevalence)

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

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Morbidity data are reported by doctors, usually based on compulsory reporting of specific infectious and noninfectious diseases. Some diseases such as plague, cholera, yellow fever, louse-borne typhus, and louse–borne relapsing fever are noted by international convention. Locally endemic diseases are noted under national public health laws in order to monitor their prevalence and the impact of public health measures. Other diseases or health events may be added to routine reporting (or to special surveys) according to endemic environmental conditions.

Morbidity is measured by incidence and prevalence rates, as well as severity and duration, though these are not usually available on routine reporting and may require special investigation. Incidence is more useful for acute conditions, whereas prevalence is more important in measuring chronic disease and assessing the long-term impact of a disease.

Incidence rates measure the frequency of health–related events in a certain population during a specified time period. The denominator for incidence rates is defined as the “population risk”.

There are a number of ways to define the denominator for incidence rates: 1. Ordinary incidence rate is used when a calculating incidence rates in a changing

population. In that case, the average size of the population in the specified period is used as the denominator, usually including both the “population at risk” and cases already with the disease (prevalence).

2. Cumulative incidence rate is usually calculated in longitudinal epidemiologic studies. When a cohort (a group of people), initially free from the disease, is being followed during a certain period of time, incidence cases can be identified as they occur.

Unlike incidence (indication of occurrence), prevalence is the measure of the total

existing situation of a health-related condition or risk factor, including old and new cases. Several measures of prevalence rates exist:

1. Point prevalence. The proportion of persons with the condition being studied at a certain point in time is divided by the size of the group or population.

2. Period prevalence: the proportion of persons who developed the condition before and during the specified period. It allows comparison over time with the same or other population groups

3.2.3 Screening

A major strategy for secondary prevention of disease is screening. Screening is defined as the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures that can be applied rapidly and inexpensively to populations. Its purpose is to distinguish among apparently well persons, those who probably have a disease from those who probably do not. Screening is not intended to be diagnostic; persons with positive results on a screening test require additional diagnostic tests and examinations to establish a definitive diagnosis. Screening procedures may include cytological tests, blood tests, x-rays, urinalysis, amniocentesis, examination for scoliosis, and a variety of other procedures.

Screening tests may be applied unselectively to an entire population (e.g. blood pressure screening of all persons attending a health fair) or may be applied selectively to certain groups of persons known to have a high risk for a disease (e.g. using mammograms to screen women with a family history of breast cancer). Such applications of screening tests are examples of mass screenings.

Screening may also be used as part of periodic health examinations (e.g. PAP smears for women, electrocardiograms for the middle-aged population, regular height, weight, hearing, and vision measures of children). This type of screening, where clinicians use

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screening tests to search for disease among their own patients who have come in for a general checkup or for consultation regarding unrelated symptoms, is called case finding.

Multiphase screening, the use of a variety of screening tests on the same occasion, is another application of screening.

Mass screening, case finding, and multiphase screening are all examples of prescriptive screening - screening performed for the purpose of better controlling disease through early detection in presumptively healthy individuals. Screening is also used by epidemiologists for research purposes. Screening of a population may be performed to estimate prevalence of disease. Furthermore, these screened populations may be followed over time, using periodic screens to identify new cases of the disease to determine incidence rates.

3.2.3.1 Screening Tests vs. Diagnostic Tests

Screening tests detect the disease before symptoms appear. Diagnostic tests are

generally used on patients who have come to a treatment center seeking an explanation for

symptoms, they are experiencing. Diagnostic tests which are ordered by a physician, often require specialized equipment or expertise to administer, are generally expensive, often time consuming, and may incur a degree of discomfort, pain, or risk for the patient. Results of diagnostic tests are usually of sufficient accuracy to establish a definitive diagnosis; they can thus be used as a basis for initiating treatment. In contrast to diagnostic tests, screening tests are generally offered to apparently

healthy populations as a way of determining whether it is probable that they have a disease; it is presumed that identifying probable disease before symptoms appear permits early initiation of treatment and, therefore, will affect the prognosis for the patient. The accuracy of screening tests is insufficient as a basis for initiating treatment; follow-up diagnostic testing of individuals with abnormal results on the screening test must be performed (e.g. and individual who tests positive on a tuberculosis test would need to have a complete history taken and, at a minimum, have a chest x-ray and a sputum test that can be cultured for the tubercular bacillus). Although the initial cost of doing a screening test may be low because these tests are generally inexpensive and can be administered by an individual with minimal training, the economic cost of the following testing of those screened as abnormal can be considerable. Screening tests are generally simpler, less accurate, less expensive, less risky, and more acceptable to a presumably well population than are diagnostic tests. To induce participation, an ideal screening test should take only a few minutes to perform, require minimal preparation by the patient, and require no special appointments.

3.2.3.2 Test Accuracy

Accuracy is dependent on two characteristics, the validity and the reliability of the test. Reliability involves the repeatability or replicability of the results - the ability of a test

to give consistent results in repeated applications. Reliability is dependent both on the precision of the test - how much variation is present in the test itself - and on variation introduced by different persons applying the test. Variability in the results of a test procedure administered at two different times to the same sample by the same tester could be a function of variability in how the procedure was performed or interpreted by the tester, or a function of variability in the test conditions. Validity indicates how well a test result represents reality. Validity is measured by

the sensitivity, specificity, and predictive values of the test. Sensitivity is the frequency with which persons with who have the disease test positive - the probability of the test correctly identifying a case. Specificity is the frequency with which persons who do not have the disease test negative - the probability of correctly identifying non-cases. The measures are

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illustrated in Table 3.1, and the distribution of a population with respect to disease status and screening test results, which are used as the basis for these measures, is shown in Table 3.2. Those persons with the disease can have two test results, true-positives or false-negatives (negative test result appears in a person who does the condition for which the test is being conducted). Sensitivity then is the percentage of all those with the disease (true-positives and false-negatives) who test positive. Persons without the disease may have false-positive results (positive test result occurs in a person without the condition for which the test is being conducted), on the screening test or true-negative results. Specificity is based on the percentage of these two test results that are true negative. Conversely, increasing specificity decreases sensitivity.

Table 3.1 Measures of validity of screening tests.

Measures How calculated

Sensitivity True-positives x 100 (True-positives + False-negatives)

Specificity True-positives x 100 (True-negatives + False-positives)

Predictive value positive test True-positives x 100 (True-positives + False-positives)

Predictive value negative test True-negatives x 100 (True-negatives + False-negatives)

Source: Valanis B. Epidemiology in health care. Third edition. Stamford: Appleton & Lange, 1999

Table 3.2 Distribution of disease status and screening test results in a population.

True diagnosis Screening

test result Diseased �ot Diseased Total

Positive True-positives False-positives True-positives + False-positives

Negative False-negatives True-negatives False-negatives + True-negatives

Total True-positives + False-negatives

False-positives + True-negatives

True-positives + False-positives + False-negatives + True-negatives

Source: Valanis B. Epidemiology in health care. Third edition. Stamford: Appleton & Lange, 1999 Predictive values of screening test, unlike sensitivity and specificity, are measures dependent on the prevalence of disease in the population to which the test is applied. Predictive values describe the frequency with which test results represent correct identification of

disease status among those screened. The predictive value of a positive test is the proportion of those testing positive that have the disease. The predictive value of a negative test is the proportion of those testing negative that do not have the disease. These are usually expressed as the percentage of positives or percentage of negatives that were correctly identified (Table 3.1).

3.2.3.3 Criteria for Screening Programs

The criteria that should be met by a good screening program are listed in Box 3.5. These criteria address the scientific, social, and ethical issues relevant to screening. They imply careful selection of tests based on accuracy, good epidemiological description of the natural history of the disease, evidence of the efficacy of earlier treatment and a positive cost-

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benefit to society. The criteria for screening programs also imply careful selection of the population to be screened and inclusion of plans for program evaluation.

Box 3.5 Criteria for screening program

1. Test has high sensitivity and specificity. 2. Test meets acceptable standards for simplicity, cost, safety, and patient acceptability. 3. Disease that is focus of screening should be sufficiently serious in terms of incidence, mortality, disability,

discomfort, and financial cost. 4. Evidence suggests that the test procedure detects the disease at a significantly earlier stage in its natural

history than it would present with symptoms. 5. A generally accepted treatment that is easier or more effective than treatment administered at the usual time

of symptom presentation must be available. 6. The available treatment is acceptable to patients as established by studies on compliance with treatment. 7. Prevalence of the target disease should be high in the population to be screened. 8. Follow/up diagnostic and treatment service must be available and accompanied by an adequate notification

and referral service for those positive on screening. Source: Valanis B. Epidemiology in health care. Third edition. Stamford: Appleton & Lange, 1999

3.2.3.4 The Individual Risks vs. Benefits

Because screening procedures are applied to well persons and because of the potential economic and psychological costs incurred by misclassification of disease status, a benefit should accrue to the screened individuals as a result of the program in addition to the cost-benefit to society accruing from earlier detection and treatment of the disease. Consider the four possible outcomes of a screening test: 1. true-positive, 2. true-negative, 3. false-positive, 4. false-negative. Individuals with accurate results, the true-positives and true-negatives, can benefit from screening. Individuals with true-negative results benefit from the peace of mind that comes from knowing they are disease free. Those screened individuals with true-positive results, however will benefit from the detection of their disease only if three conditions are met:

1. the screening test has detected their condition at an earlier stage of disease than would have the presence of symptoms;

2. earlier detection can lead to improving their prognosis because an effective treatment is available;

3. the available treatment is acceptable to the patient and the physician. If these conditions are not met, then there is no benefit to individuals with true-positive results. Screened individuals with false-positive results are likely to be somewhat unhappy with the screening program:

1. they experience a period of time they must worry whether they have disease; 2. they must undergo a series of diagnostic tests that, at the very least, take time away

from work, home, and friends: these tests may be uncomfortable or painful and involve unpleasant side effects or some degree of risk;

3. costs of diagnostic tests. Individuals with the false-negative test may be harmed as a result of the screening program:

1. when symptoms appear, the individual recognizes them as early signs of the disease for which they were recently screened negative and ignores them rather than seeking medical attention;

2. the cost of treating the condition may be higher than otherwise would be the case.

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3.2.4 Epidemiologic Studies

Special survey - study is necessary to undertake when more detailed social or physical characteristics must be learned (as in many etiological enquiries), or when morbidity or the natural history of disease needs to be assessed.

Epidemiologic methods of study are important, not only to define the extent of disease in the population, but also to look for specific risk or causal factors for the disease. Epidemiologic studies permit analysis of a risk factor, variable, or an intervention (such as a new vaccine or drug). This permits testing of new hypotheses and innovations in medicine and public health. Epidemiologic studies are classified as observational or experimental (Figure 3.3). The observational study allows nature to take its course, with no intervention, as opposed to experimental studies, involving interventions.

Figure 3.3 Classification of epidemiologic studies.

Source: Valanis B. Epidemiology in health care. Third edition. Stamford: Appleton & Lange, 1999

3.2.4.1 Observational Studies

Observational studies are studies of the population without direct control of the investigator, but nature is allowed to take its course. They may be descriptive or analytical. Descriptive studies are limited to describing the occurrence of a disease in population, which is often the first step in investigation, as it may provide clues for more in-depth investigation. Analytical studies go further by looking for specific variables which may be causally associated with the disease. Descriptive epidemiology uses observational studies of the distribution of disease in terms of a person, place, and time. The study describes the distribution of a set of variables, without regard to causal or other hypotheses.

Analytical studies are concerned with establishing causes or contributory risk factors to disease, including social, economic, psychological, or political conditions that impinge on health. Analytical epidemiology has made vital contribution to modern medicine through identification of key risk factors, such as higher rates of stroke among people with hypertension. Analytical studies may include cross-sectional (or prevalence studies), as well as retrospective, prospective, and ecological studies.

Descriptive

Analytical

Cross sectional

Longitudinal

Ecological

Prospective

Retospective

Experimental

Clinical trials

Community trials

Observational

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Ecologic studies

The objective of ecologic studies is to examine the association between exposure and occurrence of disease with population-level data (i.e. the units of analysis are populations rather than individuals). Their key features are (Memon, 2006):

• Ecologic studies compare aggregate exposure and disease across different populations over the same time period or within the same population over time.

• They are excellent for generating hypotheses (particularly when the disease is of unknown etiology) but they cannot establish causality.

• They are generally inexpensive and quick to conduct if routine data on exposure (e.g. per capita income, mean ambient temperature, air/water quality, weather conditions, smoking prevalence, per capita intake/annual sale of food items/alcohol) and disease (e.g. incidence/mortality rates, prevalence) are available.

• They are useful for examining the effect of short-term variations in exposure within the same population (e.g. effect of temperature on mortality in the elderly) and evaluating the impact of public health interventions by comparing aggregate-level information before and after the intervention (e.g. fluoridation of drinking water, seat belt law).

Ecologic studies have a number of limitations: • they are subject to confounding as information on potential confounder(s) is generally

not available, • associations at the population level do not necessarily represent associations at the

individual level (ecologic fallacy or ecologic bias). The mean values may not be truly representative of the actual situation because causation of exposures and

outcomes for individuals is not established. If a group has high prevalence of an exposure (e.g., oral

contraceptive use among women) and has also higher prevalence of positive outcome (breast cancer) than not

exposed group, we still don’t know whether the individuals with a positive exposure status are also those with a

positive outcome.

Cross-Sectional Studies or Prevalence Studies

These studies examine the relationship between specific diseases and health-related factors as they exist in individuals in a population at a particular time. Their key features are (Memon, 2006):

• Cross-sectional studies take a ‘snapshot’ of the sample of individuals in the population at one particular time. They are conducted to determine the burden of exposure and/or disease in the population, assess knowledge, attitude, and practice in relation to health-related issues, public health monitoring, and planning interventions and health services, and to generate hypotheses and examine association between exposure and disease.

• Unlike case–control and cohort studies, the study population is commonly selected without regard to exposure or disease status, and you can examine multiple exposures (e.g. smoking, high cholesterol, family history) and outcomes (CHD, asthma, diabetes) simultaneously in each individual.

• They can be conducted in a relatively short time; and when based on a representative sample, their findings can be generalized to the whole population.

This type of study is relative simple and easy to perform. When investigating two variables (a presumed exposure and presumed outcome) it may be impossible to determine which one is the determinant, which one is the exposure and which is the outcome, as we have no information about a time relationship. For example, a cross- sectional study of body mass index (BMI) and blood pressure may find that high BMI

correlates with high blood pressure, but will not be able to indicate whether persons with high BMI had an

increase in blood pressure or if persons with high blood pressure became fatter.

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Case-Control Studies Case-control studies are observational studies of persons with the disease - cases (or

other outcome variable of interest) and a suitable control group of persons without the disease. These studies are retrospective, taking a known outcome status (e.g., disease status) and looking at the exposure status. They compare two similar population groups for their exposure outcomes, one with the disease or condition and the other without. When selecting controls, it is important that controls have the same chance as cases of being exposed to the study factor. The key features of case–control studies are (Memon, 2006):

• Case–control studies are conducted to generate and test etiologic hypotheses, evaluation of screening and prevention programs, vaccine and treatment efficacy, and outbreak investigation.

• It is possible to study associations of a disease with several exposures and characteristics, and measure potential confounding factors.

• They are relatively inexpensive and conducted in a short time. • They are efficient for rare diseases and those with long induction/latent period. Case–control studies have some limitations:

• they are subject to problems with control selection and matching between cases and controls

• recall bias where persons with/without a studies outcome may tend to better remember their exposure status.

• sometimes it is difficult to establish a clear temporal sequence between exposure and disease

• they are inefficient for rare exposures. An example is the study of the occurrence of a serious upper limb defect (phocomelia) in children born in

Germany in the late 1950s which showed that of those born with this defect, 41 out of 46 mothers had taken the

medication thalidomide as an antinausea pill promoted for use during pregnancy.

The odds ratio is commonly used to summarize findings of case-control studies. It is a ratio of the odds of exposure among cases to the odds of exposure among controls. Cohort studies

The objective of cohort studies is to study associations of an exposure(s) with a disease and/or several health outcomes; participants are grouped according to exposure (exposed/unexposed) and followed over time to compare the incidence of health outcomes. For a prospective (longitudinal) cohort past or current exposure is determined at the beginning of study and participants are followed into the future to observe the outcome. For a historic (or retrospective) cohort participants are grouped on the basis of historic exposure data at a defined time in the past and the outcome up to the present time is observed (i.e. both the exposures and outcomes have already occurred in the past, and the investigator reconstructs the outcomes between the defined time of exposure in the past and the present). Key features of cohort studies are (Memon, 2006):

• Cohort studies are conducted to test etiologic hypotheses, understand physiology, pathogenesis, prognosis, and natural history of disease, and evaluation of screening and prevention programs and vaccine and treatment efficacy.

• The study design is the most robust in observational epidemiology. It is possible to establish temporal sequence as the exposure is assessed at baseline and incidence (or mortality) rates of disease among the exposed and unexposed groups are determined.

• In prospective studies, the length of the follow-up period can range from a few days/weeks for infectious disease to several years/decades for diseases such as cancer or cardiovascular disease.

• It is possible to study associations of an exposure with several outcomes, and also to study multiple exposure (when a general population cohort is selected irrespective of any particular exposure).

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• Prospective studies are less vulnerable to bias because the outcomes have not occurred when the cohort is assembled and the exposure is assessed at the beginning of the study.

• Historic studies take less time and money to conduct, and are commonly used for studying outcomes of occupational and clinical exposures.

The outcome measures of a cohort study are the incidence (and/or mortality) rates in the exposed and unexposed groups. From these measures, one can calculate relative risk, attributable risk, and population attributable risk. Cohort studies have a number of limitations:

• Prospective studies are relatively expensive to conduct, take a long time to yield results, and are usually inefficient when studying rare outcomes. Subjects lost to follow-up (generally >10%) may undermine the validity of the study.

• In historic studies the available data on exposure, outcome, and other key variables may be inadequate.

Examples: The British doctors´ smoking habits study carried on from 1951-2001 showing the harmful effects of

smoking in terms of lung cancer, coronary heart disease, and early mortality.

The Framingham Study initiated in 1949 has provided a wealth of epidemiologic information of risk

factors for cardiovascular disease in the population of Framingham, Massachusetts.

3.2.4.2 Experimental Epidemiology

Experimental studies are studies of conditions under the direct control of the investigator, conduced as closely as possible to a laboratory experiment. Experimental epidemiology involves changing a variable and measuring the effect in one or more population groups. Clinical epidemiology applies experimental epidemiologic research methods to clinical problems and practice.

Controlled Trials Controlled trials are epidemiologic experiments designed to study an intervention (preventive or therapeutic). It requires a random method of allocating the cases to the experimental or the control groups, and then both are observed for change over time in relation to the condition being studied. If the people in both the test and control groups do not know which group they are in, the study is called blind. If in addition the people judging the outcome are also not aware whether the person tested is in the test or control group, the trial is called double blind. Further, if those analyzing the data also do not know who was in each group, the study may be called triple blind. This helps to avoid various biases which limit the value of a study. If the difference in outcomes is statistically significant for the control group and the treatment group, then the treatment is deemed to have been effective. Assignment to the treatment or the control group is by random selection. Controlled trials are often not available for important policy issues and would be unethical to conduct because denying the benefits of a known positive intervention would be ethically unacceptable.

Field Trials Field trials follow people who are disease-free in two groups, one with and one

without a specific intervention, to determine if the intervention affects the risk of developing the disease. This is often used to test a new vaccine in a susceptible population.

Community trials Community trials are conducted on whole communities measuring the effect of a risk

factor or intervention. This cannot easily be randomized because the entire community is selected, and it may not be possible to isolate the community from changes going on within the general population. Community-based heart disease prevention programs have been undertaken in many settings, such as in North Karelia, Finland.

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Nevertheless, community trials are necessary in evaluating health interventions to reduce risks or adverse health outcomes. As with individual health assessment, evaluation of the health status of a population is based on the accumulation of a portfolio of observations and data from a variety of sources and their interpretation, with comparison to international, national, or regional databases.

3.3 SUMMARY MEASURES OF POPULATIO� HEALTH

Rising life expectancy makes it more important for public health professionals to have information on non-fatal health problems and rates of good health. Many of the most common chronic conditions reported by the growing proportions of older people, such as musculoskeletal and sensory impairments, may have serious implications for health status but are not directly life-threatening and are not featured as prominent recorded causes of death. If, as some have argued, recent reductions in mortality are due partly to the prolongation of the process of dying rather than an extension of healthy life, then life expectancy may be becoming a less valid summary indicator of population’s health. In response to these concerns, increasing attention has been paid to disaggregating life expectancy into ‘healthy’ and ‘unhealthy’ or ‘persons with disabilities’ components.

HALE (healthy life expectancy) and DALYs (disability-adjusted life-years) allow this analysis, and reveal that higher levels of health development mean more healthy years of life and that non-communicable diseases present the Region with its biggest challenge. Summary measures of population health combine information on population mortality and non-fatal health outcomes, to represent a population’s state of health in a single number

3.3.1 Healthy Life Expectancy

HALE can be used to answer two strategically important questions. Has an increase in health accompanied the increase in longevity? What is the average time that people live in good health, and what is the percentage of time spent in less-than-good health? The answers are that the general increase in life expectancy has also meant a general increase in healthy years of life, and the proportion of life spent in less-than-perfect health has decreased. This is a major improvement of the health situation. Nevertheless, the health differentials between populations are wider in terms of HALE than in life expectancy estimates only.

Healthy life expectancy at birth takes account of years lived in less than full health. In addition, although women live an average of 7.5 years longer than men, the average difference in healthy life expectancy is only 5 years, meaning that women live a smaller share of their lives in good health or free of disability than men. Thus, towards the end of life, women have accumulated a larger burden of ill health than men as a result of both longer longevity and multiple illnesses (EHR 2009).

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Figure 3.4 Summary measures of population health. Source: WHO European health report 2005

3.3.2 The Burden of Disease

Burden of disease refers to the combined measurement of mortality and nonfatal health outcomes. The assessment of burden of disease (BOD) serves to design, test, and implement methodologies to aid in setting priorities for effective allocation of health resources. The challenge is to develop valid, reliable, comparable, and comprehensive measures of population health and comparative assessments of the burden of diseases, injuries, and risk factors. This assessment can then be linked with the investigation of costs, efficacy, and effectiveness of major health interventions in order to establish appropriate cost known as effectiveness estimations, which should be a major tool in policy design and decision making. The BOD is an important epidemiologic research instrument. This approach recognizes that social and other factors contribute to diseases which are multi-factorial in origin, These estimations, combining economic and epidemiologic data use disability-adjusted life year (DALY) as the unit of measurement of the burden of disease, representing the loss of 1 year of “healthy” life.

The measures of ill-health used so far (incidence, prevalence) do not give a good indication of the burden of disease borne by individuals in different communities. The summary measure used to give an indication of the burden of disease is the DALY . One DALY represents the loss of the equivalent of one year of full health. Using DALYs, the burden of diseases that cause early death but little disability (e.g. drowning or measles) can be compared to that of diseases that do not cause death but do cause disability (e.g. cataract causing blindness), (WHO, 2008).

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3.3.2.1 Disability-adjusted Life Year DALY

One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability.

DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for incident cases of the health condition:

DALY = ∑YLL + ∑YLD The YLL basically correspond to the number of deaths multiplied by the standard life

expectancy at the age at which death occurs. The basic formula for YLL (without yet including other social preferences discussed below), is the following for a given cause, age and sex:

YLL = � x L where:

• N = number of deaths • L = standard life expectancy at age of death in years (for women at birth L = 82.5

years, for men at birth L = 80 years) Because YLL measure the incident stream of lost years of life due to deaths, an incidence

perspective is also taken for the calculation of YLD. To estimate YLD for a particular cause in a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). The basic formula for YLD is the following (again, without applying social preferences):

YLD = I x DW x L where:

• I = number of incident cases • DW = disability weight • L = average duration of the case until remission or death (years) Egalitarian principles are explicitly built into the Disability-Adjusted Live Year (DALY)

metric, and the global burden of disease studies apply these to all regions of the world. The studies use the same "ideal" life expectancy for all population subgroups and exclude all non-health characteristics (such as race, socio-economic status or occupation) apart from age and sex from consideration in calculating lost years of healthy life. Most importantly, they use the same "disability weight" for everyone living a year in a specified health state. Disability weights A disability weight is a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (equivalent to death). Years Lost due to Disability (YLD) are calculated by multiplying the incident cases by duration and disability weight for the condition. Age weighting and discounting.

• 3% discounting and non-uniform age weighting is used in the GBD study. These adjustments result in less weight given to years lived at young and older ages.

Applications of Burden of disease analyses Burden of disease analyses are useful for informing health policy in • Assessing Performance

The burden of disease provides an indicator that can be used to judge progress over time within a single country or region or relative performance across countries and regions.

• Identifying �ational Control Priorities National assessments of disease burden are one input into the process of establishing a shortlist of disease control priorities.

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• Creating Knowledge Allocating time to training for interventions where the disease burden is high and cost-effective interventions exist.

• Allocating Resources across Health Interventions A key task for priority-setting analyses in health is to create the evidence base to stimulate the reallocation of resources to interventions that, at the margin, will generate the greatest reduction in health loss.

3.3.2.2 Leading Causes of Morbidity and Mortality

While the two leading causes of death – ischemic heart disease and cerebrovascular disease – remain among the top six causes of burden of disease in 2004 (Table 3.3), four primarily non-fatal conditions are also among the 20 leading causes of burden of disease; these are unipolar depressive disorders, adult-onset hearing loss, refractive errors and alcohol use disorders (WHO, 2008a). This again illustrates the importance of taking non-fatal conditions into account, as well as deaths, when assessing the causes of loss of health in populations. The two leading causes of burden of disease in the world are infectious diseases – lower respiratory infections and diarrhoeal diseases. HIV/AIDS is now the fifth cause of burden of disease globally, and three other infectious diseases also appear in the top 15 causes

The 1990 GBD study brought the previously largely ignored burden of nonfatal illnesses, particularly neuropsychiatric disorders, to the attention of health policy makers. The findings of the 2004 GBD study, based on updated data and analyses, confirm that disability and states of less than full health caused by diseases and injuries play a central role in determining the overall health status of populations in all regions of the world. Neuropsychiatric conditions, vision disorders, hearing loss, and alcohol use disorders dominate the overall burden of nonfatal disabling conditions. The disabling burden of neuropsychiatric conditions is almost the same for males and females, but the major contributing causes are different. While depression is the leading cause of disability for both males and females, the burden of depression is 50 percent higher for females than males, and females also have higher burdens from anxiety disorders, migraine, and senile dementia. In contrast, the male burden for alcohol and drug use disorders is nearly six times higher than that for females and accounts for a quarter of the male neuropsychiatric burden. More than 85 percent of disease burden from nonfatal health outcomes occurs in low- and middle-income countries, and South Asia and Sub-Saharan Africa account for 40 percent of all DALYs. Even though the prevalence of disabling conditions such as dementia and musculoskeletal disease is higher in countries with long life expectancies, this is offset by lower contributions to disability from conditions such as cardiovascular disease, chronic respiratory diseases, and long-term consequences of communicable diseases and nutritional deficiencies. In other words, people living in developing countries not only face shorter life expectancies than those in developed countries, but also live a higher proportion of their lives in poor health.

Box 3.6 Causes of disability - facts

1. Globally, 60% of DALYs are due to premature mortality. 2. DALYs in Africa are at least two times higher than in any other region. 3. Non-communicable diseases now cause almost half of the burden of disease in low- and

middle-income countries. 4. Children bear more than half of the disease burden in low-income countries. 5. Four non-fatal conditions are in the 20 leading causes of burden of disease. 6. There are considerable variation between regions in the burden of disease.

Source: World Health Organization. The global burden of disease: 2004 update. Geneva: WHO Press 2008.

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Table 3.3 Leading causes of burden of disease (DALYs), all ages, 2004

Disease or injury DALYs

(millions)

Percent

of total

DALYs

1. Lower respiratory infections 2. Diarrhoeal diseases 3. Unipolar depressive disorders 4. Ischemic heart disease 5. HIV/AIDS 6. Cerebrovascular disease 7. Prematurity and low birth weight 8. Birth asphyxia and birth trauma 9. Road traffic accidents 10. Neonatal infections and others 11. Tuberculosis 12. Malaria 13. Chronic obstructive pulmonary disease 14. Refractive errors 15. Hearing loss, adult onset 16. Congenital anomalies 17. Alcohol use disorders 18. Violence 19. Diabetes mellitus 20. Self-inflicted injuries

94.5 72.8 65.5 62.6 58.5 46.6 44.3 41.7 41.2 40.4 34.2 34.0 30.2 27.7 27.4 25.3 23.7 21.7 19.7 19.6

6.2 4.8 4.3 4.1 3.8 3.1 2.9 2.7 2.7 2.7 2.2 2.2 2.0 1.8 1.8 1.7 1.6 1.4 1.3 1.3

Source: The global burden of disease: 2004 update. Geneva: WHO Press 2008.

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4 �O�-COMMU�ICABLE DISEASES

The health status of the population in developed countries has improved in the past

decades, as indicated by longer life expectancy at birth. Nevertheless, important and growing inequality in longevity is associated with gender and social and economic factors. Gains in life expectancy have been attributed to overall decreasing mortality, mainly from declining communicable diseases in early childhood and delays in premature death among adults due to improved health care. In addition, changes in lifestyles and behaviour have led to further changes in the patterns of mortality and the burden of disease, with chronic non-communicable conditions, injuries and violence affecting health more strongly. Nevertheless, despite newer and more effective medical technology and treatment that limit acute effects and mortality, the incidence and prevalence of non-communicable diseases have decreased for some conditions but not overall, leading to increased disability. Combined with the need for longer term care and rising health care costs, these aspects can create additional demands on the health system and a need to adjust it (WHO, 2009a).

According to global burden of disease estimates for 2004, non-communicable diseases caused 8.45 million deaths (87% of total deaths) in Europe, 52% of which occurred among females. The leading causes of death, cardiovascular diseases and cancer, together caused 71% of total deaths, followed by digestive diseases and respiratory diseases (Figure 4.1). Projections to 2030 are that the ageing of populations in low- and middle-income countries will significantly increase the total deaths caused by most non-communicable diseases so that they will account for 90% of total deaths in Europe.

Figure 4.1 Deaths by cause in Europe, 2008. Source: WHO European Health Report 2009.

In 2004, non-communicable diseases caused 112.4 million DALYs lost (77.8% of the total burden of disease). The leading contributors were cardiovascular diseases (23.0%) and neuropsychiatric conditions (19.6%) followed by cancer (11.9%) and sense organ disorders (5.8%). Projections for the burden of disease to 2030 predict that, with an ageing population, the balance will shift to a relative increase in neuropsychiatric conditions (22.1%), cancer (13.7%) and sense organ disorders (7.3%), with cardiovascular diseases at 22.3%.

Disease prevalence indicates the number of people living with a condition and the resulting conditions at a given time, but not severity and impairment, which may vary significantly among disease conditions. The prevalence of the most frequent conditions by broad group in Europe includes:

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• Neuropsychiatric conditions (unipolar depressive disorders, bipolar affective disorder, schizophrenia, epilepsy, alcohol use disorders, Alzheimer and other types of dementia and Parkinson’s disease);

• Cardiovascular diseases (including angina pectoris and stroke); • Respiratory diseases (chronic obstructive pulmonary disease andasthma); • Hearing loss (moderate and severe); • Inflammatory disorders (rheumatoid arthritis and osteoarthritis); and • Diabetes (moderate to severe), the most frequent single condition.

Much evidence suggests that these diseases impose substantial costs on society. The direct, indirect and intangible costs of illness burden individuals and their families, and include treatment costs, reduced income, early retirement and increased reliance on welfare support for ill people and/or their carers. Employers and wider society carry a burden of absenteeism, reduced productivity and employee turnover. Many people with chronic diseases need lifelong medication, and the out-of-pocket cost relative to income may place enormous strain on families and on adherence.

The onset of non-communicable diseases needs to be prevented by changing lifestyle behaviour, developing health-promoting environments and taking action on the socioeconomic determinants of health. Once disease is established, such interventions, alongside effective and timely treatment and rehabilitation, are also important throughout the course to prevent conditions from becoming chronic and the development of disability.

From non-communicable diseases we will focus our attention on cardiovascular diseases, cancer and external injuries as the leading causes of mortality in developed countries

4.1 CARDIOVASCULAR DISEASES

Cardiovascular diseases (CVD) refer to a group of diseases of the heart and blood vessels, including coronary or ischemic heart disease, hypertension, and cerebrovascular disease (stroke). CVD are the leading causes of death in the developed and in many developing countries. They have been called the diseases of “modern living” because etiologically they are due to factors such as smoking, lack of physical exercise, and a diet rich an animal fats. These are collectively known as “lifestyle” risk factors and are amenable to change by the individual at risk and through community interventions. These risk factors and diseases can be reduced dramatically by suitable public interventions.

Precise measurement of the prevalence of these diseases through epidemiologically sound, community-based prevalence studies is difficult because of lack of standard diagnostic criteria and terminology and limitation of resources. Measures such as mortality rates and hospitalization data may not give true prevalence rates, but they do provide important time trends and inter-area comparison that are valid for planning public health interventions.

4.1.1 Trends in Cardiovascular Disease Mortality

Mortality rates from cardiovascular diseases vary widely between countries, as between regions of a country, for men and women, or for different time periods in the same country. Diseases of the circulatory system cause nearly 50% of deaths in Europe, ranging from 35% to 65% among different country groups, with the overall mortality rate, 430 per 100 000 population. This rate is nearly 50% lower in EU member countries before the year 2004 but almost twice as high in the CIS countries (Commonwealth of Independent States - former Soviet Union countries) (WHO, 2009a). In the countries of Eastern Europe the

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mortality rates for CHD and strokes continued to increase in the 1990s, but may have peaked in (1994-1996), (Figure 4.2).

The distribution of diseases of the circulatory system, mainly ischemic heart and cerebrovascular diseases, varies considerably by age, sex and other factors. For example, the risk of dying from ischemic heart disease increases with age and is almost 25 times higher among people 65 years or more than younger people. Further, this risk is 90% higher among males than females. In addition, countries in south-western Europe have the lowest mortality rates from ischemic heart disease and the risk is 5–7 times higher in the easternmost parts of the European region. The trends for cerebrovascular disease are similar for age and increasing on a west-to-east gradient, but people 65 years and more have 31 times the excess risk of younger people. Males have only 30% higher mortality than females. The differences between the western and eastern parts of Europe have been suggested to result from interaction between key lifestyle factors (diet, smoking and physical activity) and psychosocial factors (stress), but other aspects, such as access to and the quality of health care, are thought to play a role (Figure 4.3 and 4.4).

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Figure 4.2 Standardized death rates, cardiovascular disease, all ages per 100 000 in WHO European region. Source: WHO/Europe, European HFA Database, July 2010. Notes: EU - European Union, CIS - Commonwealth of Independent States

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Figure 4.3 Standardized death rates, ischemic heart disease, all ages per 100 000 in WHO European region. Source: WHO/Europe, European HFA Database, July 2010. Notes: EU - European Union, CIS - Commonwealth of Independent States

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Figure 4.4 Standardized death rates, cerebrovascular disease, all ages per 100 000 in WHO European region. Source: WHO/Europe, European HFA Database, July 2010 Notes: EU - European Union, CIS - Commonwealth of Independent States

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Inter-country comparisons can be helpful in evaluation of public health needs and priorities. The experience of one country or region is not necessarily applicable directly to another, but the trends in cardiovascular disease mortality are now well established with declines of 40-50 percent in many countries. All countries or regions within a country that have persistent high rates should review their program priorities in public health. Finland has been a country with very high rates of cardiovascular mortality, but since the 1970s it experienced a sharp decline, possibly due to adoption of new innovations, treatment of acute myocardial infarctions, and emphasis on dietary and smoking risk reduction. Many studies of CVD mortality have shown racial, gender, and regional differences, but there may be many contributing factors to these differences, which are important to identity to be able to plan suitable intervention programs. Such factors include education, lifestyle and diet, access to health care, knowledge, attitudes, and practices. Primary prevention to reduce risk factors is an important aspect of reducing the burden of CVD. Less than one-third of the reduction of mortality rates is attributed to primary prevention, while improved treatment accounted for half the reduction along with secondary prevention.

4.1.2 Prevention of Cardiovascular Diseases

The decline in cardiovascular disease mortality common in the industrialized counties over the past 25 years has been attributed to many factors, without clear evidence of the relative importance of each factor. This decline in mortality does not necessarily indicate a decline in prevalence or severity (case-fatality rates) of the disease. It may be the result of reduced prevalence of risk factors and improved access to and quality of care with secondary and tertiary prevention including better medications, resuscitation, and emergency care delaying mortality. Higher standards of living, leisure and recreation, greater awareness of healthful nutrition and availability of appropriate foods at reasonable cost, and wider community and individual awareness of risk factors have all played a role in the reduction of mortality from CVD. Prevention of non-communicable diseases include organized efforts of primary prevention (e.g., screening) and tertiary prevention (e.g., emergency medical services). Primary prevention of CVD involves a spectrum of health promotion activities related to reduction of specific risk factors. This includes reduction of smoking and obesity, better dietary habits, and healthful foods, with increased physical activity. Prevention requires a public health approach based on creating population-based and individual changes in the factors that contribute to heart attack or stroke, along with good medical supervision. Implementation of primary and secondary preventive activities to reduce the burden of CVD involves building institutional support, education of the public, community-based risk factor reduction activities, a healthy working environment, adequate information systems to monitor morbidity and risk factors, and a well-informed medical community. Medical interventions include identification and aggressive treatment of hypertension and diabetes, counselling to promote healthful dietary habits, a tobacco-free lifestyle, regular physical activity, and supportive psychosocial environment. The medical care provider is involved in screening, treatment, and advising patients of the importance of reducing risk factors both before and after the onset of symptoms. The client has to take personal responsibility for many aspects of prevention as a vital factor in screening for and sustained management of high blood pressure, reduction of obesity, screening and management of diabetes, as well as in smoking cessation and healthier exercise and dietary regimens. Community-based programs have been designed to change life habits as a method of reducing the risk of CHD and have become accepted parts of public health. Governments and

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manufacturers may directly or indirectly promote smoking or alcohol consumption. Where governments permit advertising of alcohol and cigarettes in the media or fail to restrict tobacco use in public places there is a tacit approval of the practice. Manufacturers promote sales of their products among the young and the poor, and in developing countries where defence mechanisms such as awareness of health risks are lower than in a middle-class population. When governments profit from taxes derived from tobacco and alcohol sales and consumption, there is a major conflict of interest between health issues and government revenues. In order to facilitate the implementation of intervention programs to reduce lifestyle-related risk factors, the international CI�DI (Countrywide Integrated Non-communicable Diseases Intervention) program was initiated by the World Health Organization. CINDI was started in 1990 to address the wide gap between eastern and western Europe in the prevalence of chronic disease and to address lifestyle–related behaviour (such as smoking, high blood pressure, high blood cholesterol, obesity, and excessive alcohol consumption) which is associated with the major chronic diseases such as cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes. The WHO member states collaborate on the implementation of an integrated approach to chronic disease prevention. The objectives are health promotion in order to reduce morbidity by reducing common risk factors with inter-country collaboration in 29 countries. Countries with very high rates of CVD should develop aggressive intersectoral intervention programs at the national and community levels. Concreted national efforts of the ministry of health, other relevant ministries, the media, nongovernmental organizations, food manufacturers, and local communities are needed in order to reverse the high rates of CVD in some U.S. states and northern and eastern Europe. In developing countries, the problem of CVD is hidden beneath more acute issues of high morbidity and mortality from infectious diseases, and those associated with maternal and child health. But there is a pattern of increasing CVD morbidity and mortality affecting the growing middle class, with changes in diet and smoking. Smoking is promoted for commercial reasons in developing countries, without countervailing health hazard warning labels, limits on advertising, and other restrictive legislation. This warrants attention by health authorities in developing countries and application of lessons learned in the industrialized countries over the past 30 years. The global pandemic of cardiovascular disease is made up of a number of trends. One is a major decline in mortality in the industrialized countries, while stroke and coronary heart disease mortality are increasing in developing countries. The downward trend of the past 4 decades due to health promotion success in reduced smoking and improved treatments in the western countries may not sustain as women may be more vulnerable than in the past. Health promotion has a crucial role in tackling these trend shifts because they mean life or death to millions of people.

4.2 CA�CER

Cancer is the second leading cause of death in the industrialized countries, and is rapidly emerging as a major factor in the epidemiology of developing countries. According to WHO, cancer occurs because of changes of the genes responsible for cell growth and repair. These changes are the result of the interaction between genetic host factors and external agents which can be categorized as physical carcinogens such as ultraviolet (UV) and ionizing radiation; chemical carcinogens such as tobacco smoke; biological carcinogens such as infections by virus (hepatitis B virus and liver cancer, human papillomavirus and cervical cancer) and bacteria (helicobacter pylori and gastric cancer) and contaminations of food by mycotoxins such as aflatoxins (product of Aspergillus fungi) causing liver cancer.

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Cancer is responsible for much suffering and heavy economic demands on society in terms of health services, loss of work, and premature mortality. The potential for prevention of cancer is so important that any public health program must include it as part of its duties.

Many advances have been made in clinical management and in understanding of the causes of some cancers. There is strong and increasing evidence of specific risk factors which are amenable to public health intervention. The most striking example is smoking, directly related to lung cancer, and is a factor in bladder and cervical cancers. Exposure to chemical carcinogens, such as asbestos, is major public health interest, as is prevention of liver cancer by immunization against hepatitis B. Recent research indicates that dietary factors are important contributors to colorectal, breast, and factors possibly lung and cervical cancers. The findings linking H. pylori infection to peptic ulcers, gastritis, and stomach cancer have been instrumental in declining incidence of these conditions internationally and the possibility of an effective vaccine for H. pylori would greatly enhance this benefit, vaccines for hepatitis B and human papillomavirus as vaccines to prevent cancers.

Lung cancer is the most common cancer worldwide, 2-3 times more common in men than women, but has surpassed the breast as the leading cancer site in women. Survival rates are low so that screening for lung cancer is of dubious value. Primary prevention to reduce the number of new smokers and encourage cessation of smoking is the most crucial public health activity for lung cancer prevention.

The single largest preventable cause of cancer in the world today is tobacco. It causes 80-90 percent of all lung cancer deaths in developing countries. It is currently responsible for the death of 1 in 10 adults worldwide. Half the people who smoke today will eventually die of tobacco-related diseases so the efforts to reduce tobacco consumption and exposure are vital elements of public health.

4.2.1 Trends in Cancer Mortality

Cancer incidence rates vary widely between countries and within countries, with declining rates since the late 1980s in some (e.g., United Kingdom), and rising and then stabilizing rates in others (e.g., Poland). The expansions of such differences are not at all clear, but there may be differences both in risk factors – for example, diet, environment, and smoking – as well as in treatment. Such international comparison can generate hypotheses for further investigation.

The mortality for cancer in Europe in 2007 accounted for nearly 20% of all deaths. The mortality rate is more than 10 times higher among people aged 65 and more than among younger people and 80% higher among males than females. Cancer of the trachea, bronchus and lung, colon, stomach, liver and prostate accounts for nearly 50% of mortality from cancer among men. Cancer of the breast, trachea, bronchus and lung, stomach, liver, colon, cervix uteri and ovary accounts for 60% of mortality from cancer among women. In contrast to cardiovascular diseases, cancer has the highest mortality rates in the EU members’ countries (Figure 4.5). This has been suggested to be the result of increasingly high smoking rates, especially among women (WHO, 2009a).

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Figure 4.5 Standardized mortality rate, malignant neoplasms, all ages per 100 000 in WHO European region. Source: WHO/Europe, European HFA Database, July 2010. Notes: EU - European Union, CIS - Commonwealth of Independent States

4.2.2 Prevention of Cancer

Primary prevention of cancer requires a reduction of major risk factors: smoking (lung and bladder), fatty diet (breast and colorectal) carcinogenic chemical exposures (mesothelioma, lung, leukaemia, lymphoma), exposure to infectious carcinogenesis agents (hepatic), multiple sexual partners (cervical cancer), and excess sunlight exposure (melanoma). Lung and skin cancer, occupation-related cancers, and some gastrointestinal cancers are most amenable to primary prevention by reduced smoking and exposure to sunlight, asbestos, radon, and other carcinogens. Immunization against hepatitis B is protective against most liver cancers. Secondary prevention in clinical services or in screening programs for high-risk groups focuses on early case finding. The medical care system has a major role to play, with a variety of activities, such as screening for breast, prostate, cervical, and colorectal cancer. Occupational, environmental, and social factors all play important roles in cancer. As a result, intersectoral preventive activities are needed for cancer prevention. Cancer prevention involves reaching the total population to increase awareness of risk factors and promoting change in them. Health care providers have a vital role to educate the public, to decide when and how to screen for disease, and to cross socio-economic barriers in reaching patients. More research will bring important breakthroughs in this field. Identification of genes that increase risk or cause cancer, infective agents associated with carcinogenesis, medications which stop or delay progress of cancer, and other research appear very promising. The evidence for a causal relationship between nutrition and cancer is increasingly convincing.

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Table 4. 1 Prevention of cancer

Modality Method

Self-care Smoking cessation Sun protection Healthy body weight Physical exercise Sexual safety (e.g., reduce sexual risk behaviour of multiple partners, promote the use condoms)

Screening Cancer of cervix (e.g., Papanicolau smears) Colorectal screening (e.g., occult blood and colonoscopy Breast self-examination, mammography

Diet Reduce fat and red meat intake Increase fruit, vegetable, and grain consumption

Vaccination Liver cancer – hepatitis B Immunization and catch-up Cancer of cervix – human papillomavirus (HPV)

Medical examination Breast examination Rectal examination Skin examination

Medical management Peptic ulcers for Helicobacter pylori Treatment of STIs HIV care

Toxic and carcinogenetic exposures

Environmental and occupational health Standards and enforcement Control asbestos products, pesticide use, radon

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

4.3 EXTER�AL I�JURIES

External injuries, is a broad category that includes accidents, poisonings, suicide, homicide, and violence. In many countries, trauma is the leading cause of death because of its greater frequency among the young and the middle-aged. It is often the leading cause of years of potential life lost (YPLL) in most developed countries and has become a major focus of intervention in modern public health program development. An accident is a sudden, unintended event that may be associated with human injury. The term does not imply that the event is not potentially anticipated, since there may be neglect of fundamental safety and preventive procedures and therefore increased risk of the even occurring. Injuries and deaths inflicted intentionally include homicide, rape, assault, battery, child abuse, and suicide.

4.3.1 Trends in External Causes of Mortality

External causes of death – particularly injuries from accidents (including falls), transport related causes and violence, both self-inflicted and done to other people – result in considerable mortality in Europe. External causes account in 2007 for 8% of all deaths. The overall standardized death rate from this cause in the European Region was 71.8 per 100 000 population in 2007, declining more than 10% since 1990. People 65 years and older have the highest rate, almost twice the average, but the age-related excess risk varies by specific cause. The excess risk for older people is 2 times higher for transport crashes, suicide and homicide but 9 times higher for falls. In addition, mortality from external causes is nearly four times higher among males than females. The geographical distribution tends to increase from west to east in the European Region, with CIS countries having 2–3 times higher risk overall and for specific causes (Figure 4.6). The differences for accidents, suicide and homicide have

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been attributed to various lifestyle and socio-economic factors, including high alcohol intake, roads and vehicles in poor condition, and limited enforcement of the law (WHO, 2009a).

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Figure 4.6 Standardized death rates, external cause injury and poison, all ages per 100 000 in WHO European region. Source: WHO/Europe, European HFA Database, July 2010. Notes: EU-European Union, CIS- Commonwealth of Independent States

4.3.2 Motor Vehicle Accidents

The most common cause of loss of life from trauma is motor vehicle accidents. Motor- vehicle-related injuries kill more children and young adults than any other single cause. Motor vehicle injuries are a problem not only in developed countries, but also in developing countries where road crash rates are extremely high. The Figure 4.7 shows the last available data for standardized mortality rate for motor vehicle accidents in some European countries. Alcohol use may be less restricted than in developed countries, road safety less advanced, cars poorly maintained, and drivers less experienced. Statistically, women are safety drivers than men and should be encouraged to drive buses, trucks, and military transports. Law enforcement is a major factor in reducing road crash deaths and injuries. Compulsory seat belt laws are major contributions to reduced severity of injuries, and enforcement increases compliance. Enforcement of speed limits and incarceration of drunk drivers have a strong deterrent effect and reduce death and severe injury rates. Emergency care has made important strides in the past several decades. This has undoubtedly contributed to declining mortality rates from trauma. Organized ambulance services with well-trained and supervised paramedics transporting patients to central trauma centres have been shown to be effective in reducing mortality and collateral damage rates. Improved care during the early minutes following violence, whether from terrorism or motor vehicle crashes, or at the earliest stages of acute myocardial infarction can be improved by continuous training of “first responders” including police, firemen, ambulance personnel, and the general public.

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Figure 4.7 Standardized mortality rate, motor vehicle accidents, all ages per 100 000 in Europe, last available. Source: WHO/Europe, European HFA Database, July 2010. Note: CIS- Commonwealth of Independent States

4.3.3 Suicide and Suicide Attempts

Internationally, there are wide variations in suicide rates, with the majority of cases occurring among adolescent men and the elderly. In Europe as it is shown on Figure 4.8 overall suicide rates are lower (less than 5 per 100,000) in the Mediterranan countries (Italy, Spain, and Greece) and above 10 per 100,000 in France, Switzerland, Sweden, Denmark, Finland, Austria, and Belgium. Suicide rates in CIS and Hungary are above 20 per 100,000 population in 2008. For each ten suicide attempts there is one suicide, with men more common in the latter group. It is estimated that 30 percent of suicides are the result of mental disorders, with the remainder due to decisions regarding life circumstances, low self-esteem, binge drinking, and situational depression. Restriction of access to methods of suicide, such as firearms, is believed to reduce suicide, and restriction of publicity about suicides is thought to reduce suicide rates. Threats

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of suicide should be taken seriously; health care providers, teachers, counsellors and religious leaders should be instructed in suicide prevention and how to assist people through periods of depression. Mental health and supportive counselling must be part of any health care system because the suicidal individual requires immediate attention and care. Telephone counselling by volunteers on hotlines has proved to be valuable in suicide prevention.

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Figure 4.8 Standardized mortality rate, suicide and self-inflicted injuries, all ages per 100 000 in Europe, last available. Source: WHO/Europe, European HFA Database, July 2010. Note: CIS-Commonwealth of Independent States

4.3.4 Domestic Violence

Family or domestic violence is more readily identified and brought to public attention than in previous generations. Some factors that determine these intentional injuries include socio-economic status, alcohol use, and family history of members who may have been abused themselves. Increased public awareness in recent years has led to increased reporting.

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4.3.5 Homicide

Homicide has become one of the major causes of death in some countries, such as in Colombia. The epidemiologic analysis of murders shows a relation to drug traffic, both involving rich drug competitors and street-level violence for control of the street traffic. Random violence among schoolchildren is a frequent event, as are drive-by or “road-rage”, shootings, often resulting in child deaths. Murders associated with rival gangs and random violent crime with murder is now common in many former Soviet countries. Gang violence in U.S. cities is matched by concern in rural areas where murderous rampages by adolescent occur with increasing frequency. The United States remains well above other industrialized countries in homicide rates, but well below rates in Russia.

8.5 percent of U.S. students have carried weapons to school and 7.4 percent of students reported being threatened with weapons during the past 12 months. This is often attributed to a high level of violence portrayed in the media, through films, television, or the Internet. The consensus is that this gives troubled youth the opportunity to act out fantasies or murder and mayhem with the goal of either satisfying a need for revenge, acting on an ideological hatred, or achieving notoriety. Many different strategies documented are effective at all school levels.

4.3.6 Prevention of Violence

In many countries, violence is one of the leading causes of death, especially among teenagers and young adult males. Prevention of violence and violence-related injuries is a major public health concern because the large of loss of life and personal injury as well as the long-term damage to society. Interventions involve the whole of society, and not the health system alone.

Trauma morbidity can be reduced by public health measures including primary, secondary, and tertiary prevention. Primary prevention reduces risk factors that are associated with trauma by such measures as enforcement of laws against alcohol abuse with driving, motorcycle helmet, car seat belt, and speed limitation laws. Secondary prevention involves early and adequate medical care at the scene of an accident and rapid transportation to a hospital trauma centre. Prevention of consequences of the trauma by such intervention as cardiopulmonary resuscitation, maintaining an airway, stopping bleeding, and treatment of shock at the accident site can reduce case fatality rates. Tertiary prevention involves effective and early rehabilitation by which the degree of disability and long-term management are made more effective, as in cases of head injury.

Violence prevention involves increased awareness by teachers, police, social workers, health professionals, and the public at-large in spotting potential and actual signs of violence, especially of abused children or women. Other forms of violence prevention include gun control, preventing weapons from entering schools, “hotlines” for victims to telephone to seek help, shelters for potential and actual victims, self-defense training, rapid response of police, enforcing drinking restrictions, and promotion of supervised teenage recreational activities.

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5 HEALTH OF VUL�ERABLE POPULATIO� GROUPS

5.1 FOCUS O� �O�-DISCRIMI�ATIO� OF VUL�ERABLE

GROUPS

A focus on vulnerable groups is fundamental to a human rights approach to health. United �ations (U�) International Covenant on Economic, Social and Cultural Rights

(CESCR) spells out that all states have an immediate obligation to ensure non-

discrimination in access to health care and underlying determinants of health; in order to reduce existing health inequities within and between populations. The obligation to ensure non-discrimination is closely linked to the principle of equity, which implies that states must pay attention to all sectors of the population. This does not mean that everyone should be treated in exactly the same way, but rather that health systems must recognise, and provide for, the differences and specific needs of groups within the population who experience a disproportionate level of mortality, morbidity and disability (Asher, 2004).

Thus, the obligation to ensure non-discrimination calls for specific health standards to be applied to particular population groups, such as women, persons with disabilities, and children particularly in developing countries. The reason is because generic and other standard approaches to health issues can perpetuate and reinforce existing inequalities between the health status of vulnerable groups and the general population (Asher, 2004).

The obligation to ensure non-discrimination requires governments to take any special measures that may be needed to ensure equal treatment and to meet the needs of vulnerable groups such as:

BOX 5.1 Vulnerable groups of population

• older persons • prisoners and detainees • indigenous and tribal populations • migrants and displaced populations

• children, including specifically: - the girl child - children involved in armed conflicts - children involved in child labor - adolescents • persons living with HIV/AIDS

• women (with particular emphasis on women living in rural areas)

• ethnic, religious, linguistic and national minorities

• persons with mental and physical disabilities • refugees and internally displaced persons Source: Asher J.: Right to Health: A Resource Manual for NGOs. London: Commonwealth Medical Trust, 2004.

There are various UN human rights instruments that aim to provide the above-mentioned groups with increased protection. Such instruments set internationally accepted standards and norms for state duties and outline the special measures that are needed to comply with the related obligations. Many measures, such as most strategies and programs designed to eliminate health-related discrimination, can be pursued with minimum resource implications through the adoption, modification or abrogation of legislation or the dissemination of information. … even in times of severe resource constraints, the vulnerable members of society must be protected by the adoption of relatively low-cost targeted programs. With respect to the right to health, equality of access to health care and health services has to be emphasized. States have a special obligation to provide those who do not have sufficient means with the necessary health insurance and health care facilities, and to prevent any discrimination on internationally prohibited grounds in the provision of health care and health services (CESCR General Comment 14).

Inequity and discrimination often lie at the root of low health status among the poor and otherwise vulnerable and disadvantaged groups. But discrimination is not always straightforward. It can occur in a complex and wide variety of ways. Generally speaking, discrimination results from legislation, policies and practices, which create, maintain or

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aggravate the disadvantages suffered by a given group in any given society. Discrimination can be direct (or overt), as with policies that explicitly privilege some groups at the expense of others. It can also be indirect, or implicit, occurring as an unintended result of policies or of their implementation processes. Indirect discrimination may also result from neglect, such as when certain groups are given inadequate consideration in targeted policies, programs, or access to services (Asher, 2004).

Vulnerability, as a result of discrimination, is a key factor in determining the health status of individuals and groups throughout the world. In any given country, these groups carry the greatest burden of disease and ill health. In turn, most differences, both in health issues and in the consequences of disease, that affect these groups can be explained by patterns of systematic discrimination. Indeed, if discrimination were to be eradicated in any given country, many potential violations of the right to health would be avoided.

States have an obligation to provide vulnerable groups with opportunities and tools to participate in decision-making on issues that affect their health and well-being. This means enabling such groups to contribute to shaping the special measures needed to address their specific needs (Asher, 2004).

5.2 HEALTH OF WOME�

While women and men share many similar health challenges, the differences are such that the health of women deserves particular attention. Women generally live longer than men because of both biological and behavioural advantages. But in some settings, notably in parts of Asia, these advantages are overridden by gender-based discrimination so that female life expectancy at birth is lower than or equal to that of males.

Moreover, women’s longer lives are not necessarily healthy lives. There are conditions that only women experience and whose potentially negative impact only they suffer. Some of these – such as pregnancy and childbirth – are not diseases, but biological and social processes that carry health risks and require health care. Some health challenges affect both women and men, but have a greater or different impact on women and so require responses that are tailored specifically to women’s needs. Other conditions affect women and men more or less equally, but women face greater difficulties in getting the health care they need. Furthermore, genderbased inequalities – for example in education, income and employment – limit the ability of girls and women to protect their health.

While there are many commonalities in the health challenges facing women around the world, there are also striking differences due to the varied conditions in which they live. At every age, women in high-income countries live longer and are less likely to suffer from ill-health and premature mortality than those in low-income countries (WHO, 2009b). Key facts about women’s health are highlighted in BOX 5.2.

BOX 5.2 Key facts about health of women

• On average, women live six to eight years longer than men globally. • In 2007, women's life expectancy at birth was more than 80 years in 35 countries, but only 54 years in

Africa. • Girls are far more likely than boys to suffer sexual abuse. • Road traffic injuries are the leading cause of death among adolescent girls in high- and middle-income

countries. • Essentially all (99%) of the half a million maternal deaths every year occur in developing countries. • Breast cancer is the leading cancer killer among women aged 20–59 years in high-income countries.

• Globally, cardiovascular disease, often thought to be a "male" problem, is the leading killer of women. Source: World Health Organization. Women and health: today’s evidence, tomorrow’s agenda. WHO 2009.

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States must take into account the adverse effect of societal factors (not just biological differences) that influence women’s health, including any unequal power relationship of men over women. Such factors include:

• women’s lower socio-economic status resulting, for example, in their higher incidence of disease, as well as a lower quality, or relative lack, of health care services that cater for their needs;

• adverse cultural and religious factors, such as female genital mutilation/cutting (FGM/C), son preference, wife inheritance, and the much higher priority that is given in many societies to feeding boys;

• environmental factors, including unsafe working conditions, to which affect women disproportionately;

• unequal access to education, which is an important determinant of women’s health; and

• violence against women.

The adoption of a gender-sensitive approach to health is an obligation to fulfill for states. Health problems associated with poverty and inequity are the main obstacles to most

of the world’s population attaining minimal levels of well-being, and 70 percent of the poorest people in the world are women. Women comprise the largest vulnerable group in the population and they suffer multiple and compounding forms of health-related discrimination throughout the course of their lives, especially disabled women, women from ethnic or linguistic minorities, indigenous women, and women living in rural communities.

In addition to the social disadvantages associated with adverse gender roles and relationships, there are also significant biological factors that contribute to the different and disproportionate effects of disease on women. Women’s health differs from men’s in a number of ways, the most obvious being that the female reproductive system can result in diseases or conditions that affect only women. There are also other conditions that affect women either uniquely or differently from men (including Sexual transmitted diseases, diabetes, hypertension, and diseases resulting from malnutrition), as well as conditions that are more prevalent or have different risk factors in women (such as breast cancer, depressive disorders, and anaemia).

Ensuring non-discrimination and equal treatment for women therefore means that governments must take account of, and provide for, women’s unique experience of disease. Not only must they be provided with the same health services as men, but where their health needs differ from men they must be given access to comparable services to meet those needs, including preventive, diagnostic, treatment and follow-up services, as well as access to appropriate, accurate and reliable health-related information and education (Asher, 2004).

5.3 HEALTH OF CHILDRE� A�D ADOLESCE�TS

The hazards facing schoolchildren include many public health issues. A central goal of public health regarding this young population is life skill training to promote healthful practices and avoidance of risk behaviour. Public health efforts to reduce the toll of teenage premature loss of life must be in concert with educational, social and police authorities. Efforts to convey a message to these risk groups should involve popular figures from the sports world and popular music fields being recruited to stress a positive image of teen adjustment and transition to adulthood. A school health program should ensure a safe and healthful environment for the children, including sanitation, safety from violence, temperature control, and physical facilities for study and recreation. School-aged children need physical activity for their healthful development as an integral part of a comprehensive school health education

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program. School meal services contribute to good child and adolescent nutrition, learning, and performance. Health monitoring includes ensuring full immunization, monitoring of growth, vision, hearing, scoliosis, and skin testing for tuberculosis are frequent elements of school health programs. The potential for learning about health in the school setting should be exploited by the public health system by encouraging the educational authorities to include health as part of the regular curriculum and preparing the teachers on how and what to teach in this area. Secondary school health programs include attention to personal behaviour issues, including personal and family communication, sexual relationships, the right to say no, parental responsibilities, birth control, and STD (sexual transmitted diseases) and HIV prevention. Special needs for those with physical or mental disabilities should be identified and recognized as part of the regular duties of the school. Teaching staff should be trained and facilities modified to accommodate children with special problems and to be able to recognize physical and social ill-health, in a wide range of areas from nutrition to child abuse. Adolescence is a difficult and dangerous period of transition from childhood to adulthood. The teenager feels insecure, yet demands independence and responsibility for his or her own well-being. The mix provides for a stormy personal and family transition, with important physical and mental health dangers. Violence, accidents, and suicide are major causes of death in this age group, especially for males. Sexual activity causes dangers of teenage pregnancy, hepatitis C, STDs, and HIV infection, especially when illicit drug use is involved. Developing individual responsibility in each of these categories is required of each individual, with the support of the family, the educational system, the public health system and the community. Male young adults are the highest risk group for suicide in North America and Europe, where rates in some countries, such as Hungary, Finland, and Sweden, are extremely high. Smoking, alcohol, and drug abuse are among the most common contributing factors for disease and early death in modern societies. These personal behaviour or “lifestyle factors” which cause personal ill health and early death constitute an enormous burden on society. They usually begin in late childhood, preadolescence, or adolescence, and their health effects continue into adulthood. Nearly all first use of tobacco occurs before age 18, and most adolescent smokers are addicted to nicotine. There are identifiable psychosocial risk factors in smoking. Community-wide projects showed that public health efforts can successfully reduce adolescent use of tobacco. Adolescence is also a period of experimentation, intense social pressure, and risk-

taking behaviour. Teenage sexuality risks include unplanned pregnancy and parenthood, STDs, and inadequate preparation for adulthood. The educational role in prevention of these is a vital element of a school health program.

Eating disorders are a common form of behavioural disorder especially among teenage girls influenced by the fashion model body type. They enter a vicious cycle of anorexia nervosa or bulimia which can be fatal, or in less severe forms extremely traumatic to the teen and family. Dietary deficiency conditions, especially iron-deficiency anaemia, are common in adolescent girls due to dieting behaviour and the extra need for iron to compensate for menstrual losses.

This phenomenon of increased obesity is a worldwide phenomenon and associated with increasing prevalence of diabetes with occurrence at younger ages than in the past. Addressing the increase in overweight and obesity requires both public health and individual approaches. With growing food abundance and sedentary lifestyles and working condition contribute to this pandemic. The contributing factors to overweight and obesity are complex,

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including psychological, behavioural, cultural, and socio-economic, as well as genetic, metabolic, environmental issues. Slowing this trend requires attention by the health system in partnership with other sectors of society providing accessible and affordable healthy food choices, opportunities for regular physical activity and a supportive environment to facilitate individual behaviour change.

Teenage violence in developing and industrial countries is a growing public health hazard. Teenage alienation, availability of drugs, weapons, and violent cultural icons provide breeding grounds, for gangs and violence, or individual violent outbursts which can lead to random or organized shootings or terrorist outrages. Youth violence refers to harmful behaviour that may start early and continue into young adulthood. School authorities, students and teachers are increasingly aware of these acts and the threat they pose. Preventive factors include security services, alert mental health services, and cooperation between student and school authorities. The best interests of the child must be the guiding principle for all laws, policies and programs aimed at ensuring that children can enjoy the right to health. Based on UN CESCR General Comment 14 governments are required to take the special measures in order to comply fully with their obligations to ensure non-discrimination and equitable treatment

to children and adolescents. The measures are taking to: • reduce infant and child mortality; • promote the healthy development of infants and children; • ensure access to essential health services for the child and his/her family, including pre-

and post-natal care for mothers, and, in particular, the provision of primary health care; • ensure access to information about preventive and health-promoting behaviour,

including child nutrition, breast-feeding, hygiene, environmental sanitation, and accident prevention, as well as the provision of support for families and communities to adopt these practices;

• ensure that girls, as well as boys, have equal access to adequate nutrition, safe environments and physical as well as mental health services;

• abolish harmful traditional practices affecting the health of children, particularly of girls, including early marriage, FGM/C and preferential feeding for boys; and

• ensure that children with disabilities are given the opportunity to enjoy a fulfilling and dignified life and to participate within their communities.

In the case of adolescents governments should take special measures to provide them with a safe and supportive environment and the opportunity to:

• participate in decisions affecting their health; • develop life-skills; • acquire the appropriate information that they need about health; • receive counselling; and • negotiate the choices they make about adopting behaviour affecting their health.

5.4 HEALTH OF ELDERLY

Improved health of the population leads to increased longevity and an increase in the elderly population in good physical, mental, social and financial condition in industrialized countries. With the changes in disease patterns in the population, more people are living and remaining relatively disease-free longer. Many life-threatening conditions that occurred during middle age are now postponed to much later in life. As a result, it is not uncommon for older adults to be well and free from major disease processes. Elderly - adults 65 years and older comprise the fastest-growing group in the population of the industrialized countries. As the mortality rates in adult and middle-aged years have declined, more people survive into the over 65, the over 75, and the over 85 years

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old groups. In the developed countries, this proportion is growing and will reach 30 percent in some countries, with the group over 75 years of age being the most rapidly growing segment of the population. The aging of the population has important implications for health services because the elderly are large consumers of health care in the context of a shrinking workforce. Internationally there are wide variations in life expectancy (Figure 5.1) and in care programs for the elderly. The tradition of caring for the frail elderly in the family context is changing in the industrialized societies where both men and women work, housing conditions may be crowded, and tolerance for older adults is reduced. This, together with a growing elderly population, has increased the reliance on long-term care in institutional settings.

65

70

75

80

85

1995 2000 2005 2010 2015

EU EU members before May 2004 EU members since 2004 or 2007CIS

Figure 5.1 Life expectancy at birth in years, WHO European region. Source: WHO/Europe, European HFA Database, July 2010. Notes: EU - European Union, CIS - Commonwealth of Independent States

Biological aging is measured by various functional abilities and performance of the individual, not necessarily reflected by chronologic age. Aging carries with it social, occupational, psychological, financial, and physical changes as it is shown in Box 5.3. These all directly impact health and the appropriate health and support needed by the elderly to sustain themselves. Physical and mental deterioration is associated with aging, frequently resulting in a heavy burden on the family unit and on social and health support systems. Physical limitations can affect social interaction and mental status, with depression affecting physical abilities.

Box 5.3 Potential Adverse Changes Affecting the Elderly

1. Social/Occupational/Economic Status:

retirement; widowhood and bereavement; relocation; loss of friends and family; loss of financial security; loss of professional status and self-esteem; poor nutrition; physical inactivity 2. Physiological:

hormonal changes; onset of non-insulin-dependent diabetes; hypertension; thyroid dysfunction; osteoporosis; decreased absorptions (e.g., vitamin B)

3. Pathophysiological:

chronic disease of one or more organ systems; medical/surgical conditions, medication, or support services; disabilities limiting mobility, activities of daily living 4. Mental:

loneliness and depression; loss of memory; senility and agitation; isolation from children, family, friends

Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

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Health Maintenance for Older Adults Public health attempts to promote well-being by encouraging a healthful lifestyle and

access to good health care. With rapid growth of the population of older adults, health targets for European countries have addressed prevention and health maintenance for this group with specific targets as indicates in Box 5.4.

Box 5.4 European Objectives for the Elderly

1. Ensure equity in health by reducing the gap in health status between countries and groups within countries.

2. Add life to years by ensuring full development and use of physical and mental capacity to derive full benefit and to cope with life in a healthy way.

3. Add health to years by reducing disease and disability. 4. Add years to life by reducing premature deaths, thus increasing life expectancy for

adults over age 65. Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

Good nutrition, vital for a healthy old age, can be impaired by financial, social, and psychological factors. In many industrialized countries, the elderly are protected by good pensions from their employment and social security, but there are also those with inadequate pensions or other financial support who live in poverty. Isolation, loneliness, passivity, and malnutrition become a lifestyle which produces illness. Many elderly live on very limited budgets allowing little for food purchases.

Individual assessment by any caregiver should bear in mind the potential for low-level malnutrition among the elderly, especially those who are physically or mentally frail, or have severe dental problems. Community or voluntary programming to assist the elderly in nutrition and activity is a crucial contributor to maintaining the person in an independent life situation.

Physical fitness is an important preventive measure in preparation for advanced age and to maintain health when reaching that state. Regular physical activity, individually or in groups, tailored to the individual’s capacity is helpful in promoting good appetite, sound sleep, and good physical appearance. It can help prevent lethargy, apathy, and atrophy. Familial and social relations have direct health benefits, including reduced hospitalization and long-term institutionalization. Mental health is strongly affected by the older person’s self-perception of his or her role in the family and society. Recreational and social facilities designed to stimulate the often socially isolated older person to participate in recreational and support activity is dependent on development of a complex of adequate support systems. Prevention services for the elderly begin well before age 65. A health maintenance approach to preserve the well-being involves preparation for healthy old age, and requires self-care and a preventive oriented approach begun in earlier years. This involves early case finding of chronic disease and care of existing diseases in order to prevent debilitating complications.

Communication is vital to the life health of the older adult. The availability of an emergency communication system may be lifesaving, as well as providing the frail person with independence and confidence in activities, personal security, and familial and others social relationship. Transportation for seniors or the persons with disabilities enables them to have access to medical care, social activities, shopping and other activities of daily living. Retirement from work brings with it the potential for rest and recreation or the possibility of isolation and depression. Training people for transition in life may be as important as their physical well-being. Organized community systems for assistance and interventions, based on community or social networks, require public health activities and support. Identification of needs,

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professional support for resource development, as well as direct provision of services are all part of public health. Public health plays an advocacy and promotion role, but many services will be provided by other agencies, such as hospital-based home care programs or nongovernmental voluntary organizations that provide support services for the elderly. Finding methods of assisting seniors to remain functional and adjusted in their own homes and in the community is essential to preserve the capacity of the health system to meet the needs of this population group. Such measures can be simple helping services, such as shopping or housecleaning.

Finances in old age may be a serious burden for the younger generation. Children may need to provide financial assistance to the older members of their family who may have an inadequate pension or national social security system allocation. National social security systems have been developed in most industrialized countries to provide income security for seniors, through contributions from wages during the working years. Many social security systems are under pressure financially and politically. Increased life span and fewer births have created a situation in which the labor force may become smaller than the dependent members of society.

Older adults in many countries comprise a significant proportion of the population and constitute a powerful political force. This has created a situation in which there is pressure on politicians to take into account the special needs of this population group.

The economic aspects of aging of the population are their pension support and increased health care needs. On the other hand, the older adults are consumers whose accumulated savings or social benefits employ many persons as producers and care providers. They also constitute a social asset to a country. Grandparents are important to cultural and social well-being of their grandchildren and to their society.

Despite, or perhaps because of, their use of health resources, seniors are healthier than ever before, with many continuing in the labour or volunteer workforces. Further, they are an important consumer group and tend to have the time, money, and health to play important economic and social roles. A healthy older population should not be seen as a burden but as a vibrant contributing part of the family society generally.

Based on UN CESCR General Comment 14 governments are required to take the special measures in order to comply fully with their obligations to ensure non-

discrimination and equitable treatment to older persons. The measures are taking to ensure:

• an integrated approach to the health care of older persons that combines preventive, curative and rehabilitative elements;

• regular medical check-ups for persons of both sexes; • physical and psychological rehabilitation to maintain their function and autonomy; and • attention and palliative care, including pain relief and death with dignity.

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5.5 PERSO�S WITH DISABILITIES

Disability is defined according to The International Classification of Functioning, Disability and Health (ICF) as an umbrella term for impairments, activity limitations and

participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors). ICF puts the notions of ‘health’ and ‘disability’ in a new light. It acknowledges that every human being can experience a decrement in health and thereby experience some disability. This is not something that happens to only a minority of humanity. ICF thus ‘mainstreams’ the experience of disability and recognizes it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability.

Two major conceptual models of disability have been proposed. The medical model

views disability as a feature of the person, directly caused by disease, trauma or other health condition, which requires medical care provided in the form of individual treatment by professionals. Disability, on this model, calls for medical or other treatment or intervention, to 'correct' the problem with the individual.

The social model of disability, on the other hand, sees disability as a socially created problem and not at all an attribute of an individual. On the social model, disability demands a political response, since the problem is created by an unaccommodating physical environment brought about by attitudes and other features of the social environment.

On their own, neither model is adequate, although both are partially valid. Disability is a complex phenomena that is both a problem at the level of a person's body, and a complex and primarily social phenomena. Disability is always an interaction between features of the person and features of the overall context in which the person lives, but some aspects of disability are almost entirely internal to the person, while another aspect is almost entirely external. In other words, both medical and social responses are appropriate to the problems associated with disability; we cannot wholly reject either kind of intervention. A better model of disability, in short, is one that synthesizes what is true in the medical and social models, without making the mistake each makes in reducing the whole, complex notion of disability to one of its aspects.

This more useful model of disability might be called the bio-psycho-social model. ICF is based on this model, an integration of medical and social. ICF provides, by this synthesis, a coherent view of different perspectives of health: biological, individual and social. (WHO, 2002).

There are persons with disabilities in all parts of the world and at all levels in every society. The number of persons with disabilities in the world is large and is growing. Both the causes and the consequences of disability vary throughout the world. Those variations are the result of different socio-economic circumstances and of the different provisions that states make for the well-being of their citizens.

Present disability policy is the result of developments over the past 200 years. In many ways it reflects the general living conditions and social and economic policies of different times. In the disability field, however, there are also many specific circumstances that have influenced the living conditions of persons with disabilities. Ignorance, neglect, superstition and fear are social factors that throughout the history of disability have isolated persons with disabilities and delayed their development.

Over the years, disability policy developed from elementary care at institutions to education for children with disabilities and rehabilitation for persons who became disabled

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during adult life. Through education and rehabilitation, persons with disabilities became more active and a driving force in the further development of disability policy. Organizations of persons with disabilities, their families and advocates were formed, which advocated for better conditions for persons with disabilities. After the Second World War the concepts of integration and normalization were introduced, which reflected a growing awareness of the capabilities of persons with disabilities.

Towards the end of the 1960s organizations of persons with disabilities in some countries started to formulate a new concept of disability. That new concept indicated the close connection between the limitation experienced by individuals with disabilities, the design and structure of their environments and the attitude of the general population. At the same time the problems of disability in developing countries were more and more highlighted. In some of those countries the percentage of the population with disabilities was estimated to be very high and, for the most part, persons with disabilities were extremely poor (UN, 1993).

Persons with disabilities constitute some 10 percent of any given country’s

population, but they receive much less attention in health service and social service system. Despite progress made, the persons with disabilities are still not on the social agenda in most countries; only 45 countries have disability discrimination law. The United Nations and WHO have undertaken to promote of political and professional awareness of the scope of the problem and the unmet needs in the area, with a stress on prevention and rehabilitation. Many people with disabilities need long-term care. These needs will only partially be met in a hospital environment; most care will be delivered within the community by families. In most countries, services and legislation for the persons with disabilities have developed in a piecemeal fashion, often as the result of lobbying by social reformers. In more recent years this lobbying has been by organized groups of the persons with disabilities themselves. The rights of the persons with disabilities were addressed internationally in a series of international declarations including the 1975 in the United Nation’s Declaration of the Rights of Persons with disabilities. The UN Convention on the Rights of Persons with Disabilities was adopted in 2006. This Convention is the first human rights treaty negotiated in the twenty-first century by the United Nations. Principles that should be common include a widespread recognition that prevention of

disability is one of the most essential elements of a comprehensive approach. Prevention of disabilities from birth injury, prematurity, as well as injury in accidents is among the most important issues to address. Many countries have developed a comprehensive range of laws, activities, and programs for the persons with disabilities that include prevention of disability, reduction of the severity of complication, and physical, social, and employment rehabilitation, as well as support or compensation systems. In most countries there are difficulties coordinating policies, services, and support systems, National programs in addition to medical, rehabilitative, and preventive health services include income maintenance and compensation, legal rights, normal and special education, vocational training, work in protected or normal settings, housing and the physical environment, communication and transport, leisure and sport, and self-help groups. Progress is being made in developing national programs in prevention, care, and services for the persons with disabilities. Sharing experiences from one country to another can help in defining how health and social services can be more effectively arranged both to prevent disability and to integrate the persons with disabilities into society. Review of legislation and service organizations as well as the incorporation of new medical, therapeutic, and technological innovations are part of that process (Tulchinsky, Varavikova, 2009).

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Based on UN CESCR General Comment 14 governments are required to take the special measures in order to comply fully with their obligations to ensure non-

discrimination and equitable treatment to persons with disabilities. The measures are taking to ensure that persons with disabilities:

• receive as adequate a standard of physical and mental health care as is provided for the population as a whole;

• can benefit from those medical and social services (including orthopaedic devices) that will help them to remain independent; prevent them from becoming more dependent; avoid further disablement and support their social integration;

• have access to rehabilitation services that can help them to achieve the maximum possible degree of independence and functioning while, at the same time, preserving their rights and dignity; and

• are given the same protection from discrimination by providers of health care services in the private sector as they do in the public sector.

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6 ECO�OMY I� HEALTH CARE

6.1 BASIC CO�CEPTS I� HEALTH ECO�OMICS

A health care is a complex economic input–output system. Patients with a need for care, demand (in economics usage) to use a service and, together with professionals and plans, are the inputs. The primary outputs are health outcomes: changes in patients’ health status and quality of life. Health services differ from most other economic systems in important ways (Lawrence, 2006):

• The usual pyramidal power hierarchy is inverted: doctors and other frontline health-care professionals are numerous, wield political and managerial power, and effectively control resource use in the system.

• Most users of health care have relatively little health knowledge and so consumer sovereignty and choice are limited.

• Health care has a special political and social position in most societies. A health-care system comprises the organization or organizations that together finance

and provide health care to a defined population. Typically, health-care systems are defined by sources of finance, e.g. at the level of country or state, or by membership of a defined organization (Hicks, 2006). It is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently (WHO).

Health-care systems are a significant direct determinant of health (Tulchinsky, Varavikova, 2009):

• they can reduce mortality for major conditions, e.g. coronary heart disease, appendicitis, pneumonia,

• they can help eliminate and prevent infectious diseases, e.g. polio, smallpox, mumps, measles, etc

• they can reduce morbidity, e.g. hip arthritis, cataract repair. More recently, as the links between health and poverty have become better understood

and the economic impact of health-care systems has increased, it has been recognized that health-care systems also have indirect effects on health. In developed countries health-care systems:

• create a sense of security, safety, and well-being among those who have secure and convenient access to high-quality health services

• create a market for goods and services, according to OECD spending about 6–14% of a country's wealth as measured by gross domestic product

• create employment • may contribute to wealth redistribution (when the poor pay less for health care yet

consume more than the wealthy) or may exacerbate inequalities (if the poor have inferior access to health services or contribute a greater percentage of their wealth to pay for access to care). Strengthening health systems means addressing key constraints related to health

worker staffing, infrastructure, health commodities (such as equipment and medicines), logistics, tracking progress and effective financing. The poor state of health systems in many parts of the developing world is one of the greatest barriers to increasing access to essential health care. However, problems with health systems are not confined to poor countries. Some rich countries have large populations without access to care because of inequitable arrangements for social protection. Others are struggling with escalating costs because of

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inefficient use of resources. Overall there is a growing recognition that to maintain and improve the health of the world’s people governments must shape sound, efficient health systems that provide effective disease prevention and treatment to all women, men and children, no matter who they are or where they live (WHO).

All societies have limited resources and must, according to politically determined priorities, provide funds for health care in competition with funds for education, defense, agriculture and others. The availability of limited funds requires making choices. These choices reflect the overall political commitment to health and should, as far as possible, be based on an objective assessment of costs and benefits. The components of economic evaluation in health care are seen in Figure 6.1. Expenditure of resources (in terms of financial and human resources), both direct and indirect, is targeted to a health program. This is expected to produce health benefits or utilities, which can also be both direct and indirect. Health benefits may be expressed in terms of a direct reduction in morbidity and mortality, or as improved productivity and quality of life.

Measurement of both input and output is an essential part of health management. Health inputs include resources such as expenditures on buildings, hospital or nursing home beds, equipment, personnel, home care, ambulatory care, and preventive programs. Other elements of health costs, not directly related to the provision of health services but resulting from it, include patient’s travel time, loss of work time for both patients and caregivers, loss of full functioning years of life, and loss of quality of life. The “input-output” theory of health economics may sound simplistic, but it provides a useful marker when examining the benefits and costs of a specific health intervention. Alternatives can be examined and analysis of their cost-effectiveness made, in order for decision makers to select the most suitable ones.

Input alternatives

Process alternatives

Outcome alternatives

Costs Benefits/targets

Resources consumed

Health care program

Health utilities

Direct, Indirect alternatives

Alternatives Direct, Indirect intangible effects

Figure 6.1 Economic models of health evaluation: resources-programs-benefits. Source: Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

6.2 SUPPLY, �EED, DEMA�D, A�D UTILIZATIO� OF HEALTH

CARE

Supply and demand are fundamental concepts of economics, particularly of a market economy. Demand refers to quantity of a product or service wanted by buyers, and this relates to the price of the availability of supply. Supply is the quantity of the service or product available. Demand is affected also by price, which if too high will reduce demand for that specific product. In health care, price and demand are not the same as products on a free market. Supply may be limited by government regulation and price is offset by third-party payment through insurance mechanisms. In most industrialized countries, these are established by government

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and cover the entire population. In the United States, health insurance coverage is through a combination of governmental and private insurance arrangements, with a substantial population without adequate or any such coverage. So the supply of services and the method of payment are important economic factors in demand and utilization of health care. Need and demand for health care are not necessarily the same.

�eed for health care exists when an individual has a disorder or risk of such, with symptoms, illness, or disability, for which he or she believes there to be an effective, acceptable, and beneficial treatment or cure. Need also refers to preventive care which may not be a pressing issue for the individual.

Demand for health care exists when the individual considers that he or she has a need and is willing to spend resources including money, time, energy, loss of work, travel, and inconvenience to receive care.

Utilization of health services occurs when the individual acts on this demand or need and receives health services.

6.2.1 �eed for Health Care

The distinction between individual needs and the wider needs of the community is important to consider when assessing needs. If individual needs are ignored then there is a danger of a top-down approach to providing health and other services, reflecting what a few people perceive to be the needs of the population, rather than what they actually are.

It is important to appreciate that health needs assessment involves the active, explicit, and systematic identification of needs rather than a passive, ad hoc, implicit response to demand. The assessment of health needs can be made clearer by differentiating the issues into needs, demands, and supply, remembering that health needs are not restricted to health-care needs. Health needs include wider social and environmental determinants of health such as deprivation, housing, diet, education, and employment. Health needs should ideally be appropriately addressed (‘met’), but these needs are too often unmet (e.g. waiting lists, undiagnosed hypertension, ignored moderate depression) or ‘over-met’ (e.g. prescribing antibiotics for sore throats), (Wright, Kyle, 2006).

1. �ormative �eeds Formative needs are those services determined by experts to be essential for a specific

need or condition for a specific population group. Normative needs are what health professionals define as need. These include many standard guidelines for both preventive and clinical health care (e.g. prenatal care, immunization, child care for infants and toddlers, management of diabetes and hypertension, screening for breast and prostate cancer).

Professional value judgments may be traditions or biases in medical opinion, and not adequately responsive to advances in clinical, technological, and epidemiologic evidence, and evidence from best practices in leading countries. Therefore normative needs should be under continuous review by professional panels, with representatives from epidemiological clinical, and public health services, as well as managers and consumers of health care. Each professional field can contribute to interpretation and decision-making about standards for addressing such problems in the health system. The individual characteristics of people seeking care, including factors such as age and sex, help determine the type and amount of health services needed.

Clinical guidelines are in common use in many countries providing norms for care based on consensus by professional groups or health insurance providers. Norms are also used for payment purposes, but this method proved to be rigid and difficult to alter when health conditions change. Where economic incentives (and disincentives) can be used to help promote selected health priorities and there are limited resources, as occurs in all countries,

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then choices must be made. This often comes into conflict with public expectations in health care systems.

2. Felt �eed Felt need is the subjective view of the patient or the community, which may or may not be

based on actual physiological needs. Felt needs are what people consider and/or say they need. Though subjective, felt need is a prerequisite to whether a person actually undertakes to seek care. There is a growing recognition of the importance of sharing health information with the population to increase the possibility that rational choices will be made. Felt needs also affect health planning. A community or donor may, for example, feel that a community needs a new hospital, whereas the same resources might better be spent on developing primary care or health educational services that have a greater impact on the health of the population.

3. Expressed �eed Expressed need is a felt need that is acted on, such as in visiting a clinic or general

practitioner. Felt needs may not be acted on because economic, geographic, social, or psychological barriers may inhibit a person from seeking or receiving care. This phenomenon has given rise to the model of the “clinical iceberg” (illness that could or should be treated that does not come to the attention of formal health care systems) (Koupilova, Holcik, 1996). Accessibility may be limited because the individual cannot afford to pay the fee. A service may be free, but not readily accessible due to such obstacles as distance, language, religious or cultural barriers, difficulty in arranging an appointment, or a long waiting period. As a result, the person seeking care may not be able to receive it and may delay interfacing with the health system until a more urgent, and often more costly, problem arises. Elderly persons may sometimes avoid turning their felt needs into actions as they may not feel comfortable with the fact that they are ill, or may not wish to become a burden.

Unexpressed need may be the result of lack of knowledge, awareness, access or taboos from religious, cultural, or even political factors. This may necessitate outreach services to access such people as migrant laborers, immigrants, refugees, drug users, commercial sex workers, and other groups whose social circumstances place them at risk for disease, but whose access to appropriate preventive and curative services may be very limited.

Assessing health needs provides the opportunity for (Wright, Kyle, 2006): • assessing the population's health status, describing the patterns of disease in the local

population and the differences from district, regional, or national disease patterns • learning more about the needs and priorities of patients and the local population • highlighting areas of unmet need and providing a clear set of objectives to work

towards to meet these needs • deciding rationally how to use resources to improve the health of the local population

in the most effective and efficient way • influencing policy, interagency collaboration, or research and development priorities.

6.2.2 Demand for Health Care

Demand is based on individual and community expectations (felt needs) (Figure 6.2). The individual may feel that he or she needs a service, but expert opinion may say that this is not a reasonable demand. Priorities are therefore very much affected by prices and such considerations are unavoidably part of health care planning. If the professional agrees with the patient that there is a need for health care then the patient may use the service. The professional opinion is mediated by clinical judgment. Professional or clinical judgment may vary over time and between people and places. Professionals take decisions in the light of self-interest, patient’s interest and society’s interest. For most clinical decisions there is a lack of agreement as to the best choice (Koupilova, Holcik, 1996).

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Examples: a) A patient may ask a physician for an antibiotic to treat a viral infection which would not help and may

even cause harm. b) Patient may feel that denial of a referral by a doctor in a managed care plan is infringement of his or her

rights, but there may be a legitimate and ethical reason for the refusal. c) Doctors may wish to have the prestige and convenience of certain equipment locally, but economic and

planning assessments may say that this is not justified on economic or medical grounds. A frequently used economic demand model is that described by Michael Grossman in 1972 - Grossman’s

Demand Model. This method looks at health within the framework of a production function; that is, health status

(output) is a result of health care activities (input) by the environment, the individual, and the health services

system. Individual demand for health care is affected by many factors, such as socio-economic, educational, and

cultural barriers or incentives to health care, as well as age, gender, and health status.

In this model, everyone inherits a stock of health when born. Health depreciates over time, however, and

investment is required to sustain it. Change in health status is thus a function not only of medical care received,

but also of individual’s life style and environmental factors. Health is also an investment good. Being unhealthy

brings discomfort, a reduced sense of well-being, and a measurable loss of income from reduced work hours or

performance.

In Grossman’s model of health demand, rising income may adversely affect health because of an increase of

unhealthy or risk-taking behaviour. Together with the rise in per capita income, excessive consumption of fatty

foods, smoking, alcohol abuse, and motor vehicle accidents, increased as well, and led to increasing death rates

from cardiovascular diseases and trauma in the industrial countries in the 1940s and 1950s. This also occurred

in the 1980s and 1990s in the growing middle class of developing countries.

Individual factors (e.g., age, sex, education, occupation)

Environmental factors (e.g., physical, economic, social, cultural)

DEMA�D

Health care resource factor (e.g., supply, access, acceptability)

Prepayment factors (e.g., private insurance, tax-based health insurance, national health system, managed care, co-payment)

Figure 6.2 Factors in demand for health care. Source:Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

6.2.3 Supply of Health Care

Demand may also be induced by the supply or provision of care. Examples:

a) Making available more hospital beds may increase their use beyond justifiable need, or it may lead to an expectation or demand by patients or their families for an unnecessarily long stay in the hospital.

b) Providing some services at no cost to patients may induce people to utilize those services more than they really objectively require for health reasons according to current best standards.

c) Sometimes the interest of the health care providers is such that they may act to promote the use of services because payments are received for each service rendered (fee for service)

Investment to improve health is justified on both social and economic grounds, with health, like education, being a social right and foundation of society. Spending money on health and education is a sound investment in economic growth, and not a drain on the economy.

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6.3 HEALTH CARE FI�A�CI�G

6.3.1 The Macroeconomic Level of Health Care Financing

Health financing policy encompasses a range of functions: collection of funds for health care, pooling funds (and therefore risks) across time and across the population, and purchasing health services (Figure 6.3). It also encompasses policies relating to coverage, benefits and cost sharing (user charges). The way in which each of these functions and policies is carried out or applied can have a significant bearing on policy goals such as financial protection, equity in finance, equity of access, transparency and accountability, rewarding good quality care, providing incentives for efficiency in service organization and delivery, and promoting administrative efficiency (Thomson, Foubister, Mossialos, 2009).

Figure 6.3 Health financing function. Source: Thomson S, Foubister T, Mossialos E. Financing health care

in the European Union: Challenges and policy responses. Copenhagen: WHO, 2009c.

Financing health care has evolved from personal payment at the time of service delivery to financing through health insurance (prepayment) by employer/employee at the workplace. This has evolved in most industrialized countries toward governmental financing through social security or general taxation, supplemented by private and nongovernmental organizations (NGOs) (Table 6.1) and personal out-of-pocket expenditures. Ultimately, every country faces the need for governmental funding of health care either for the total population or at least for vulnerable groups, such as the elderly and the poor. Government funding is necessary also for services that insurance plans avoid or are inefficient in reaching, such as community-oriented services and groups at special risk such as infants and women. Health care expenditure involves money spent from all sources for the entire health sector, regardless of who operates or provides the services. The methods of financing health care include tax-supported, social security supported, employer-employee financed, charitable organizations, or consumer payment at the time of service. The total of expenditures for health care and how those funds are spent are the most fundamental issues in health

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economics and planning. Allocation of resources requires a skillful planning process to balance spending on different sub-sectors of the system and to assure equity between regions and various socio-economic groups in society. Table 6.1 Sources of financing health services

Public sources Private sources International

cooperation

Federal, state and local government general revenues, mainly from taxes income, excise, resources: business, inheritance, value added, capital gains, property, special taxes

Private health insurance United Nations affiliates

Personal expenditures Foundations Private donors, wills Religious organizations Social Security payroll tax Private foundations Other NGOs Compulsory health insurance Voluntary community service World Bank Lotteries Government bilateral aid Dedicated taxes: cigarettes, alcohol, gambling

User fees

Source:Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

Where there are multiple sources of health financing, it is more difficult to develop effective national planning. Regulation and supplemental funding by government are needed/required to prevent inequity between socio-economic groups and between urban and rural populations. Public health services very often become oriented to provision of basic services for persons excluded from health benefits because of lack of health insurance. This places a great financial burden on public health services, which are generally underfunded in comparison to clinical services. Such countries often bring in national health insurance for disadvantaged groups (e.g. elderly and poor). These insurance plans may pay less well than private insurance for the middle class and organized workers. This applies to the United States and to many mid-level developing countries. In 2004 in the U.S., there was 15.7 percent of the civilian population uninsured. Medicaid covered 12.9 percent of the U.S. population, primarily children, pregnant women, elderly, and people with disabilities. Medicare, which insures the elderly, persons with disabilities, and patients with end-stage renal disease, had 14 percent of the population in 2004. Where financing of health care is centralized, a potential exists for rational allocation of resources. But this depends on adequacy of total financing and rational allocation policies to promote equitable access to services and a balance between one service sector and another. Misallocation of resources between sectors within the health sector can lead to a wasteful and even counterproductive health system, such as excessive funding of tertiary care while primary care is lacking.

When funds are allocated to regional or local health authorities, the potential for shifting resources to meet local needs should be greater. Where there is a highly decentralized management system, some centralized functions are essential to promote national health needs and equity between regions of the country. These include setting policy and standards, monitoring health status indicators, and determining health targets with funding to promote national priorities. What is the “right” amount of health care financing? This is a political decision which reflects the social and economic value placed on health by a nation. These attitudes affect such issues as how well medical and other health care staff is paid in comparison to other professions, and the supply of physical and human resources for health care in a given society. Virtually all developed countries have recognized the

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importance of national health and the role of financing systems to make health care universally available.

�ational expenditures on health care are usually expressed in terms of U.S. dollars as a percentage of gross national product (G�P) or gross domestic product (GDP). Health care costs are also expressed:

1. directly as expenditures per capita (per person, per year); 2. indirectly as resources such as the number of hospital beds or medical

personnel per 1000 (or 10,000) population. The economic consequences of decisions made in resource allocation are major

determinants of health care economics. Each country has to cope with similar issues in reforms to correct for changing health needs and the economic results of former decisions. A comparison of total health expenditures is seen in Figure 6.4. There are large differences in levels of expenditures on health between countries. OECD countries allocate about 9% of their GDP to health. This share varies from 16% in the United States to less than 6% in Mexico and Turkey. Health expenditure per capita varies across countries. The United States spends almost two times the OECD average. Most OECD countries fund the majority of health care from either taxation or social health insurance contributions, with the exception of the USA where only 44% of total expenditure on health is publicly funded.

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Figure 6.4 Per capita health expenditures as percentage of gross domestic product (GDP) for OECD countries in 2007. Source: Organization of Economic Cooperation and Development, OECD Health Data 2009, http://www.oecd.org/health/healthdata The total per capita expenditure on health, whether as percent of GDP or as dollars per capita, does not reflect the efficiency with which the resources are used. Many countries not only have low overall levels of health expenditures but also allocate those meager resources inefficiently. Regardless of how efficiently money is allocated, countries spending less than 4 percent of GNP on health will have poorly developed health care. Those spending between 4 and 5 percent of GNP may try to have universal coverage, but often achieve this through low staff salaries, inadequate equipment, and spreading limited resources too thinly. Developed countries that spend between 8 and 16 percent of GNP on health care have made a value judgment. They have placed health care among the vital priorities in their societies. Health resources indicators are quite variable among the developed market economy countries and are usually expressed as:

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1. Total hospital beds per 1000 include all institutional beds utilized for inpatient medical care, but not geriatric custodial care. A hospital bed is not only a piece of

furniture; it represents a service unit and staffing, services, maintenance, food, laundry, and other

services. It is therefore an economic unit with fixed and variable costs when in use or even empty.

2. Acute care bed ratio represent the number of general short-term beds per 1000 or 100 000 population and is a more precise and comparable indicator (Figure 6.5).

The hospital bed supply of a country reflects historical patterns, medical practice traditions, concepts, medical technology, and organization. It is also a function of financial incentives or disincentives. Reduced hospital bed supply has become part of standard health reforms in industrialized countries as more efficient care is achieved through better diagnostic facilities and ambulatory care. There is also a wide recognition that hospitals are vital for short-term acute care, but themselves are health risks from infections and there are incidents that relate to errors, disorientation of patients, and the discomfort of being away from the family environment. The WHO recommends preferential allocation to primary and intermediate care services, especially for currently underserved rural populations. In most countries, re-allocation of resources is necessary to strengthen primary care and to adopt new technology and health programs, and has shown to be cost-effective in terms of costs as well as anticipated benefits.

Important factors in determining costs of national health systems, include also: • salary or income of providers, • levels of technology in the service, • health planning criteria (norms), • availability of home care and community

services

• methods of paying for hospital services, • use of incentive payment systems, • emphasis on prevention and health

promotion.

0 100 200 300 400 500 600

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European RegionEU members since 2004 or 2007

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SloveniaEU

FranceEU members before May 2004

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ItalyDenmark

NetherlandsMalta

PortugalUnited Kingdom

NorwaySpain

TurkeyFinland

Acute care hospital beds per 100000, 2008

Figure 6.5 Acute care hospitals beds per 100 000 population in selected European countries in 2008. Source: WHO/Europe, European HFA Database, July 2010

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6.3.2 The Microeconomic Level of Health Care Financing

Resource allocation policy, made at the national, regional, health insurance, or sick fund level, must address many specific factors affecting the way services are provided and paid for. Incentives and disincentives for efficient care include how doctors and hospitals are paid, and how services are organized. The state or insurance fund, responsible for providing services to patients, has several choices about how to provide health-care services:

• reimburse the patient for costs incurred • reimburse the providers for costs incurred • contract with providers and set out agreed terms and conditions • directly employ or own providers.

Options for paying health-care providers (Dixon, 2006): • Capitation: a fixed sum per head over a defined period of time. Commonly used in

general practice where doctors are responsible for a registered population. • Salary: a fixed sum for working a set amount of time unrelated to activity. Used in

hospitals and for non-physician staff. Increasingly combined with performance-related pay.

• Fee for service: an amount per item of service. Occasionally used to pay hospitals and hospital doctors, more common in ambulatory care. Often pre-negotiated rates.

• Budgets: fixed sum for a fixed period unrelated to activity. Calculated on the basis of historical allocations or historical or predicted levels of activity. May be hard (any overrun or under spending is borne by the provider) or soft (an indicative budget).

• Per diem: a fixed amount per day. Used extensively in the past for hospital care but incentives criticized it for excessive lengths of stay. Still used for hotel costs.

• Per case or episode payments: a fixed amount for each admitted patient or spell of activity. Diagnosis-related groups (DRGs) are the most commonly used. Payment associated with primary diagnosis on admission, often with case-mix adjustment for severity. Fee-for-service is historically the common method of paying for doctor’s services. In

some places, payment may be according to a fixed-fee schedule negotiated between the insurance mechanisms, whether public or private, and the doctors’ representatives. Fee schedules are often weighted towards medical specialists who have greater prestige than primary care physicians. Fee-for-service tends to promote an overabundance of the more expensive kinds of care, including surgery, often without real need. This is especially so when the patient is fully covered by health insurance and is therefore better able to pay for the service than the person without insurance. Some insurance systems require participation of the user in the co-payment or user fees or charges. This is often promoted by the idea that it restrains the consumer from seeking unnecessary care, as well as helping cover costs, while opponents justly reply that user fees affect the poorer sector of any population disproportionately and discourage preventive care. The method of payment for doctors has an important impact on the way in which medical services are used. Empirical evidence indicates that fee-for-service promotes excessive use of the system, including unnecessary surgical procedures, while salaried services are often criticized for diminished identification with patients and, perhaps, under servicing. Increasingly mixed systems of payment are emerging, with capitation as a predominant method. Payment for Comprehensive Care Per capita budgeting is a system of payment based on a defined population registered for care with a specific health service system providing a comprehensive range of services, such as a district health system or a managed care organization. Capitation payment covers

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responsibility for total care, so that economies in hospital care can be applied to cost-effective alternatives such as strong ambulatory care, home care, and long-term care. The population may be enrolled:

1. on a voluntary basis in prepaid health care systems as in health maintenance organizations (HMOs are a health system providing insurance and service to

enrolled population responsible for hospital, ambulatory, and preventive care),

2. on a geographic basis as in regional or district health systems. In some financing systems, the per capita payment takes into account the age and sex

distribution of the region, locality, or the registered population. It applies national hospital utilization rates for different categories of age and sex. The capitation method provides an incentive against unnecessary admissions and decreases length of hospital stay, but it is not in a hospital’s best interest to discharge a patient prematurely because of the potential for litigation and because the patient may later return in need of more care, adversely affecting hospital costs.

6.4 COMPARI�G �ATIO�AL HEALTH SYSTEMS

Within the political and institutional framework of each country, a health system is the ensemble of al public and private organizations, institutions and resources mandated to improve, maintain or restore health. Health systems encompass both personal and population services, as well as activities to influence the policies and actions of other sectors to address the social, environmental and economic determinants of health. Beyond its intrinsic value, improved health contributes to social well-being through its impact on economic development, competitiveness and productivity. High-performing health systems contribute to economic development and wealth. Therefore well-functioning health systems are essential to improving health and need to demonstrate good performance. According to The Tallin Charter adopted by WHO European Member States at WHO European Ministerial Conference on Health Systems on 27th of June 2008 in Estonia each country shall seek to contribute to social well-being by ensuring that its health system:

• Distributes the burden of funding fairly according to people’s ability to pay, so that individuals and families do not become impoverished as a consequence of ill-health or use of health services; and

• Is responsive to people’s needs and preferences, treating them with dignity and respect when they come in contact with the system.

There is no single best approach to health financing; distinctions between “models” are blurring as countries develop new mixes of revenue collection, pooling and purchasing arrangements according to their needs, their historical, fiscal and demographic context, and their social priorities and preferences.

Governments have increasingly come to recognize the economic and social value of improving the health of the population. They carry this out through public health measures to ensure the basic health of the nation, as well as through legislation regarding the nature of health insurance, whether it is provided through private or public insurance mechanisms. Each approach has strengths and weaknesses that reflect, to a large degree, the patterns of incentives associated with its institutional and regulatory arrangements.

We argue that public finance is superior to private finance. This is not surprising given the need to secure sustainability without undermining values such as equity in finance or equity of access to health care. However, our argument is also based on efficiency grounds. Publicly generated finance contributes to efficiency and equity by providing protection from financial risk and by detaching payment from risk of ill health. In contrast, private

contribution mechanisms involve limited or no pooling of risks and usually link payment to risk of ill health and benefits to ability to pay. Public finance is also superior in its ability to

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ensure value for money which, as we have argued, is central to securing both economic and fiscal sustainability. Overall, the experience of the United States suggests that increasing reliance on private finance may exacerbate health care expenditure growth, perhaps due to the weak purchasing power of private insurers and individuals against providers. Among the older Member States of the EU, those that have relied more heavily on private finance – either through private health insurance or through higher levels of cost sharing – are also those that tend to spend more on health care as a proportion of GDP (notably Austria, Belgium, France, Germany and the Netherlands), (Thomson, Foubister, Mossialos, 2009).

Because insurers serve as payers for health services, the extent of public versus private coverage is indicative of the degree of government control over health spending. Whether the system features a single, universal insurer or multiple insurers has implications within the scope of introducing competition based reform approaches and to the extent of making consumer choice available. All countries have some form of publicly financed or administered health insurance programs (Figure 6.4). Private health insurance is the dominant form of basic coverage in the United States and Switzerland, and covers a sizeable minority of the population in Germany and the Netherlands. In countries such as Hungary, Japan, Korea, Mexico, and most Nordic countries, private health insurance policies are not commonly used. In other countries, private health insurance is used to fill gaps in the benefits package (a supplemental policy) or absorb out-of-pocket payments (complementary insurance). Private insurance duplicates coverage provided by universal public programs in Australia, Ireland, Italy, Spain, and the United Kingdom, where such coverage is purchased mainly to increase choice of providers and timeliness of care. The degree to which health-care financing and delivery systems are publicly controlled or administered has important policy implications, particularly for cost control and efficiency (Docteur, Oxley, 2003). Although there is considerable variation within systems, countries can be classified as generally consistent with one of the four approaches described below:

6.4.1 The Public-Integrated Model (Beveridge model)

Aneurin Bevan, the British Minister of Health in 1948, is usually honoured as the founder of the National Health Service (NHS). However, it was the Beveridge Report which laid the foundations for the NHS. Other countries introduced similar models later in the 20th century. The Soviet Union and eastern bloc countries had a centrally-planned and state-funded system of health care called the Semashko model named after the Minister for Health of the Russian Republic (Dixon, 2006). In both the original U.K. Beveridge and the Soviet Semashko models, health care is provided and financed by the government through tax payments. These systems, which merge the insurance and provision functions, are organized and operated like any government department. Staff is generally paid on salary (although, in some cases, doctors can have private patients as well) and they are most often public-sector employees. Ambulatory doctors and other health-care professionals can be either public employees or private contractors to the health-care authority, with a range of remuneration packages. Ensuring complete population coverage is particularly easy under such systems, and as they are under the control of the budget, the growth of overall costs has been contained more easily. However, they have weak incentives to increase output, improve efficiency, or maintain quality and responsiveness to patient needs. Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Italy, Greece, Portugal, Spain, Nordic countries, and New Zealand (Docteur, Oxley, 2003).

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6.4.2 Public-Contract Model (Bismarckian model)

Chancellor Otto von Bismarck introduced national health insurance to Germany in 1883. In the Bismarck model, health care is financed through social health insurance, paid at the place of employment, with Sick Funds paying for services of private medical practice and nongovernmental hospitals. In all variations of health insurance systems, the place of the government as provider and insurer is important to the care received by the consumer and the general state of public health (Dixon, 2006). In the public-contract model, public payers contract with private health-care providers. Single-payer arrangements have a stronger position vis à vis providers (as in the public integrated model) and tend to have lower administrative costs than do multiple payer systems. In many public-contract systems, the private hospitals and clinics are run on a non-profit basis. Independent private contractors generally supply ambulatory care. This system is generally considered to be more responsive to patient needs than public-integrated arrangements, but less successful in containing healthcare costs, requiring additional regulation and control by the public authorities. The Bismarck model is found in Continental European Countries (e.g. Germany, France, Belgium, the Netherlands), Japan and, to a degree, in Latin America (Docteur, Oxley, 2003).

6.4.3 The �ational Health Insurance Model

This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated. The classic NHI system is found in Canada and Australia but some newly industrialized countries — Taiwan and South Korea, for example — have also adopted the NHI model.

6.4.4 Mixed Private/Public System

A private model uses private insurance combined with private (often for-profit) providers. Insurance can be mandatory (Switzerland) or voluntary (the United States), and in the case of the latter, affordable insurance may not be available to some individuals. Payment methods have traditionally been activity based, and the systems have featured a high degree of choice and responsiveness to patient needs, but cost control has been weak (Docteur, Oxley, 2003). The United States has elements of all previous mentioned models in its fragmented national health care apparatus. When it comes to treating veterans, they’re Britain or Cuba. For Americans over the age of 65 on Medicare, they’re Canada. For working Americans who get insurance on the job, they’re Germany. For the 15 percent of the population who have no health insurance, the United States is Cambodia or rural India, with access to a doctor available if patient can pay the bill out-of-pocket at the time of treatment or if he/she is sick enough to be admitted to the emergency ward at the public hospital. The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.

There are many variations in methods of assuring national access to health care. A typology of national health systems based on methods of financing and administration of health services provides a framework for their classification and for comparisons (Table 6.2).

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Health insurance coverage promotes access to care, particularly in those countries that separate the functions of financing and delivering health-care services. It also furnishes protection against the high costs associated with treating many acute illnesses and chronic health conditions. With the exception of Mexico, Turkey, and the United States, all OECD countries had achieved universal (or near-universal) coverage of their populations by 1990. Coverage levels vary from comprehensive, providing full financial protection to patients for all necessary health-care services, to those that exclude some services or require patient cost-sharing (Docteur, Oxley, 2003).

Lack of health insurance is the greatest risk factor for inadequate access to services. Evidence from the United States shows that uninsured persons face barriers to access, despite the fact that the provision of significant quantities of care is furnished on a subsidized or charity basis. Uninsured adults are less likely than their insured counterparts to obtain health-care for serious conditions. Those who lack insurance coverage are also at greater risk of not receiving preventive care and routine care for chronic conditions, which means they need more intensive care at later stages of illness. The uninsured obtain worse health outcomes and are at significant financial risk. These consequences make the insured status of a population an important determinant of efficiency of spending in the health sector. The approach most commonly used to attain universal coverage has been to make coverage compulsory, either by establishing a default or all-inclusive public program, or by mandating purchasing of private coverage (Docteur, Oxley, 2003).

Table 6.2 Typology of financing and administration of national health systems. Type Financing Source Administration

Bismarckian health insurance through social security (public-contract model) (e.g. Germany, Netherlands, France, Austria, Belgium, Slovakia, Israel, Japan)

Compulsory employer-employee tax payment to Sick Funds or through Social Security

Contracts with providers or patient reimbursement. Governments regulate Sick Funds which pay private services.

Beveridge public integrated model (e.g. United Kingdom, Norway, Sweden, Denmark, Italy, Spain, Portugal, Greece)

Government - taxes and revenues; U.K. national financing, Nordic countries combine national, regional, and local taxation

Central planning, decentralized management or hospitals, GP service, and public health; integrated district health systems with capitation financing in U.K.

Semashko national health system (e.g. former USSR)

Government - taxes and revenues; post-Soviet national health insurance

Strong central government planning and control; financing by fixed norms per population; allocation of facilities and manpower promote increase in hospital beds and medical staff; pos-1990 reforms emphasize decentralization with capitation and compulsory health insurance

Douglas national health insurance

through government (e.g. Canada, Australia)

Taxation - cost sharing between provincial and federal government

Provincial government administration; federal governmental regulation; medical services paid by fee-for-service; hospitals on block budgets

Mixed private/public system (e.g. United States, Latin America, Asia and African countries)

Private insurance through employment and public insurance through Social Security for specific vulnerable populations groups (children, elderly, poor)

Strong government regulation (U.S.); mixed private medical services,; public and private hospitals, state/county preventive services; DRG payment to hospitals; extension of Medicaid coverage

Source:Tulchinsky TH, Varavikova EA. The Few Public Health. 2nd edition. Elsevier Academic Press, 2009.

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Increasing the effectiveness of health-care systems in accomplishing their intended functions is a growing priority for policy makers in many countries. The notion of effectiveness encompasses a broad and growing number of dimensions, reflecting increasing expectations in many countries that health systems must do more than just improve population health and reduce disability. Notably, many countries include in their assessment of system effectiveness the extent to which systems result in an acceptable level of consumer and patient satisfaction. Ensuring safe and appropriate health-care of high technical quality is seen as a critical means of accomplishing both health and satisfaction goals. Increased pressure for reform has been heightened by better measurement of health system performance – including health outcomes, quality of care, patient satisfaction and system responsiveness – and the opportunities for improvement that this new evidence has revealed (Docteur, Oxley, 2003).

6.5 THE HEALTH CARE SYSTEM I� SLOVAKIA

6.5.1 Health Care Financing in Slovakia

Historically the system of financing in Slovakia’s territory was constructed as a Bismarck type, based on the social insurance covering accident and sickness insurances. In 1948 this system changed with the introduction of national insurance that unified all types of insurance i.e. sickness, disability and pension. This insurance system was replaced by general taxation in 1966 when all health services became free of charge for all citizens and the state assumed responsibility for financing and managing health care provision. In the years that followed 5% of the state budget was allocated to the health sector although there was substantial lack of transparency in the resource allocation. In the early 1990s general taxation implemented through the annual budgets was replaced by the mandatory health insurance system. This transformation was accomplished within two years (Hlavačka, Wagner, Riesberg, 2004). Health Care Expenditure

A mix of public and private sources funds health care in Slovakia. Public expenditure on health includes spending from the national budget and contributions to the statutory health insurance. Slovakia has three forms of private expenditure on health (Hlavačka, Wagner, Riesberg, 2004):

1. Formal (or authorized by law) payments for services provided by private physicians and facilities; co-payments for drugs, some dental services, visual aids, medical devices.

2. Informal (or unauthorized) payments for health services made to providers who are not authorized by law to receive such moneys.

3. Insurance premium payments for voluntary health insurance offered on a contractual basis. Total expenditure on health as a proportion of gross domestic product (GDP) increased

between 2000 and 2008 from 6.6% to 7.8% (Figure 6.6). During that period, however, public spending on health fell from 85% of total health expenditure to 66.8%. This decline can be attributed to significant growth in private health expenditure, which more than doubled, rising from 11.5 % in 2000 to 26.2% in 2008.

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6710 Total health expenditure as % of gross domestic product (GDP), WHO estimates6730 Public sector health expenditure as % of total health expenditure, WHO estimates6860 Private households' out-of-pocket payment on health as % of total health expenditure

Slovakia

Figure 6.6. Trends in health care expenditure in Slovakia, 2000-2008. Source: WHO/Europe, European HFA Database, July 2010. Coverage and Benefits

The statutory health insurance scheme in Slovakia covers all residents for a comprehensive defined package of benefits including preventive, curative and rehabilitative care. Cost sharing was introduced for doctor visits and inpatient care in 2003, but abolished in 2006. At the beginning of 2007, co-payments were applied to visits to an emergency department, outpatient prescription pharmaceuticals, transport to hospital, spa treatment and dental care (Thomson, Foubister, Mossialos, 2009). Collection of Funds

Health care is mainly financed through the statutory health insurance scheme (Figure 6.7), which generates revenue from earnings-based contributions, and funds are transferred from the central Government to cover people that do not work. The centrally set contribution rate is 14% of gross earnings for employed people and self-employed individuals (4% paid by employees and 10% by employers), with a reduced rate of 7% for disabled people. There is a ceiling on contributions. Private voluntary health insurance plays a very marginal role in the Slovakian health system. It was intended to play a complementary role, covering statutory co-payments, following a 2004 reform. However, the market has not experienced much development (Thomson, Foubister, Mossialos, 2009).

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Figure 6.7 Breakdown of the percentage of total expenditure on health in Slovakia by main contribution mechanisms, 1996 and 2005. Source: Thomson S, Foubister T, Mossialos E. Financing health care in the

European Union: Challenges and policy responses. Copenhagen: WHO, 2009. Notes: OOP- Out-of-pocket-payments

Pooling Public and private health insurance funds are responsible for collecting and pooling

contributions and for purchasing health services for their members. Most of the population is covered by public health insurance funds. Purchasing Health Services

The health insurance funds negotiate volume-based contracts with providers and are required to monitor provider performance. General practitioners play a gate keeping role, referring patients to specialist care. Patients have free choice of provider. Provider Payment

Provider payment has undergone several reforms, moving from a predominantly retrospective reimbursement system to a system of prospective payment. Budgets were introduced for hospitals and outpatient specialists in 1998. Since 2002, case-based payments for hospitals (DRGs) have also been used to pay hospitals. Since 2001 the capitation payment system for primary care has been adjusted for age and supplemented by fee for service payment for preventive services. 6.5.2 Health Care Reforms

The early health care reforms in the Slovak Republic were initiated by the radical political, social and economic changes following the velvet revolution in 1989. They were influenced by the overall desire to move towards a democratic society with a social market-oriented economy. There was a strong political decision to replace the socialist health system (Semashko) with a mandatory statutory health insurance system including an organizational split of purchasers and providers, acting in a specifically regulated market.

Slovakia largely has managed to transform its health care sector from an integrated tax-based system with a state monopoly in providing care into a pluralistic and decentralized social health insurance system with a mix of private and public providers. The reforms appear to have been implemented without significant adverse effects on the population’s health. However, the introduction of a pluralist health insurance market has not fulfilled the hopes of increasing funding and the accountable provision of health care, and has resulted in many problems. Growing internal and external debts have raised fears about the future sustainability

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of the financial basis and the public-private mix of financing health care benefits. Trust in the governance of the current system has been eroded by a lack of appropriate regulatory and control mechanisms and inadequate systems for information, monitoring and feedback (Hlavačka, Wagner, Riesberg, 2004).

Various measures to contain costs and increase technical efficiency have succeeded in keeping overall and public health expenditures at a low level, by international comparison. Payment methods which encourage appropriate behaviour in health care providers and patients were introduced recently. However, their combination (e.g. capitation in primary care, fee-for-service for specialists) has proved to be financially unsustainable since it does not encourage the delivery of care at the most appropriate and cost-effective level. The recognition and quality of primary care delivery and the social status of primary care physicians have not improved because of the many restrictions on the volume and range of primary health care services. The way in which the privatization of health care services was carried out in Slovakia enabled physicians in primary health care to leave the state sector and become independent contractors within a very short time. Bed capacities have been reduced but they remain comparably high, while community-based services and day-treatment are regarded as underdeveloped. Currently, there seem to be increasing incentives to encourage efficiency in hospital managers, increased support for day treatment and shifting from inpatient to outpatient care (Hlavačka, Wagner, Riesberg, 2004).

Despite profound socioeconomic transformation and resource limitations, equity of

provision of health care largely has been maintained under the new system. The density of providers is comparably high and so access remains very good overall, although there is a lower density of providers and longer distances in rural areas.

Equity in financing health care may have been reduced to some extent as insurance contributions from employees and employers are proportionate instead of progressive. The ceiling on contributions produces a certain regressive component in the contribution system. In addition, private out-of-pocket payments have increased although, until recently, Slovakia relied on a relatively small share of private expenditures. Also the state contribution on behalf of the economically inactive represents a significant progressive component.

6.6 HUMA� RESOURCES FOR HEALTH CARE

6.6.1 Human Resources Planning

The numbers, types, and distribution of personnel supply are major determinants of access, availability, appropriateness, and costs of health care. The factors influencing the supply of health workers are presented in Figure 6.8. The training, quality, and performance of health personnel and the technology they use are all important health planning issues. Explicit and well-designed policies for human resources for health constitute an important mechanism by which governments may improve health system performance. Policies may affect the current state of human resources for health along three broad dimensions (Bossert et al., 2007):

• density level (the number of health workers in different professional, administrative and support categories relative to populations being served);

• distribution and composition (intra-national distribution of human resources across geographical regions, skill categories and personal or institutional characteristics, and intra-organizational distribution of skill sets or cadres);

• performance (what the health workers do and how they do it).

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Figure 6.8 Supply of health workers: inflows, stocks and outflows. Source: Health at a Glance. OECD health indicators. OECD, 2009

Benchmarking what should be an “adequate” density level however is seldom easy. Recently, there have been attempts to posit international minimum standards for some health cadres. For instance, World Health Report 2006 suggests a minimum of 2.3 health workers per 1,000 people is required to attain adequate coverage of some essential health interventions. The situation in workforce density level for different professions in the WHO European Region according to the data published in European Health Report 2009 is shown in Table 6.3.

The average density levels may mask significant differences in the distribution of human resources along geographic, skills, gender and sectoral dimensions. These distributional differences may be some of the most important obstacles to achieving the broad goals of improved health status in a population, citizen satisfaction and sustainable financial protection. Geographical imbalances usually imply a clustering of the health workforce in cities, and therefore scarcity of health workers in rural areas. Skills imbalances, for instance the ratios of nurses to doctors, or unskilled to skilled human resources, may also reflect differences in availability and quality of services. Gender distribution, which results in clustering of women and men in certain health professions, such as physicians being predominantly male and nurses and lower-status staff being predominantly female, may have some justification for certain categories where female patients are more comfortable with female providers. Sector differences may be assessed by determining the ratio of private to public sector health workers. While there are no guidelines for this ratio, it may be important in determining the policy options for access for poor people, regulating quality of services, and determining subsidy policies. Distributional imbalances are felt to entail a number of adverse consequences, including: the brain drain from public rural to private urban centres; inattention to gender-specific health problems and patterns of service use; lower quality and productivity of health services; increased waiting time and reduced numbers of available hospital beds; and certain interventions being carried out by lower-qualified personnel.

Performance of human resources for health comprises both personnel efficiency and provider quality. The efficiency of the health workforce may be analyzed as financial

efficiency (e.g. the number of health workers employed per dollar expended) and productivity

(e.g. the number of services provided per person−hour). Both are important for health systems performance, in terms of making optimum use of scarce resources and containing costs of health workers. Quality in health care can be divided into two subcategories: clinical quality (measured objectively as clinical performance); and patient satisfaction (quality measured

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subjectively as perceived by patients). Clinical quality is crucial in improving health outcomes, while patient satisfaction is an important health system objective in and of itself and may ultimately affect population health as well. Table 6.3 Human resources for health in the WHO European Region, 2007 or latest available year.

Source: The European Health Report 2009. Health and health systems. Copenhagen: WHO, 2009a.

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6.6.2 Problems in Human Resources

The principal problems in human resources development vary from country to country but consistently include the following (Tulchinsky, Varavikova, 2009):

1. Non-attractiveness of health professions, inadequate funding training positions, salaries, incentives, safety, motivation and support systems for health workers;

Ad. 1. Given that the health sector is human resource intensive by nature, the

motivation of health workers plays a key role, alongside their ability, in determining

system performance. Health worker motivation may be defined as employee

willingness to “exert and maintain an effort towards organizational goals” by

influencing “workers’ allocation of personal resources towards those goals”.

Motivation in turn affects effectiveness and productivity. Job satisfaction may be a

major pathway linking motivation to organizational performance (Bossert et al.,

2007).

2. Imbalance in training of health professionals; severe shortages of nurses and other health professionals, compared to the physician workforce;

Ad. 2. While nearly all health professions face projected shortages, the situation for

nurses is most severe. Throughout the world, the nursing workforce is very insufficient

to meet the public’s needs.

3. Insufficient training for medical and nursing personnel in developing countries; 4. Excess of medical subspecialists, and insufficient incentives and training of

primary care physicians, inflating health costs and compromising access to care; 5. Geographic imbalance in distribution of vital professional categories with

concentration in urban centers and poor supply in rural areas; Ad. 4. and 5. Oversupply of medical specialists can be a serious problem for a health

system promoting a bias toward a specialized medical orientation in health care at the

expense of other more basic needs of public health, primary care, and fundamental

support systems for vulnerable groups in society. An excessively specialized medical

orientation fosters misallocation of limited resources by creation of tertiary care and

high physician density in central cities, leaving rural and primary care

underdeveloped. In some countries the problem is often compounded by an inability of

the health budget to employ needed numbers of physicians. Unemployment among

young physicians is a substantial problem in many countries.

6. Under-financing for public systems of health care in comparison to private, fostering poor work conditions, low remuneration, and inequality in career opportunities with low staff morale, performance, and client satisfaction;

7. Insufficient standards and length of training of specialist physicians to produce well-qualified professional leaders;

8. Lack of orientation of all health providers to public health, an over-medicalization in the health field, and excessive influence of the pharmaceutical industry on medical education, practice, and health priorities;

9. Lack of postgraduate accredited academic centers for research and training of public health specialists in epidemiology, health-related social sciences, health system policy analysis, or health system management;

10. Compromising the quality of human resources by inadequate recruitment and educational standards, inadequate continuing examination and recertification;

11. Conflicts of academic, professional, government, or insurer interests with public and individual patient interests in training policies;

12. Poor coordination and communication between government and managerial sectors involved in health policy;

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Ad. 12. Political policy is crucial for the preparation, composition, and work patterns

of the health workforce. Fational expenditures on health are dependent on the

political priority given to health compared to other issues that may be equally or more

pressing to the governing power.

13. Globalization and migration of the skilled workforce from developing countries, where they are most needed;

Ad.13. Emigration of health personnel to other countries is felt to pose a significant

problem to health systems of low and middle income countries. While the free flow of

physicians, nurses and other health personnel can increase information sharing and

knowledge-building, low income countries are especially vulnerable to a brain drain

of their most highly skilled workers. The departure of highly skilled health workers

can adversely affect the quality of care in the originating country’s health system, and

the depletion of human resources could jeopardize future macroeconomic prospects.

Although the nature of migration (e.g. temporary versus permanent) plays a large role

in its eventual impact, emigration often entails more negative than positive

consequences for countries already experiencing shortages in key health personnel

(Bossert et al., 2007).

14. Inadequate development of community health workforces as front line access and outreach personnel in rural and underserved urban areas as integral participants in the health system;

15. Multiple job holding in the health sector – simultaneous provision of services by government employees outside their public sector appointment - leading to a number of problems in the efficiency and quality of care (Bossert et al., 2007).

Ad. 15. On the one hand, multiple job holding may decrease productivity in the lower-

paying (often public sector) post or even overtax the provider and jeopardize

productivity and quality in both jobs. On the other hand, multiple job holding may

lead to inappropriate use of public resources for private gain or unnecessary referrals

from public to private practice.

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7 QUALITY I� HEALTH CARE

7.1 I�TRODUCTIO�

Rising patient expectations are an important health-care phenomenon evident in every country and covering all aspects of health care. Better informed and more assertive consumers of health care have higher expectations about the quality of care they receive and a lower tolerance of defects (Detels et al. 1997). People want to know that the service/care they are receiving is based on best-practice evidence and meets approved and certified standards (Quality and Fairness, 2001).

Achieving quality is the concern and responsibility of all those who are associated with the health system. Quality of health care is considered to be a usual component of professional health care performance. Traditionally quality assurance has been meant to apply predominantly, or even exclusively, to health care itself as provided directly to patients by legitimate health care practitioners (Donabedian 2003) and used to be practiced on an intuitive basis for a long time. Most medical professionals are convinced that they are performing optimally, and the very thought of having someone provide oversight of their work often provokes an angry response (Lighter, Fair, 2004). One reason could be as it is stressed in World Health Organization document “Health 21” the fact that in the European Region, almost all individual health service institutions and providers currently lack basic information about the quality of the care they provide in their daily practice (WHO, 1999).

7.2 DEFI�ITIO�S A�D TERMS

7.2.1 Definition of Quality

The quality of something can be determined by comparing a set of inherent characteristics with a set of requirements. If those inherent characteristics meet all requirements, high or excellent quality is achieved. If those characteristics do not meet all requirements, a low or poor level of quality is achieved. Quality is, therefore, a question of degree. As a result, the central quality question is: How well does this set of inherent characteristics comply with this set of requirements? In short, the quality of something depends on a set of inherent characteristics and a set of requirements and how well the former complies with the latter. According to this definition, quality is a relative concept. A requirement is a need, expectation, obligation or standard. It can be stated or implied by an organization, its customers, or other interested parties. One view of quality is that it is that which satisfies the customer. A more sophisticated view is that it is that which satisfies stated or implied needs. Thus needs may be implied and met through certain standards which the consumer may not comprehend (Ellis, 1993).

One of the basic principles of quality is prevention and continual improvement. This means that quality is a never-ending project whose goal is to spot dysfunction as quickly as possible after it occurs. Thus, quality can be represented by a cycle of corrective and preventative actions called a "Deming cycle". In quality improvement the goal is not only to improve the average performance but also to reduce inappropriate variations in the process

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7.2.2 Definition of Quality in Health Care

Quality in health care can be understood in diverse ways, using different terms, labels and models. The first step in assessing the quality of health care involves defining what is meant by quality. There are many possible definitions. An overview of the most frequently applied definitions of quality of care is presented in Table 7.1 (Legido et al, 2008). Table 7.1 Definitions of quality of health care

Author/Organization Definition

Donabedian (1980) Quality of care is the kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts.

Department of Health (UK) (1997)

Quality of care is: • doing the right things (what) • to the right people (to whom) • at the right time (when) • And doing things right first time.

Council of Europe (1998) Quality of care is the degree to which the treatment dispensed increases the patient’s chances of achieving the desired results and diminishes the chances of undesirable results, having regard to the current state of knowledge.

WHO (2000) Quality of care is the level of attainment of health systems’ intrinsic goals for health improvement and responsiveness to legitimate expectations of the population.

Source: Legido-Quigley H, McKee E, Nolte A, Glinos I, 2008

Donabedian - father of quality in health care, defined the quality of care as “that kind of

care which is expected to maximize an inclusive measure of patient welfare, after one has

taken account of the balance of expected gains and losses that attend the process of care in

all its parts”. He distinguished a “maximalist” specification from an “optimalist” specification of quality. The maximalist specification ignores monetary costs and defines the highest quality as the level that can be expected to achieve the greatest improvement in health. In contrast, in the optimalist specification of quality, very expensive interventions that do not achieve a great improvement in health would be avoided. Donabedian introduced the dual nature of medical quality by describing both the technical and the interpersonal components of care (Kelly, 2007). Interpersonal interventions are just as important as technical ones but are much less predictable in their impact. Donabedian also refers to a third aspect of quality health care which he terms the moral aspects. This includes choices which must be made between types of provision and judgments about levels of access within attainable resources. These, as he rightly notes, are issues of social justice and political philosophy (Donabedian 2003).

In a 1990 report, the Institute of Medicine (IOM) authors reviewed over 100 definitions and parameters of quality of care according to the presence or absence of 18 dimensions (Legido et al, 2008). Based on this review, the authors arrived at a definition of quality of care that considers 8 of the 18 dimensions identified (Shekelle, Pencheon, Melzer, 2006). The definition:

• includes a measure of scale or degree; • quality encompasses all aspects of care by referring to health services • identifies both individuals and populations as targets for quality assurance efforts; • is goal oriented, quality outcomes are desired without specifying for whom, thus

allowing the possibility of differing perspectives on which aspects of quality are most important (professional, patient, public, political…)

• recognizes the importance of outcomes

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• highlights the importance of individual patients’ and society’s preferences and values • underlines the constraints placed on professional performance by the state of technical

care and emphasizes that the link between the quality of care and outcomes is rarely causal by stating that which is measured is a likelihood or probability

• the phrase ‘consistency with current professional knowledge’ indicates that quality of care can only be judged relative to what is known at that moment in time.

A widely accepted definition of quality, as given by the Institute of Medicine, is this: „The

degree to which health services for individuals and populations increase the likelihood of

desired health outcomes and are consistent with current professional knowledge“.

It is important to note that compared to the definition developed by Donabedian, the IOM definition narrows the goal from improving total patient welfare to improving health outcomes

7.2.3 Dimensions of Quality in Health Care

The first step toward assessing, measuring and assuring quality is to deconstruct it into its core dimensions.

Dimensions of quality of health care are definable, preferably measurable and actionable, attributes of the health system that are related to its functioning to maintain, restore or improve health. The choice of dimensions to measure quality of care is critical as it will influence the health care policies adopted. Most common used dimensions for quality of health care are based on six dimensions suggested by Maxwell (Ellis, 1993; Shekelle, Pencheon, Melzer, 2006):

1. Effectiveness is the degree to which processes result in desired outcomes, free from

error and is appropriate to the clinical needs and based on the best current evidence. Comparison between actual performance and the performance that ideally or under specified conditions, could be expected to achieve. In questions: Does the intervention

produce the desired effect? Is it carried out well? 2. Relevance to need refers to how a system treats people to meet their legitimate non-

health expectations. The emphasis here is on the patient's report of her or his experience with specific aspects of care and goes beyond her or his general satisfaction or opinion regarding the adequacy of care. In question: Is patient

satisfied?

3. Accessibility is the ease with which health services are reached. Access can be physical, financial or psychological, and requires that health services are a priori

available (distance from the sources of care, transportation, organizational factors- opening hours, ethnic and religious preferences. Accessibility quantifies whether a

health service or treatment is available to the person needing it, at the time it is

needed. In question: Can people get this treatment/service when they need it?

4. Acceptability is conformity to the realistic wishes, desires and expectations of patients and their families. Accessibility is a part of acceptability. In questions: If right

and available does this patient want it? How humanely and considerately is this

treatment/service delivered? What does the patient think of it? How would I feel if it

were my nearest and dearest? What is the setting like? Are privacy and confidentiality

safeguarded? 5. Equity (or equitability) defines the extent to which a system deals fairly with all

concerned. Equity, in this context, deals with the fair distribution of healthcare and its benefits among a people. Depends on access, effectiveness and acceptability of the care received. In question: Is this patient or group of patients being fairly treated

relative to others?

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6. Efficiency is the system’s optimal use of available resources to yield maximum

benefits or results. It speaks to a system’s ability to function at lower costs without diminishing attainable and desirable results (Donabedian, 2003). Refers to the extent to which objectives are achieved by minimizing the use of resources. In question: How

does the unit cost compare with the unit cost elsewhere for the same

treatment/service? Is it carried out in a cost effective way?

Less commonly used dimensions: Safety is the degree to which health care processes avoid, prevent, and ameliorate adverse outcomes or injuries that stem from the processes of health care itself. According to the IOM, patient safety is “freedom from accidental injury due to

medical care, or medical errors”.

Continuity addresses the extent to which healthcare for specified users, over time, is coordinated across providers and institutions. In question: Did it progress without

interruption, with appropriate follow up, exchange of information and referral?

Timeliness is a related concept that is used in several country frameworks and refers to the degree to which patients are able to obtain care promptly.

Figure 7.1 Dimensions of quality of health care

There are many variants of the dimensions mentioned above. They all have in common three broad areas, shown in Table 7.2.

Table 7.2 Three areas of quality

1.Effectiveness/efficacy/appropriateness/safety. Whether the service actually delivers in the way it is claimed (either under ideal conditions (efficacy) or in practice (effectiveness))

Appropriate and safe. Can it work? (efficacy). Does it work? Does it do more good than harm? (effectiveness)

2. Cost/efficiency. Are there more efficient ways to deliver this service or are there other services that would be a better use of the resources? (Eliminating waste, and improving efficiency are integral to quality)

Cost. Is it worth it? (efficiency, e.g. cost–benefit). Is it wasteful?

3.Equity/acceptability/access/ownership/relevance/legitimacy/responsiveness. How is the service received by those who (might) receive it? Is it relevant, fair, flexible, and responsive to demand? Is it what patients want? Is it what professionals judge as what the public ‘needs’?

Ownership. Is the system fair? (equity). Can people use it?(accessible). Is it what individuals/society wants, and if not, can the system be changed accordingly? (acceptability, legitimacy, and responsiveness)

Source: Shekelle P, Pencheon D, Melzer D, 2006

6.

Efficiency

Safety

Continuity

Timeliness

1.

Effectiveness

2.

Acceptability

3.

Relevance

to need

4.

Equity

5.

Accessibility

Health care

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The IOM definition of quality recognizes that the link between care and outcomes is rarely deterministic, and also qualifies outcomes as having to be desirable. But for whom should they be desirable? This perspective on quality, and the priority given to particular dimensions of quality, can depend on who the interested party is. Table 7.3 gives a summary of the different perspectives of quality depending on who is considering it.

Table 7.3 Differing perspectives of quality Interested party High-priority elements of quality Consumers/patients/public (i.e. those who demand and receive the care)

Responsiveness to perceived care needs. Level of communication, concern and courtesy. Degree of symptom relief. Level of functional improvement

Practitioners/clinicians (i.e. those who deliver the care)

Degree to which care meets the current technical state of the art. Freedom to act in the full interest of the patient. Accountability to ‘professional standards’

Commissioners/funders/purchasers (i.e. those who sanction and pay for the health care)

Efficient use of funds available for health care. Appropriate use of health-care resources. Maximum possible contribution of health care to reduction in lost productivity. Accountability to politically set philosophy, objectives, targets, goals

Source: Shekelle P, Pencheon D, Melzer D, 2006

7.3 MEASUREME�T OF QUALITY I� HEALTH CARE

In order to assess and improve quality, it first must be measured. Donabedian suggested eight steps in monitoring quality (Donabedian, 2003):

1. Determining what to monitor 2. Determining priorities in monitoring (where to begin, guidelines for selection) 3. Selecting an approach to assessing performance (a way of finding if the quality of care

has been good, fair or poor - triad structure, process, and outcome.) 4. Formulating criteria and standards 5. Obtaining the necessary information (information system, medical records, surveys,

financial records, statistical reports, direct observation, test situations) 6. Choosing when and how to monitor 7. Constructing a monitoring system 8. Bringing about behaviour change (readjustment in system, educational and

motivational activities - training, socialization, reminders, feedback, rewards, penalties)

An important dimension of measuring (and thus defining) quality is to make the standards against which one is assessing quality explicit and preset. The importance of words such as ‘standards’ and ‘right’ is that they emphasize and make explicit the subjective nature of

quality (i.e. ‘quality is in the eye of the beholder or begetter’) (Shekelle, Pencheon, Melzer, 2006). Some quality indicators are mandatory, required by legislation or governmental agencies while other indicators are the result of voluntary internally motivated monitoring activities perceived as opportunities for improvement. Donabedian (2003) proposed that we can measure the quality of health care by evaluating its structure, processes and outcomes. He argued that “good structure increases the likelihood of good process, and good process increases the likelihood of good outcome. Ideally, any system of assessment would include elements of structure, process and outcome as they examine different aspects of the care provided in health systems while using process and outcome measures on their own may be misleading.

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Donabedian defined: STRUCTURE (or input) as the conditions under which care is provided (attributes of

the settings in which care occurs and the resources needed for health care.) This would include • Material resources (facilities, capital, equipment, drugs, etc.), • Intellectual resources (medical knowledge, information systems) • Human resources (number, variety, qualifications of health care professionals). • Organizational characteristics (organization of staffs, presence of research and teaching

functions, kinds of supervision and performance review, methods of paying care) Structure indicators may represent necessary conditions for the delivery of a given quality

of health care but they are not sufficient. Their presence does not ensure that appropriate processes are carried out or that satisfactory outcomes are achieved by the health system. Standards for the structural aspects of care are at least implicitly set and modified with each round of budgeting and allocation at each organizational level in each health service but the grounds on which judgments are made are often obscure (Ellis, 1993)

PROCESS denotes the use of resources in terms of what is done in giving and receiving care. This can be classified into patient-related processes (prevention, diagnosis, treatment interventions, education, etc.) and organizational aspects (administrative and technical support, supply with drugs, management of waiting lists, payment of health care staff, collection of funds, etc.). Process measures represent the closest approximation of actual health care offered and are the most clinically specific of the three types of indicators. Process data often provide a more sensitive measure of quality than outcome data, since a poor outcome does not necessarily result from a failure in the provision of care (Legido et al., 2008), thus measures of health-care quality are dominated by process measures rather than outcome measures.

OUTCOMES describe the effects of health care on the health status of patients and populations. Outcomes include: • Changes in health status (mortality, morbidity, disability or quality of life) • Changes in knowledge acquired by patients and family members that may influence future

care • Changes in behaviour of patients or family members that may influence future health • Satisfaction of patients and their family members with the care received and its outcomes.

Outcomes are more generally perceived as poor measures of quality of care as they are only partially attributable to health services and may be more strongly influenced by other factors such as nutrition, environment, lifestyle or socio-economic circumstances (Legido et al., 2008).

Structure, process and outcome are not attributes of quality. They are only kinds of information one can obtain, based on which one can interfere whether quality is good or not. There is predetermined relationship among the three approaches, so that structure influences process and process influences outcomes (Figure 7.2).

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Figure 7.2 Relationships between characteristics of structure, process and outcome. Source: Donabedian, 2003

For example (Kelly, 2007), in an internal medicine practice with multiple physicians,

the number and credentials of physicians, physician’s assistants, nurses and office staff are

considered structure measures. The percentage of elderly patients who appropriately receive

an influenza vaccine is considered a process measure, and the percentage for elderly patients

who are diagnosed and treated for influenza is considered an outcome measure for this practice.

7.4 QUALITY ASSURA�CE I� HEALTH CARE

Quality assurance means all actions taken to establish, protect, promote, and improve the quality of health care. Assurance implies that one party is convincing another that certain standards will be maintained. The term is also used more generally for all the steps which must be taken in order that the customer or other interested person will be consistently provided with quality (Ellis, 1993).

One cannot assure or guarantee quality. One can only increase the probability that care will be “good” or “better”. It is an activity by which we obtain information about the level of quality produced by the health care system and, based on an interpretation of that information, take the actions needed to protect and improve quality. This action can take one of two forms: activities meant to educate and motivate persons directly, or readjustments in system resources and design (Donabedian 2003).

However, most of health care is better conceived as a service and here the process of quality assurance and quality control become far more difficult. Services are immeasurably complicated by their interpersonal, human and hence psycho-social nature. When behavioural and social variables are involved it is usually difficult to specify let alone agree on standards.

STRUCTURE PROCESS OUTCOME

Needed equipment and qualified health care personnel

Appropriate process of technical care

Improvement in health

An empathetic, participatory patient-practitioner interaction

Satisfied patients

A high proportion of satisfied clients

Early institution of care; effective participation in the care process

Amenities of care: a properly functioning appointment system; pleasant, comfortable surroundings; privacy; etc.

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If patients, employers and indeed providers themselves are to be assured that these standards will be met, some kind of system will be necessary and it will have to be managed whatever its level or scope. Central to all this will be the commitment and competence of staff whose development to meet the requirements of the system will be a necessary component (Ellis, 1993).

If an organization sets out in detail the procedures which it will follow to maintain and hence assure quality then this constitutes its quality system. The establishment and implementation of this system constitutes quality management (Ellis, 1993). Quality management includes all the activities that organizations use to direct, control, and coordinate quality. These activities include formulating a quality policy and setting quality objectives. They also include quality planning, quality control, quality assurance, and quality improvement. Quality management refers to how health care managers understand, explain, and continuously improve their organizations to allow them to deliver quality and safe patient care, promote quality patient and organizational outcomes, and improve health in their communities. A quality management system is a set of interrelated or interacting elements that organizations use to direct and control how quality policies are implemented and quality objectives are achieved (Kelly, 2007). If the production of a quality service is to be managed so that standards are met consistently, then this can readily be shown to depend on all elements in the organization - human and material. The management of quality is so important that standards have been set for systems of prove effectiveness. Successful systems may be awarded (Ellis, 1993).

All health services are provided within and/or between organizations. Although their methods of operation and specific organizational characteristics may differ according to its purposes, focus, and values they are running on the same principles as other organizations, so it is important to focus on management and models of quality improvement used in other sectors of industry and services (Kelly, 2007).

7.4.1 Models of Quality Assurance in Health Care

7.4.1.1 ISO model

I S O is the International Organization for Standardization. It is located in Switzerland and was established in 1947 to develop common international standards in many areas. Its members come from over 150 national standards bodies. ISO's purpose is to facilitate international trade by providing a single set of standards that people everywhere would recognize and respect.

The ISO 9000 series of standards relating to quality management are considered most relevant to health care. The ISO 9000 standards were first published in 1987 as generic management system standards. ISO 9000 applies to all types of organizations. It doesn't matter what size they are or what they do. It can help both product and service oriented organizations achieve standards of quality that are recognized and respected throughout the world. ISO 9000 series of quality management standards

• ISO 9000 discusses definitions and terminology and is used to clarify the concepts used by the ISO 9001 and ISO 9004 standards.

• ISO 9001 contains requirements and is often used for certification purposes • ISO 9004 presents a set of guidelines and is used to develop quality management

systems that go beyond ISO 9001. Disadvantages of ISO 9000 standards

• ISO 9000 relates only to a company’s processes, not its outcomes.

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o For companies that have successfully implemented ISO 9000 standards, the outcomes have usually improved, but, again, the focus of the intervention was on the process not the outcome.

o ISO certification, therefore, is not a product or service validation but rather a sign that an organization has effective processes for producing quality output.

• ISO 9000 compliance does not necessarily indicate that every service meets the requirements of the customer, only that the quality system that is deployed is capable of meeting standards.

o ISO 9001 requirements describe what must be done to make up a quality system, not how to set it up.

Usefulness of ISO 9000 standards

• standards provide a generic, internationally widely accepted method of approaching quality improvement

o specifics of application to health care could be adjusted o payers are familiar with standards and begin to require health care

organizations to comply with them • the effect of working to comply with ISO 9000 standards will provide focus for the

quality improvement efforts of an organization • achievement of ISO 9000 certification can make an organization more competitive

o the international imprimatur of quality gives substantial credibility o payers may contract preferentially with the organization that has achieved ISO

9000 registration o Comparing to accreditation processes (JCI etc.) is much easier to manage, less

time-consuming, and less costly.

7.4.1.2 EFQM model

The European Foundation for Quality Management (later to be renamed simply 'EFQM') is a non-for-profit membership foundation founded in 1988 by leaders from fourteen companies who were convinced that a new membership organization, based in Europe, was necessary to promote higher standards of management through shared knowledge and mutual recognition. Subsequently the mission and membership base of EFQM has been extended, as enthusiasm for its values and frameworks grew in the public sector, into small and medium sized enterprises, and to other organizations around the world. EFQM helps member organizations implement their strategies by sharing what works between them. This mission extends beyond the borders of Europe, to wherever organizations are willing to open their doors to structured assessment and exchange. The EFQM Excellence Model is the most widely used organizational framework in Europe and it is the basis for the majority of

national and regional Quality Awards. Used as a tool for assessment, it delivers a picture of how well the organization compares to similar or very different kinds of organization. EFQM model is not widely used in health care sector.

The EFQM Excellence Model: • Is a structure for the organization’s management system • Can be used as part of a self-assessment • Provides a framework for comparison with other organizations • Helps to identify areas for improvement The EFQM Excellence Model is a non-prescriptive framework based on 9 criteria.

Five of these are 'Enablers' and four are 'Results'. The 'Enabler' criteria cover what an organization does and how it does it. The 'Results' criteria cover what an organization

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achieves. 'Results' are caused by 'Enablers' and 'Enablers' are improved using feedback from 'Results'.

The Model, which recognizes there are many approaches to achieving sustainability, is based on the premise that:

Excellent Key Results, Customer Results, People Results and Society Results are achieved through Leadership driving the Strategy that is delivered through People, Partnerships and Resources, and Processes, Products and Services.

The EFQM Model is presented in diagram form below. The arrows emphasize the dynamic nature of the Model. They show innovation and learning helping to improve enablers that in turn lead to improved results.

Figure 7.3 EFQM Model, Source: The European Foundation for Quality Management. Official website. www.efqm.org.

Today, EFQM membership base of 600 organizations actively exchanges experience on issues ranging from quality and risk management, to leadership and supplier development programs.

7.4.1.3 Accreditation

It should, however, be noted that the concept of accreditation has at least three different meanings, which is why the term can sometimes be rather confusing. These relate to accreditation of health professionals, health care delivery programs and facilities. Accreditation is primarily relevant where there is a choice of provider and a desire to have an alternative to government control of external quality assurance. In this respect there is a difference between accreditation, certification and licensing. In general, licensing is obligatory, by inspectors, using minimal standards of structure and inputs. Accreditation, which was often voluntary in Europe in the past, is increasingly being funded or managed by governments. In particular, in several countries some hospitals have been encouraged to seek accreditation in order to procure better contracts with the insurance funds.

Accreditation is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assesses the health care organization to determine if it meets a set of standards requirements designed to improve quality of care. This voluntary process provides a visible commitment by an organization to continually ensure a safe environment for its patients and staff.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO or Joint Commission) is very well known in the health care industry for its work in accrediting hospitals for over 70 years. It evaluates and accredits more than 16, 000 health care organizations in the USA and around the world. The organization was formalized in 1951 as

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Joint Commission on Accreditation of Hospitals (JCAH) and the organization gradually assumed responsibility for certifying other types of health care organizations, and in 1987 the organization’s name was changed to the JCAHO to reflect the broadening scope of organizational activities.

The mission of JCI is to continuously improve the safety and quality of care in the international community through the provision of education and consultation services and international accreditation and certification. Joint Commission International (JCI) accreditation can help international health care organizations, public health agencies, health ministries and others to evaluate, improve and demonstrate the quality of patient care in their nations while accommodating any specific legal, religious and cultural factors within a country. JCI standards and evaluation methods are:

• Designed to stimulate and support sustained quality improvement • Created to provide a framework for risk reduction • Focused on creating a culture of patient safety • Developed by health care experts from around the world—and tested in every world region • Created by health professionals specifically for the health care sector • Applicable to individual health care organizations and national health care systems

The review process entails a site visit by trained surveyors who evaluate the facility according to standards maintained by the JCI. Surveyors spend several days at the health care organization, during which time they examine documents, check the facility and physical plant, and talk with staff members regarding operations and compliance with standards (Lighter, Fair, 2004).

7.5 CO�CLUSIO�

In designing approaches to quality improvement (QI), managers and physicians need to be cognizant of both the internal and external environment to ensure that they are supporting effective QI. QI implementation is unlikely to improve quality of health care without a commensurate fit with the organizational factors, administration, culture, cooperation, financial, strategic and market imperatives faced by the health care organization.

Quality improvement in health care often requires the adoption and implementation of new processes. To bring quality improvement concepts into practice, the motivation and education of health care professionals should be emphasized as it is stressed in WHO document „Health 21“(WHO, 1999). An organization’s “capacity for change” and the transformation of the culture of health care delivery into one in which everyone is committed to continuous quality improvement and has the skills to participate in it potentially represent a key success factors in working toward quality improvement goal. This commitment, as Donabedian highlights, must arise from values and impulses within an organization itself. The commitment to quality in moral terms is the ethical imperative that must govern the conduct of all caregivers. The external pressures are insufficient to truly motivate individuals and organizations unless they are correspondingly predisposed (Donabedian, 2003).

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8 EQUITY I� HEALTH A�D HEALTH CARE

8.1 EQUITY I� HEALTH

Equity in health is an ethical value, inherently normative, grounded in the ethical principle of distributive justice and consonant with human rights principles. In operational terms, and for the purposes of measurement, equity in health can be defined as the absence of

disparities in health (and in its key social determinants) that are systematically associated

with social advantage/disadvantage. Health inequities systematically put populations who are already socially disadvantaged (for example, by virtue of being poor, female, or members of a disenfranchised racial, ethnic, or religious group) at further disadvantage with respect to their health. According to the WHO working definition equity in health means, in ideal

conditions, that everybody ought to get the same opportunity to reach his or her own full

health potential, thus nobody ought not to be handicapped doing this, if only we can do it (Braveman, Gruskin, 2003).

While equity and equality are distinct, the concept of equality is indispensable in operationalising and measuring health equity. Equity in health means equal opportunity to be healthy, for all population groups. Equity in health thus implies that resources are distributed and processes are designed in ways most likely to move toward equalizing the health outcomes of disadvantaged social groups with the outcomes of their more advantaged counterparts. This refers to the distribution and design not only of health care resources and programs, but of all resources, policies, and programs that play an important part in shaping health, many of which are outside the immediate control of the health sector.

Awareness of the need for greater clarity about the definition of health equity has arisen in the context of a recently proposed approach to the measurement of health inequalities that does not reflect how health is distributed across different social groups. Not all health inequalities necessarily reflect inequity in health, which implies unfair processes in the distribution of resources and other conditions that affect health. Assessing health equity requires comparing health and its social determinants among more and less advantaged social groups. Without that information, we will be unable to assess whether policies and programmes are leading toward or away from greater social justice in health. (Braveman, Gruskin, 2003).

Box 8.1 Key points regarding equity in health

• A definition of equity in health is needed that can guide measurement and hence accountability for the effects of actions.

• Health equity is the absence of systematic disparities in health (or its social determinants) between more and less advantaged social groups.

• Social advantage means wealth, power, and/or prestige— the attributes defining how people are grouped in social hierarchies.

• Health inequities put disadvantaged groups at further disadvantage with respect to health, diminishing opportunities to be healthy.

• Health equity, an ethical concept based on the principle of distributive justice, is also linked to human rights.

Source: Braveman P, Gruskin S. Defining Equity in Health. J Epidemiol Community Health 2003;57:254–258

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8.1.1 Equity in Health and the Social Determinants of Health

“There are no conditions of life to which a man cannot get accustomed, especially if he sees

them accepted by everyone around him.” (Tolstoy, 1877)

We have become all too accustomed to premature death and disease and to the conditions that give rise to them. But much of the global burden of disease and premature death is avoidable, and therefore unacceptable. It is inequitable. Health equity has two

important strands:

• improving average health of countries and • abolishing avoidable inequalities in health within countries.

In both cases – average health of countries and distribution within countries – the aim should be to bring the health of those worse off up to the level of the best.

Traditionally, societies have looked to the health sector to deal with its concerns about health and disease. Certainly, maldistribution of health care – not delivering care to those who most need it – is one of the social determinants of health. But the high burden of illness responsible for appalling premature loss of life arises in large part because of the conditions in which people are born, grow, live, work, and age – conditions that together provide the freedom people need to live lives they value.

Poor and unequal living conditions are, in their turn, the consequence of deeper structural conditions that together fashion the way societies are organized – poor social policies and programmes, unfair economic arrangements, and bad politics. These ‘structural drivers’ operate within countries under the authority of governments, but also, increasingly over the last century and a half, between countries under the effects of globalization. This toxic combination of bad policies, economics, and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible. Daily living conditions, themselves the result of these structural drivers, together constitute the social determinants of health.

Putting these inequities right is a matter of social justice. The right to the highest attainable standard of health is enshrined in the Constitution of the World Health Organization (WHO) and numerous international treaties. But the degree to which these rights are met from one place to another around the world is glaringly unequal. Social injustice is killing people on a grand scale.

Figure 8.1 Three principles of action to achieve health equity. Source: World Health Organization. Comission on Social Determinants of Health. Closing the gap in a generation. Health equity through action on

the social determinants of health. Geneva: WHO, 2008b.

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8.2 EQUITY I� HEALTH CARE

8.2.1 Horizontal Equity

Horizontal equity is peer-to-peer comparison for identical needs. It could be exercise for each stage of systemic process of health care for

• the entry • the process • the exit

The criteria for horizontal equity

1. Equal access for equal needs. For example the same time of waiting for the admission to hospitals for patients with the same illness.

2. Equal costs for needs. For example the same food price for equal need. 3. Equal consumption of service for equal need.

For example the same time of medical treatment for the patients with same illness. 4. Equal reduction of inequalities, which are taken on comparable base. For example the comparison of mortality or morbidity, which has been standardized

according to sex and age. Leeman talks about equal quality of health care too. This would require that medical methods are standardized for each type of health need. It is not easy to fulfill this condition because there is a lot of variability in clinical practice and this phenomenon is not researched sufficiently. The introducing of norms should be the result of universal analysis, based on the study of effects of all alternative methods (Holcik, Zacek, Koupilova, 2002). 8.2.2 Vertical equity

Vertical equity is related to antinomy: ill – healthy, old – young, poor – rich, grave illness – banal illness, substantial risk – trivial risk. The criteria for vertical equity

1. Unequal method – like the solution in case of unequal need.

For example different conception in health care for diabetes and cancer. 2. Economical inequality and ability to pay for services.

For example the payment by the level of the income, or employer’s progressive taxation.

Vertical equity asks the question about the extent to which the people, who are unequal biologically, should be treated differently. There are big problems connected with financial equity, which considers the capability of payment for the health care services. It is ethically desirable, that society should be eliminating barriers, which are an impedimentmto the socially weak classes in access to necessary health care. According to Gottschalk, there are four parallel goals for a solution of this social problem from the point of view of equity:

a) to specify effective and sufficient levesls for the health care consumption, b) to separate the risks from the results of the illness for the entire population, c) to separate the risks throughout the duration of human life, d) to divide the sources by need, which considers the financial situation as well as health.

Speedy and unstoppable growth of the health care costs and its complexity lead many theorists to the claim of central adjustment in spite of private sector’s extensiveness and to the idea of selective reduction of services. According to Callahan health care equity could be reached only by radical change of accepted values and priorities, particularly giving up

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illusory of never-ending possibility of medical technology. Equity can be reached on the following conditions:

• The basic (sufficient) health care will be provided by public and state institutions for citizen (mostly within primary health care).

• In serious cases, reasonable but limited individual medical care will be offered by the state, the insurance companies and public health symmetry principle, which will take into consideration social goals too.

• The central health authority are still striving so as significantly smaller part of the health care was given to none of significant social groups ( particularly to the elderly and otherwise disadvantaged people).

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9 HEALTH A�D HUMA� RIGHTS

9.1 CO�CEPT OF HUMA� RIGHTS

(Source: The Right to Health: a Resource Manual for �GOs, J. Asher) Human rights, as part of international law, are rights that every human being

possesses, irrespective of race, religious or political beliefs, legal status, economic status,

language, color, national origin, gender, ethnicity, etc. In other words, human rights are accorded to every human being. They apply to all individuals and groups on the basis of equality and non-discrimination. Even if they are not always honored in fact (de facto), everyone is entitled by international law (de jure) to enjoy benefits of human rights. A fundamental aspect of human rights is that they protect human dignity and integrity. They are based on generally accepted principles of equality and justice and, in this way, protect individuals and groups from elementary forms of injustice. Human rights belong to all and must never be regarded as a favor, gift, or privilege conferred by the state or by any organization or individual. Another basic feature of human rights is that they regulate relationships between the state and individuals or groups. Human rights are claim rights. This means that the rights of one party impose a corresponding duty on another party (or parties) to protect those rights. Human rights therefore create obligations, usually on governments. These obligations correspond with the entitlements to rights of individuals and groups. Human rights require minimum standards of legal and administrative practice that must be followed and enforced by governments if individuals are to enjoy their fundamental rights. There is, furthermore, a duty on the part of governments not to obstruct any person’s ability to claim his or her rights. Obstructing can mean either action or inaction — in other words, by actively preventing someone from exercising a right or by failing to take the necessary action to ensure that the right can be exercised. Human rights place a particular emphasis on the protection of individuals and groups that are vulnerable or otherwise disadvantaged, as they are most likely to suffer from discrimination and deprivation. Examples include most women, and particularly adolescent girls, in developing countries; indigenous peoples; refugees; asylum seekers; minorities; migrant workers; and children. Human rights are stated as being interrelated, interdependent, and indivisible. What

does this mean? It means that each right depends on, and connects with, others and each human right gives added meaning to the others. The right to life, for example, cannot be conceived without rights to food, shelter, clean water, freedom from torture, etc. This ‘interconnectedness’ reflects the complex variety of overlapping needs and situations that people all over the world face throughout their lives. All human rights are essential to preserving the dignity, security and survival of individuals, and to ensuring that every person is treated with decency and basic elements of respect. Human rights can and should be claimed. Sometimes, the relevance of human rights is questioned because the necessary national legislation and/or enforcement procedures are not in place everywhere to allow all human rights to be protected and enforced by courts of law. But this does not mean that human rights are irrelevant. It simply underlines the importance of demanding and working for their recognition and enforcement. The relevance of human rights is reflected in the fact that the international community has agreed upon and accepted them. As a result, it has included them in a body of international law that affirms their legitimacy and defines them as legal entitlements which

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every individual possesses. In practice, the universal recognition and implementation of human rights requires a long, ongoing process to which many parties must contribute. Human

rights in practice means the creation of conditions where human rights can be claimed and enjoyed, and where violations of them exposed, condemned and rectified. (The Right to Health Resource Manual, pp. 7-8) 9.1.1 Difference Between Medical Ethics and Human Rights Obligations

It has long been recognised that sick and disabled persons are vulnerable to exploitation in their anxiety to obtain relief from pain and suffering, and that they need to be protected from unscrupulous or incompetent healers. The earliest attempts to deal with this problem came about as the result of the development, a long time ago, of the principles of medical ethics. The term ‘ethics’ connotes relationships and the purpose of those principles is to regulate the relationship between the healer, who is in a position of power and privilege, and the patient, who is in a position of trust and dependence on the healer.

It is by following the principles of medical ethics in their professional practise that health professionals should be able to feel confident that they are protecting the rights of their patients. But this is by no means always the case today. It is important, therefore, to understand the differences between ethical obligations on the one hand and human rights obligations on the other. Human rights obligations are directed primarily at governments in respect of rights to which their citizens are entitled, (and therefore own), whereas ethical obligations are directed primarily at the conduct of medical and other health professionals during their professional practice towards those with whom they come into contact in a professional relationship, mainly their patients, but also their colleagues and other members of the community. (The Right to Health Resource Manual, p. 142-143) 9.1.2 International Human Rights Laws and �orms

The international community has developed a number of human rights instruments setting out the various principles and norms which constitute the fundamental rights that individuals everywhere should be entitled to enjoy. What is the nature of their legal status? Those that are referred to as declarations, principles, guidelines, standard rules and

recommendations have no binding legal effect. They are the result of an international consensus or agreement and provide practical guidance for states on their conduct. Their value lies in their recognition and acceptance by a large number of states and, even without binding legal effect, they can be seen as declarations of broadly accepted principles within the international community. They must be distinguished from those international treaties that are referred to as covenants, protocols or conventions, all of which are legally binding on states that ratify or accede to them. Treaties adopted within the United Nations system are open for signature and ratification by all UN member states, while those adopted within the framework of regional organizations depend for their acceptance on membership in the organization concerned. The first international codification of human rights took place in the aftermath of World War II, with the adoption by the United Nations’ General Assembly of the Universal Declaration of Human Rights (UDHR) on 10 December, 1948. This document was intended to set a common standard of achievement for all nations. The rights and freedoms contained in the UDHR establish guidelines to which all UN member states should aspire and adhere, and which people everywhere should strive to achieve. The UN has continued ever since to emphasise the importance of the UDHR as a source for human rights among its member nations. Although declarations are not legally binding documents under international law, the UDHR is seen to be exceptional because of its universal acceptance. It therefore remains a

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valid standard and is widely regarded as carrying the status and authority of international

customary law. In 1966 the UN General Assembly adopted two treaties to strengthen the UDHR by converting the principles it contains into legal obligations for the states that ratify them, namely the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). These covenants and the UDHR are referred to collectively as the International Bill of Rights, from which has evolved most of the basic principles contained in the body of international human rights law today. The International Bill of Rights contains a broad definition of human rights together with an affirmation that its provisions apply universally. For these reasons, it is generally considered to be the most important set of instruments dealing with international human rights law. (The Right to Health Resource Manual, pp. 7-8) The ICESCR was the first human rights treaty to require states to recognize and realize progressively the right to health, and it provides key provisions for the protection of the right to health in international law:

1. The States parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

2. The steps to be taken by the States parties … to achieve the full realization of this right shall include those necessary for:

a. The provision for the reduction of the still birth rate and of infant mortality and for the healthy development of the child;

b. The improvement of all aspects of environmental and industrial hygiene; c. The prevention, treatment and control of epidemic, endemic, occupational

and other diseases; d. The creation of conditions which would assure to all medical services and

medical attention in the event of sickness. (The Right to Health Resource Manual, p. 18)

9.2 THE RIGHT TO HEALTH: A TOOLKIT FOR HEALTH

PROFESSIO�ALS

(Authors: J. Asher, D. Hamm, J. Sheather; Publishers: BMA, Commonwealth Medical

Trust, IFHHRO) 9.2.1 The Aims of the Toolkit

The right to the highest attainable standard of physical and mental health is a fundamental human right, protected by international law. This toolkit lays out what this right means for health professionals and their associations. Although the right to health is legally grounded, this toolkit is not about the law. It shows the practical meaning and significance of the right to health in the day-to-day work of health professionals and their associations. It gives concrete examples based on current health practice. Many health professionals are already working in ways that promote the right to health. Developing an understanding of the right to health does not entail the adoption of a different way of working. The right to health is a practical tool for health professionals that sets their day-today practice within a universally accepted framework of values. The right to health does not ask governments to commit resources they do not possess to the provision of health care. It asks those who make decisions that affect people’s health – be they health professionals, private corporations or public bodies – to promote and protect health, and to understand and to justify the effects of their decisions.

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9.2.2 What is the Right to Health?

�ot a ‘right to be healthy’ The right to health is not a right to be healthy. The state cannot provide people with

protection against every possible cause of ill health or disability such as the adverse consequences of genetic diseases, individual susceptibility or the adoption of unhealthy lifestyles. Nor is it a limitless right to receive medical care for any and every illness or disability. It is a right to the enjoyment of a variety of facilities and conditions that are necessary for good health. These can be divided into two basic components: those related to health care and those related to general living conditions affecting health, such as safe water, food, sanitation and shelter. More specifically, the right to health can be understood as a right to an effective and integrated health system, encompassing health care and other determinants of health.

A broad concept of health The right to health recognizes that both health care and social conditions are important

parts of health. These include factors such as gender, age differences and resource distribution, poor sanitary conditions as well as events that may damage health such as violence and armed conflict. The right to health is related to other human rights such as the right to food, housing, education, and safe working conditions.

What does a human rights approach to health imply?

Human rights are particularly concerned about disadvantaged individuals and groups. In the UK context for example, they highlight the needs of those who have suffered discrimination such as people with mental health problems, asylum seekers and those in custodial settings. Take immunization programs. In a human rights framework health immunization is not simply a necessary medical requirement for children and a responsible public health measure; it is a right of all children, with corresponding government obligations. A government’s immunization program cannot therefore be bargained away because of financial constraints without overwhelming justification. The bearer of rights, in this case the child, is the focus. A human rights approach ensures that the necessary resources are given to those who have the greatest needs. It exposes situations where public funds are being used to build yet more hospitals in large cities, or where expensive equipment is being purchased for elective procedures that benefit only the wealthy or urban populations, while rural populations or vulnerable groups are denied even the minimum standard of health care.

Key elements of the right to health

Accountability By signing international human rights treaties that affirm the right to health, a state

agrees to be accountable to the international community, as well as its citizens, for the fulfillment of its obligations. Participation

The right to participate in decision-making is a guiding principle of all human rights. A human rights approach to health emphasizes that good health services can only be achieved if people participate in their design and delivery. The involvement of communities has been shown to increase the likelihood that the needs of the community will be met more effectively and thus contribute to achieving better health. Participation helps ensure that the health system is responsive to the particular health needs of disadvantaged groups.

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Standards of health care services

The right to health imposes four essential standards on health care services: availability, accessibility, acceptability and quality. • Availability of services requires that public health and health care facilities are available in

sufficient quantity, taking into account a country’s developmental and economic condition. The health system has to be accessible to all.

• Accessibility has four overlapping dimensions: o �on-discrimination: health facilities, goods and services must be accessible to all,

especially the most vulnerable. o Physical accessibility: health facilities, goods and services must be within safe

physical reach of all parts of the population. o Economic accessibility (affordability): health services must be affordable for all.

�OTE: Equity refers to the obligation of the government to ensure that such services, whether they are publicly or privately provided, are affordable to everyone and that poorer households are not burdened disproportionately with health expenses as compared with richer households. (Asher, p. 38)

o Information accessibility: accessibility includes the right to seek, receive, and impart information concerning health issues. For example, governments must ensure that young people have access to sexual and reproductive health education and information presented in an unbiased manner.

o Acceptability requires that health services are ethically and culturally appropriate, i.e. respectful of individuals, minorities, peoples, and communities, and sensitive to gender and life-cycle requirements.

o Quality requires that health services must be scientifically and medically appropriate and of the highest quality.

‘Costing’ the implementation of the right to health

Many governments argue that fulfilment of the right to health is costly. But to a large extent it involves no more than ensuring that available resources are distributed as effectively as possible and that people do not suffer adverse health effects from discrimination. Even on a small health budget, for example, countries can design health systems to improve access to services for poor, vulnerable, or otherwise disadvantaged groups.

9.2.3 What does the Right to Health Mean for Health Professionals and

their Associations?

Professional associations are a diverse group of organizations. Likewise health professionals work in a variety of contexts, and differ in their role and influence. Not everything outlined here will be applicable either to every health professional or to all professional associations. In some cases, it might be more profitable for health professionals to work with development or health charities, or other nongovernmental organizations to further human rights goals. While some of the recommendations given below can be put into effect immediately, others will remain aspirational. Nevertheless, health professionals come into contact with human rights-related issues in a variety of contexts ranging from everyday clinical practice to participation in the shaping of health policies at the national and international levels.

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A human rights-based approach to professional practice

Human rights impose duties on both governments and those in their direct employment. Health professionals working in public health institutions share a direct responsibility to realize the right to health. The most effective way for the majority of health professionals to fulfill their obligations under the right to health is to ensure that they provide the highest possible standard of care and treatment in a way that respects the fundamental dignity of each of their patients. This involves a number of interrelated factors including:

• Being honest, polite and respectful to all patients without discrimination • Ensuring professional skills are maintained to the highest possible level • Respecting the autonomy and dignity of patients and their right to self-

determination • Providing up-to-date and relevant information without discrimination to support

patients’ decision-making • Respecting patient confidentiality • Treating patients to the highest ethical standards However, there are several types of human rights abuse that may involve the direct

participation of health practitioners. These include: some forms of torture, administration of the death penalty, facilitating cruel and inhuman physical punishment, forced feeding, sedation against the will of the person in question, illegal organ trade, female genital mutilation and other harmful traditional practices, forced sterilization and other coercive reproductive health practices.

Another area that involves a heightened risk of human rights abuse is scientific experimentation involving human subjects, and in particular experimentation that involves members of vulnerable groups. While medical research and clinical testing is indisputably a force for the good, it can be misused and should be approached with care, ensuring that relevant national and international ethical codes are respected.

Some professional associations, and some medical academics, may be in a position where they can influence the medical curriculum. Where possible they should try to promote

human rights education and consider whether they can: • Examine the curricula of medical and other health professional training schools,

together with the educational requirements of licensing bodies for granting a licence to practice, to identify whether they include appropriate instruction in medical ethics and human rights;

• Advocate, in co-operation with professional associations and licensing bodies, the adoption of an ethical and human rights approach to health care in the training of health professionals at all levels;

• Include within the curricula of medical schools, a component on the legislative framework of the right to health.

Reacting to human rights violations perpetrated by others Some health professionals have privileged access to sensitive information about the

conduct of public authorities such as governments, military or law enforcement officers or prison personnel. This provides a valuable opportunity to promote human rights. Where possible, professional associations should work to ensure that health professionals are aware of the channels through which they can draw attention to the information they have identified and documented. For example, familiarity with ombudsmen institutions, national human rights institutions, the UN system of treaty body reporting, and the work of the UN Special Rapporteurs is essential in this regard. Due respect must always be accorded to confidential information relating to patients. In their regular practice, health professionals may also

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encounter evidence of occasional or systemic discrimination that violates the right to health. Such patterns of discrimination should be documented and reported to appropriate authorities.

A human rights-based approach to participating in the management of health care

systems and shaping of health policies Some health professionals, individually and as members of professional associations,

work as advisers in the organization and delivery of health services. Where possible, it is important that health professionals work with governments to ensure that these services are respectful of human rights. They can do this both as partners and as watchdogs of governments. Action could include reviewing existing legislation, policies and practices and helping to shape health policies at the national level. Health professionals can similarly give valuable input to the human rights treaty monitoring process, either by contributing to government reports to the UN bodies or by presenting or contributing to a shadow report. 9.2.4 What does the Right to Health Mean for Governments?

Health professionals working with the right to health also need to be familiar with the obligations that it imposes on governments. The right to health, like all human rights, imposes three levels of obligations on governments. These are the obligations to respect, to protect, and to fulfill.

The obligation to respect implies a duty of the state not to violate the right to health by its actions.

• The state must refrain from denying or limiting equal access for all persons, including prisoners, detainees, minorities, asylum seekers and illegal immigrants;

• The state must refrain from censoring, withholding or intentionally misrepresenting accurate health-related information, including sexual health education and information.

The obligation to protect implies a duty of the state to prevent violations of the right to health by others. It must take measures which prevent third parties from interfering with or violating the right to health.

• The government must introduce and enforce appropriate controls for the marketing of medical equipment and medicines by third parties;

• The government must ensure that medical practitioners and other health professionals meet appropriate recognized standards of education, skill and ethical codes of conduct.

The obligation to fulfill means that governments must act in order to ensure that rights can be enjoyed.

• The government must focus on rectifying existing imbalances in the provision of health facilities, goods and services. For example, it should allocate sufficient public resources to the most deprived regions in the country, in particular to the poor and otherwise vulnerable and disadvantaged groups.

• The government must promote activities that benefit good health and ensure the dissemination of appropriate information.

Immediate and progressive obligations Given the differences between countries, fully realizing the right to health will need

variable amounts of time and resources. The most appropriate measures to implement the right to health will also vary from one country to another. While international law sets out the various state obligations, each government must determine for itself which measures are the most suitable for complying with these obligations. However, beyond a certain point the same basic minimum standards must apply everywhere. These are the immediate obligations.

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Governments are also under an obligation to put in place policies to progressively realize the right to health. As more resources are made available, so governments have to fulfill more of their responsibilities.

Core obligations

Core obligations are intended to ensure that people everywhere are provided with, at the very least, the minimum conditions under which they can live in dignity; enjoy the basic living conditions needed to support their health; and be free from avoidable mortality. Core obligations require immediate and effective measures and are not subject to progressive implementation.

In the case of health care, governments must provide: • immunization against major infectious diseases; • measures to prevent, treat and control epidemic and endemic diseases; • essential medicines, as defined by WHO’s Action Programme on Essential

Medicines; • reproductive, maternal (pre-natal and post-natal) and child health care; • essential primary health care as described in the Alma-Ata Declaration;10 • access to health facilities without discrimination; • equitable distribution of all health facilities, goods and services. In the case of underlying determinants of health, governments must provide: • access to the minimum amount of food that is sufficient, nutritionally adequate and

safe, to ensure their freedom from starvation and malnutrition; and • access to basic shelter, housing and sanitation, together with an adequate supply of

safe and potable water.

In the case of health education and information, governments must provide: • education and access to information about the main health problems in the

community, including methods of prevention and control; and • appropriate training for medical and other health professionals, including education

in health and human rights.

Governments must also adopt and implement a national public health strategy and

action plan, based on epidemiological evidence, which takes into account the health concerns of the whole population.

International obligations arising from the right to health

International human rights law makes it clear that the responsibility of states includes international assistance and co-operation. This is required where the fulfillment of government obligations is beyond the scope of available resources, and the international community must assume some responsibility, for example by contributing to development aid or following responsible trade policies. Depending on the availability of resources, developed countries should promote access to essential health facilities, goods and services in resource-poor countries and provide the necessary aid when required. In all cases of international assistance and co-operation, priority must be given to the fulfillment of core obligations arising from the right to health.

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9.2.5 Summing up

Basic consequences of a human rights approach to health • Increased accountability of governments for health; • Increased attention to the health needs of the poor and otherwise vulnerable and

disadvantaged groups, and to the correction of unacceptable imbalances between the health status of different population groups;

• Focus is placed on achieving and maintaining an effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to local and national priorities, and accessible to all;

• More participatory approaches to the provision of health services and the determinants of health;

• Governments cease imposing retrogressive measures in health related legislation and budgetary and administrative practices;

• Governments honour concrete obligations to provide immediately for the minimum standards that are essential to enjoyment of the right to health (i.e. core obligations);

• Governments accept that they have obligations to take progressive steps towards realizing the right to health and immediately take steps to set the stage for progress. This includes the setting of goals (indicators) and targets that will demonstrate progress;

• Governments must comply with duties regarding international assistance and co-operation, both individually as providers of international aid and as members of international organizations;

• All members of society, including health professionals, have responsibilities regarding the realization of the right to health.

The material „The right to health: a toolkit for health professionals“ was published in an edited version with the permission of International Federation of Health and Human Rights Organisations.

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10 TECH�IQUES A�D I�STRUME�TS I� SOCIAL MEDICI�E A�D

PUBLIC HEALTH RESEARCH A�D PRACTICE

10.1 QESTIO��AIRES

Definition: Questionnaire is the list of questions drafted in accordance to certain rules which the members of a particular group answer in written form. The questionnaire method is a commonly used empiric research method used to obtain information about opinions, attitudes, interests, etc. Advantages: Disadvantages:

1. obtains a large amount of 1. Impossibility to verify the information in rather short time truth of answers 2. anonymity 2. construction and evaluation is rather time – consuming

10.1.1 Design of a Questionnaire

The aim of the questionnaire designer is to communicate with a potential respondent using the medium of the questionnaire. It is his or her responsibility to ensure that the question can be fully understood and that the respondent is encouraged to reciprocate in this communication process. For this it is important that the researcher understands something of the nature of the communication process and thus appreciates the task he or she is setting for the respondent.

Responding is not a simple stimulus – response process but rather a complex procedure by which the respondent selects a small amount of his or her total information to become questionnaire data. Each question will lead the respondent in a particular direction causing him or her to focus on some aspects of total experience.

10.1.1.1 Questionnaire Content

The content of a questionnaire is generally designed to investigate a minimal amount of an individual’s total experience which will provide sufficient information concerning the problem under consideration. This limited selection of a respondent’s experience will mean that a good deal of information concerning the individual will be lost. One must consider also the information which the questionnaire will not pick up. Pre-testing of questionnaires by administering to a sample population, where the sample is representative of potential respondents, may indicate where additional information is required. Obviously the greater the number of topics that the questionnaire can cover, the less information will be omitted: but on the other hand there are the disadvantages that a long questionnaire will be difficult to process and it may also make the respondent reluctant to give full responses so that information loss will then occur through respondent fatigue. Information loss may be reduced if the respondent is permitted to add personal comment concerning information which he or she feels is important and has not been adequately covered by questionnaire.

10.1.1.2 The Construction of Questionnaire Items

The writing of questionnaire items should begin with the selection of a question type. This is important for it will influence the type of data which the questionnaire will yield. Broadly speaking two main questions types may be defined, the “open” and the “closed”.

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a) Open questions - they don’t suggest any specific response. The respondent is allowed to answer freely, in his own words, and his response is recorded in full. Example: “Have you received any medical treatment in the past year?” or

“What medical treatment have you received in the past year?”

The second question is more “open” in that it can be expected to generate a larger variety of positive answers. Both questions require the respondent to frame his or her own responses using his or her own vocabulary, thus permitting the expression of individual experience. The open question may, therefore, elicit information and areas of interest not predicted by the investigator.

b) Closed questions – they require the respondent to choose his or her answer from a given, limited selection. There are various types of closed questions: • Dichotomous questions represent a response choice of alternatives such as Yes/No,

High/Low. A third category of “Neither”, or “Undecided” or “Don’t know” is sometimes included, although this category is given no statistical significance unless so many responses fall into this category that it is obvious that the questionnaire is not useful.

Example: “Do you have any pain or discomfort in the chest?”

Yes Fo

“Is your interest in foreign languages”

High Low

• Multiple choice questions can have various forms: Item check list: consists of a statement of the problem, followed by a list of possible answers. Example: “Have you taken any of the following in the past year?”

Codein, darvon, penicillin, Demerol, morphine

Alternative statement:

Example: Symptoms of fatigue may be considered to lie on a continuum

represented by the following statements:

1) I never get tired

2) I only get tired after a very hard day

3) I generally feel a little tired by the end of the day

4) I always feel very tired by the end of the day

5) I feel very tired most of the time

Rating scales: a special form of the multiple choice question in which respondent quantifies his or her response.

Example: Rate your present health

bad 1…2…3…4…5…6…7 very good

Problems concerning the question wording: the wording of items may present considerable problems for the questionnaire designer as he or she must seek a balance between two needs of two interests. On one hand there are the medical personnel who will make use of the data obtained by the questionnaire for diagnosis or research. They require precise statements of the problem and symptom entities which comprise it. On the other hand, there is the respondent who requires that items are written in simple non-technical language. Sophisticated terminology is not the only barrier to communication. The use of terms which are vague or ambiguous such as “occasionally” or “often” should also be avoided. Such words should be replaced by more precise words. For example: “Have you, in the past six months two or more had nose bleeds which were not caused by an injury or cold?”

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Some other important aspects of questionnaires design: • Question length: a well-worded questionnaire is grammatically simple avoiding

where possible technical terms, adjectives, adverbs or vague descriptive terms. Each item contains only one idea.

• Question sequence: the items of questionnaire should follow a logical sequence resembling as far as possible the sequence which the respondent might be expected to follow. A common approach to question sequence is to use the technique of the item “funnel”, that is, to ask general questions first followed by successively more detailed and specific questions. Items at the beginning of a questionnaire should be as neutral as possible while also appearing relevant to the subject of inquiry.

• Bias: the intrusion of any unplanned or unwanted influence. It may occur firstly through inappropriate wording of questions, such as the use of leading questions and loaded words as previously described. Alternatively it may result from a failure to state all possible response alternatives as in the following example:

“Do you prefer to be examined by a doctor of your own sex?”

It would be more impartial to have asked: “Would you prefer to be examined by a male or by a female doctor or you have no

preference towards either?

• Halo-effect: can be positive or negative. A positive halo-effect is a tendency on the part of the respondent constantly to over-estimate qualities which he or she feels are desirable due to an over all feeling of approval of the person to whom the questions refer. Conversely, a person who is not generally well liked might be rated poorly on all characteristics. This may be termed “negative halo-effect”. For example, a respondent may continually overstate the effectiveness of certain treatment if prescribed by a doctor whom the respondent really likes (positive halo-effect).

• Response set: a tendency for a respondent persistently to respond in a certain way, irrespective of the content of the question (for example always answer with “yes”). This problem can be overcome by the use of dichotomous questions and varying the position where the appropriate response was to be made. For example:

“Do you get a pain or discomfort in the chest after having a big meal?”

don’t know/yes/no

“Do you get a pain or discomfort in the chest in bed at night?”

no/don’t know/yes

• Layout: the questionnaire should begin with an introduction for the respondent, written on a separate page to allow him or her to read it before glancing at the questions. The introduction should include the name of the relevant organizing body; the name of a professional organization is usually more acceptable than the names of individuals. Printing allows the use of different sizes and styles of type to distinguish questions from instructions, etc. Questions should be clarified by the use of lined insets to help guide the interviewer or respondent through the form so that he or she will not write responses in the wrong places or omit subsidiary questions. The paper on which the questionnaire is written should be strong as it will receive a great deal of handling. Page size should be selected so that the questionnaire folds easily into a standard size envelope should it need to be posted.

It must be added that in designing a questionnaire one cannot give too much emphasis on the importance of rigorously pre-testing the forms. The objective is simple one: to achieve the layout that reduces to minimum errors by interviewers, respondents, coding clerks, or key punch operators.

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10.1.2 The Evaluation of a Questionnaire

For potential usefulness questionnaire must be assessed in terms of two criteria: validity and reliability. Validity

Validity refers to the efficiency with which a measuring instrument measures what it purports to measure, and as such may be seen as a function of three variables:

• Relevance: referring to whether the questionnaire obtains the type of information it was design to obtain. • Completeness: referring to the extent to which a questionnaire has collected all relevant information. • Accuracy: which is a measure of the reliance that can be placed upon the response to each question. It is an indication of the proportion of times that an answer to a question will be correct.

Reliability Reliability is a measure of the questionnaire’s ability to distinguish the extent to which

a variable apparently fluctuates as a result of errors measurement as opposed to real changes in the object of measurement itself. Basically there are two types of reliability: internal consistency and repeatability.

• Internal consistency: referring to the consistency of answers to items in the Questionnaire • Repeatability: the extent to which the questionnaire provides the same results on the same subject on two or more occasions, with the same or

another observer, the subject of the test being in the same state of health.

Item assessment

Questionnaire must not only be evaluated as a whole, but individual items must also be assessed in terms of their relative contribution. Item assessment takes into account the fact that the content of each item is not of equal value as an index of health status in that a positive response to one item in a questionnaire may be far more significant to the investigator that a positive response to another. The discrimination of items in terms of their potential significance may be made by, for example:

a) Reference to clinical experience. For example, distinguishing “major” and “minor” symptoms on the assumption that items recorded in the history of the presenting complaint would be more important than those in the clinical review.

b) Value judgments by panels. For example, the relative importance of individual items may be determined by a series of value judgments given by a group of physicians.

c) Reliability of individual items. For example, differentiation of the symptoms of medical history by test-retest repeatability for each item.

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10.2 OBSERVATIO�AL TECH�IQUES

Definition: Observation is an intentional perception which is aimed at whole complex of educational phenomena. It is realized by means of our senses and can be improved with help of various aids and instruments. Types:

• short and long term Short term observation serves the teacher as a help to his or her daily work (it is also called occasional observation)

Long term observation is intentional systematic following of a large amount of facts which could have caused some problem. • direct and indirect

Direct observation: the research worker is in direct contact with the observed person, and he or she observes and records his or her reactions. Indirect observation: observer follows the reaction of observed persons by means of statements of other persons.

• partial and total Partial observation is aimed at one particular problem Total observation follows the most important problems of educational process.

Instruments:

• written report • record • tape –record • photograph • video-recordings • films

10.3 I�TERVIEW

Definition: Interview is an explorative research method. The interview tries to obtain more detailed or personal information from the respondent by means of various types of questions. Types: According to the number of participants

• Individual

• Group

According to the types of questions • Standardized

• �on standardized

• Combined

Both styles of interview have their advantages and disadvantages. The standardized interview has the advantage of consulting a standard instrument of measurement which allow for the comparison of information derived from various sources and gives good results on test – retest repeatability. However, reliability does not necessarily imply validity and the greater adaptability of the non standardized procedure might in some circumstances produce more valid information. According to the method

• Obvious: The respondent is informed about his or her role the research as well as about the character, objectives and content of the particular research.

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• Hidden: the respondent does know anything about the purpose and aim of the interview. It seems as a free talk between two persons.

10.3.1 Interviewer

Interviewer – respondent interaction

The quality of the relationship which is developed between the interviewer and respondent is important as it may encourage the respondent to talk more honestly and openly of his or her experience or alternatively cause him or her to conceal or distort his or her experience. Some characteristics of good interviewer – respondent relationship: The need of warmth and responsiveness, interest in and acceptance of the respondent, permissiveness of expression, and freedom from pressure and coercion. The selection and training of interviewers

Differences in results obtained by interviewers may be attributed to: a) Variations in the personal characteristics of the interviewers b) Deviations by the interviewer from the standardized procedure.

The first problem must be dealt with by careful selection of interviewers, and the second by careful training of interviewers.

Personal characteristics of interviewer

Sex: Various studies identify the tendency for respondents to formulate their opinions in accordance with the sex of the interviewer. It would thus seem advisable to use interviewers of the respondents’ own sex where possible, particularly when the information sought is of a very personal nature. However the influence of the interviewer’s sex on questionnaire data should be examined by protesting and not simply assumed.

Age: The appropriate age for an interviewer is another factor to be considered. It seems that the quantity and validity of interview data is greatest when interviewer and respondent are approximately the same age. This would seem appropriate in that to some extent persons of the same generation would be more familiar with each others experience and percepts. However, such a situation is not always feasible as, for example, in the interviewing of children and elderly persons. An age range for interviewers of 25 to 45 years seems desirable.

The general appearance: Many of the decisions made during everyday life concerning other persons are based upon immediate impression. A respondent may, therefore, regard as untrustworthy an interviewer who appears irritable, impatient or condescending.

Social status: Class differences and ‘social distance’ may influence the communication process. Resulting from some studies lower-class respondents were more pleased to be asked to discuss their problems and opinions than upper-class respondents who tended to feel that they had little to gain by talking to an interviewer. However, class differences may give rise to other reactions. A lower-class respondent may resent the authority assumed by the interviewer or may distort his responses if he feels the interviewer is in a position of influence.

Attitude towards the questionnaire study: An interviewer who is pessimistic from the beginning as to the success of his interviews may well be unable to produce sufficient data. It has been also found that in many cases that interviewers tend to elicit replies similar to their own views.

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10.3.2 Standardization of Interview Procedure

Failure by an interviewer to adhere to the standardized administration procedure has been shown to constitute a common source of error in studies using administered questionnaires. A prime source of interviewer error arises when the interviewer introduces subsidiary questions or probes to clarify the respondent’s initial replies. Probes formulated spontaneously by the interviewer may also be leading or loaded, or stress the interviewer’s attitude to the subject so influencing the response obtained. Interviewers’ expectations of the frequency distributions of the responses also affect the results obtained. Interviewers’ perceptions may be biased by their background or experience. Interviewer variation has also been demonstrated to occur as a result of faulty coding of responses.

Interviewer variation cannot be totally controlled, it can, however, be reduced by training. The means that should be employed in such training are:

1. Supervised practice interviews where observed faults can be pointed out and corrected.

2. Interpreting and coding responses from recorded interviews. 3. The need for strict standardization should be explained. 4. Interviewers should be warned of any foreseen difficulties. The initial training of interviewers is not sufficient to ensure a standardized procedure

because over time efficiency may wane and the interviewer may cease to uphold his or her initial standards. Obviously there is a need for some type of check to be made on the interviewer’s progress. The following methods may be used:

1. Observation of the interviewer from time to time in the process of administering the questionnaire.

2. Serial analysis of completed questionnaires - interviewer’s work is rated regularly, and upon the completion of each assignment errors are pointed out to interviewer.

3. Retraining sessions which check knowledge of administrative procedures and provide opportunity for fresh interviewer comparisons.

4. Re-interviewing of respondents by different interviewers and comparing results. The questionnaire form should be constructed in such a way that some of the questions

are logically interdependent. This provides a potential check on interviewer inattention or false reporting of answers.

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APPE�DICES

WORLD HEALTH ORGA�IZATIO�

The World Health Organization (WHO) is a specialized agency of the United

Nations (UN) that acts as a coordinating authority on international public health. The WHO's Constitution states that its objective "is the attainment by all people of the highest possible level of health". Its major task is to combat disease, especially key infectious diseases, and to promote the general health of the people of the world. Through its Constitution, WHO has a special mandate to promote closer cooperation for health development, both internationally and in its work to support individual countries.

WHO Constitution formally coming into force on the first World Health Day, (April 7, 1948), when it was ratified by the 26th member state. Jawarharlal Nehru of India had given an opinion to start WHO. Prior to this its operations, as well as the remaining activities of the League of Nations Health Organization, were under the control of an Interim Commission following an International Health Conference in the summer of 1946. The transfer was authorized by a Resolution of the General Assembly. Governance

The World Health Assembly is the supreme decision-making body for WHO. It generally meets in Geneva in May each year, and is attended by delegations from all 193 Member States. Its main function is to determine the policies of the Organization. The Health Assembly appoints the Director-General, supervises the financial policies of the Organization, and reviews and approves the proposed program budget. It similarly considers reports of the Executive Board, which it instructs in regard to matters upon which further action, study, investigation or report may be required.

The Executive Board is composed of 34 members technically qualified in the field of health. Members are elected for three-year terms. The main Board meeting, at which the agenda for the forthcoming Health Assembly is agreed upon and resolutions for forwarding to the Health Assembly are adopted, is held in January, with a second shorter meeting in May, immediately after the Health Assembly, for more administrative matters. The main functions of the Board are to give effect to the decisions and policies of the Health Assembly, to advise it and generally to facilitate its work.

The Secretariat of WHO is staffed by some 8000 health and other experts and support staff on fixed-term appointments, working at headquarters, in the six regional offices, and in countries. The Organization is headed by the Director-General, who is appointed by the Health Assembly on the nomination of the Executive Board. Structure

The WHO has 193 Member States, including all UN Member States except Liechtenstein, and two non-UN members, Niue and the Cook Islands. Territories that are not UN Member States may join as Associate Members (with full information but limited participation and voting rights) if approved by an Assembly vote: Puerto Rico and Tokelau are Associate Members. Entities may also be granted observer status: examples include Palestine (a UN observer), Vatican City (a UN non-member observer state) and Chinese Taipei (an invited delegation).

WHO Member States appoint delegations to the World Health Assembly, WHO's supreme decision-making body. All UN member states are eligible for WHO membership, and, according to the WHO web site, “Other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly.”

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The WHO Assembly generally meets in May each year. In addition to appointing the Director-General every five years, the Assembly considers the financial policies of the Organization and reviews and approves the proposed program budget. The Assembly elects 34 members, technically qualified in the field of health, to the Executive Board for three-year terms. The main functions of the Board are to carry out the decisions and policies of the Assembly, to advise it and to facilitate its work in general. Regional Offices

Uncharacteristically for a UN Agency, the six Regional Offices of the WHO enjoy remarkable autonomy. Each Regional Office is headed by a Regional Director (RD), who is elected by the Regional Committee for a once-renewable five-year term. The name of the RD-elect is transmitted to the WHO Executive Board in Geneva, which proceeds to confirm the appointment. It is rare that an elected Regional Director is not confirmed.

Each Regional Committee of the WHO consists of all the Health Department heads, in all the governments of the countries that constitute the Region. Aside from electing the Regional Director, the Regional Committee is also in charge of setting the guidelines for the implementation, within the region, of the Health and other policies adopted by the World Health Assembly. The Regional Committee also serves as a progress review board for the actions of the WHO within the Region.

The Regional Director is effectively the head of the WHO for his or her Region. The RD manages and/or supervises a staff of health and other experts at the regional headquarters and in specialized centers. The RD is also the direct supervising authority—concomitantly with the WHO Director General—of all the heads of WHO country offices, known as WHO Representatives, within the Region. The Regional Offices are:

• Regional Office for Africa (AFRO), with headquarters in Brazzaville, Republic of Congo.

• Regional Office for Europe (EURO), with headquarters in Copenhagen, Denmark. • Regional Office for South East Asia (SEARO), with headquarters in New Delhi, India.

North Korea is served by SEARO. • Regional Office for the Eastern Mediterranean (EMRO), with headquarters in Cairo,

Egypt. EMRO includes the countries of Africa, and particularly in the Maghreb, that are not included in AFRO, as well as the countries of the Middle East, except for Israel.

• Regional Office for Western Pacific (WPRO), with headquarters in Manila, Philippines. WPRO covers all the Asian countries not served by SEARO and EMRO, and all the countries in Oceania. South Korea is served by WPRO.

• Regional Office for the Americas (AMRO), with headquarters in Washington, D.C., USA. It is better known as the Pan American Health Organization (PAHO). Since it predates the establishment of WHO, PAHO is by far the most autonomous of the 6 regional offices.

The World Health Organization operates 147 country and liaison offices in all its regions. The presence of a country office is generally motivated by a need, stated by the member country. There will generally be one WHO country office in the capital, occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question.

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HEALTH21 - HEALTH FOR ALL POLICY FRAMEWORK FOR THE WHO

EUROPEA� REGIO�

Good health is fundamental to sustainable economic growth. Intersectoral investment

for health not only unlocks new resources for health but also has wider benefits, contributing in the long term to overall economic and social development. Investment in outcome-oriented health care improves health and identifies resources that can be released to meet the growing demands on the health sector.

The HEALTH21 policy for WHO’s European Region has the following main elements.

The one constant goal is to achieve full health potential for all. There are two main aims:

• to promote and protect people’s health throughout their lives; and • to reduce the incidence of the main diseases and injuries, and alleviate the suffering

they cause.

Three basic values form the ethical foundation of HEALTH21: • health as a fundamental human right; • equity in health and solidarity in action between and within all countries and their

inhabitants; and • participation and accountability of individuals, groups, institutions and communities

for continued health development.

Four main strategies for action have been chosen to ensure that scientific, economic, social and political sustainability drive the implementation of HEALTH21:

• multisectoral strategies to tackle the determinants of health, taking into account physical, economic, social, cultural and gender perspectives, and ensuring the use of health impact assessment;

• health-outcome-driven programs and investments for health development and clinical care;

• integrated family- and community-oriented primary health care, supported by a flexible and responsive hospital system; and

• a participatory health development process that involves relevant partners for health at home, school and work and at local community and country levels, and that promotes joint decision-making, implementation and accountability.

Twenty-one targets for health for all have been set, which specifically spell out the needs

of the whole European Region and suggest the necessary actions to improve the situation. They will provide the “benchmarks” against which to measure progress in improving and protecting health, and in reducing health risks. These 21 targets together constitute an inspirational framework for developing health policies in the countries of the European Region. HEALTH21 should be incorporated into the health development policy of every Member State of the Region and its principles should be embraced by all major European organizations and institutions.

The policy for “health for all in the 21st century”, adopted by the world community in May 1998, aims to realize the vision of health for all, which was a concept born at the World

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Health Assembly in 1977 and launched as a global movement at the Alma-Ata Conference in 1978. It sets out global priorities for the first two decades of the 21st century, and ten targets that aim to create the necessary conditions for people throughout the world to reach and maintain the highest attainable level of health. It is important to realize that health for all is not a single finite target. It is fundamentally a charter for social justice, providing a science-based guide to better health development and outlining a process that will lead to progressive improvement in people’s health.

Since it was introduced in 1980, health for all has provided a comprehensive framework for health improvement within the European Region of WHO and has had a major impact on health development. HEALTH21 builds on the collective experience of the European Member States with their regional health for all approach, which for the past 15 years has made “health outcomes” in the form of aspirational targets the cornerstone of policy development and program delivery.

Refining the previous 38 regional health for all targets in the light of past achievements and new challenges, HEALTH21 defines 21 targets for the 21st century. They are not meant as a prescriptive list, but together they make up the essence of the regional policy. They provide a framework for action for the Region as a whole, and an inspiration for the construction of targets at the country and local levels of health development. The present major revision, HEALTH21, gives effect to global health for all values, targets and strategies. It also reflects the Region’s ongoing health problems, as well as its political, economic and social changes and the opportunities they provide. HEALTH21 gives an ethical and scientific framework for decision-makers at all levels to assess the impact on health of their policies, and to use health to guide development action in all sectors of society. SOLIDARITY A�D EQUITY I� HEALTH

To foster stronger equity and solidarity in health development between Member

States of the Region and better equity in health among groups within each country

Target 1. Solidarity for health in European Region

Target 2. Equity in health

• It is imperative that public policies address the root causes of socio-economic inequities, and that fiscal, educational and social policies are designed to ensure a sustained reduction of health inequalities. All sectors of society should assume responsibility for the reduction of social and gender inequities, and the alleviation of their consequences on health. Disadvantaged groups must be ensured access to social welfare, through the provision of “safety nets”, and be given appropriate, acceptable and sustainable health care.

BETTER HEALTH FOR THE PEOPLE OF WHO’S EUROPEA� REGIO�

Strengthening health throughout life

Target 3. Healthy start in life

• Investing early in health typically pays off later in life. A good start in life means supporting parents and young children. Policies should therefore be implemented that create a supportive family, with wanted children and good parenthood capacity.

Target 4. Health of young people

• All major public sector policy decisions should be reviewed to avoid any negative impact on the health of children and adolescents, their families and carers. Investment in secure employment can benefit health and thus long-term productivity Stronger action needs to be taken to promote a healthier working environment through better legislation, standards and enforcement mechanisms.

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Target 5. Healthy aging

• Health policies should prepare people for healthy aging by means of systematically planned promotion and protection of their health throughout life. Health and social services at community level should provide outreach services to support older people in their everyday lives.

To reduce the incidence and prevalence of diseases and other causes of ill health or

death to the lowest feasible levels

Target 6. Improving mental health • Improving mental health – and especially reducing suicide – requires attention to the

promotion and protection of mental health throughout life, particularly in socially and economically disadvantaged groups.

Target 7. Reducing communicable diseases

• Reducing communicable diseases requires an integrated approach combining health promotion, disease prevention and patient treatment. Improvement and maintenance of basic hygiene, water quality and food safety are essential, as are sustainable and effective immunization programs and well directed treatment schedules.

Target 8. Reducing non-communicable diseases

• A large part of non-communicable diseases could be eliminated if all countries organized, both at country level and in local communities, an integrated program to reduce the risk factors that are common to many of these diseases. Furthermore, diagnosis, treatment and rehabilitation services for these diseases – including acute care facilities – need improvement in many Member States

Target 9. Reducing injury from violence and accidents

• Reducing injury from violence and accidents requires improved emergency services in many countries and stricter enforcement of the well known preventive measures that can cut accidents on the roads, at work and in the home.

A MULTISECTORAL STRATEGY FOR SUSTAI�ABLE HEALTH

To create sustainable health through more health-promoting physical, economic, social

and cultural environments for people

Many key health burdens are due to similar risk factors, of which poverty and socio-economic deprivation are particularly important. It is not up to the health sector alone. Vital gains, both in health and in economic advancement, can be made through well designed policies for education, employment, industrial structure, taxation and social policy. Target 10. A healthy and safe physical environment

• Environmental taxes promote health by reducing pollution. Target 11. Healthier living

• Trade and agricultural policies should continue to be realigned to promote health, provide safe food and protect the environment.

• Cycling, walking and the use of public transport instead of cars all promote health by increasing physical activity and social contact. They also reduce fatal accidents and air pollution. Financial support for public transport, and the creation of tax disincentives for the business use of cars, can be a powerful stimulus for change.

Target 12. Reducing harm from alcohol, drugs and tobacco

• Increasing taxes on tobacco products raises government revenue and saves lives. Tighter regulation of tobacco products and greater availability of treatment products and cessation advice, coupled with enhanced smoke-free environments and a ban on the advertising and sponsorship of tobacco products, will reduce the annual toll of up

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to 2 million deaths expected during the next 20 years. Effective legislation reduces tobacco consumption.

• The European Charter on Alcohol (Paris, 1995) and the European Alcohol Action Plan outline the main public health and treatment strategies of alcohol related-harm. They include taxation of alcoholic beverages, control of direct and indirect advertising, and treatment of hazardous and harmful alcohol consumption.

• Societies that can mobilize extensive and innovative approaches to services for drug users can be very successful in reducing health-damaging behaviour, as well as in limiting antisocial and criminal activity among drug users.

Target 13. Settings for health

• Informing, motivating and supporting individuals, groups and societies to lead a more healthy life can best be done by focusing systematically on the places where people live, work and play.

o The home should be designed and built in a manner conducive to sustainable health and the environment.

o In preschool settings, children can learn the basic values of healthy lifestyle, social interaction and teamwork, and be trained in issues such as accident prevention and a healthy diet.

o All children should have the right to be educated in a health-promoting school that integrates health-related issues into a comprehensive approach, thus enabling schools to promote the physical, social and emotional health of students, staff, families and communities.

o Making the working environment safe and healthy - the aim should be not just to reduce exposure to risks, but also to increase the participation of employers and employees in promoting a safer and healthier working environment and reducing stress.

o People and their living conditions should be the central consideration in town planning. Target 14. Multisectoral responsibility for health

• An effective approach to health development requires all sectors of society to be accountable for the health impact of their policies and programs and recognition of the benefits to themselves of promoting and protecting health. Health impact assessment must therefore be applied to any social and economic policy or program, as well as development projects, likely to have an effect on health.

• Countries should also aim to ensure that their foreign aid and trade policies are not detrimental to health in other countries, and that they contribute as much as possible to the development of disadvantaged countries.

CHA�GI�G THE FOCUS: A� OUTCOME-ORIE�TED HEALTH SECTOR

To orient the health sector towards ensuring better health gain, equity and cost-

effectiveness

Target 15. An integrated health sector

• A more integrated health sector is needed, with a much stronger emphasis on primary care. Secondary and tertiary care, which is largely provided in hospital, should be clearly supportive to primary health care, concentrating only on those diagnostic and therapeutic functions that cannot be performed well in primary care settings.

• More specialized services should be provided by a family health physician who, together with the nurse, would interact with local community structures on local health problems.

• Nursing homes and similar long-stay institutions should have a stronger “home atmosphere” and be a local community responsibility.

Target 16. Managing for quality of care

• The systematic measurement of health outcomes using internationally standardized quality indicators together with greater emphasis on evidence-based medicine identifies resources that can be released to meet the increasing demands on the health sector.

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Target 17. Funding health services and allocating resources

• The funding of health care should ensure equity and sustainability. Whatever system is used, governments must ensure that it provides universal coverage and access to health care, as well as containing overall costs.

Target 18. Developing human resources for health

• Educational programs for health care providers and managers should be emphasized. The education and training of public health professionals needs to prepare them not only for their technical work, but also to act as enablers, mediators and advocates for health and population based action in all sectors.

• Clear mandates must exist for the work of public health professionals with an adequate infrastructure for their work.

MA�AGI�G CHA�GE FOR HEALTH

To create a broad societal movement for health through innovative partnerships,

unifying policies, and management practices tailored to the new realities of Europe

Target 19. Research and knowledge for health

• Health policies and programs should be more clearly based on scientific evidence. Communication and cooperation between the scientific community and decision-makers for the application of new knowledge to health development needs to be strengthened in most countries. National and local health information systems are a prerequisite for the development and monitoring of effective, efficient and equitable health policy.

Target 20. Mobilizing partners for health

• Health information should be relevant for and easily accessible to politicians, managers, health and other professionals and the general public. At all levels, good governance for health requires transparency, accountability and incentives to promote participation.

Target 21. Policies and strategies for health for all

• A national, targeted policy based on health for all values is the key to providing motivation and setting a framework for policies and action in regions, cities and local communities, and in settings such as schools and workplaces

More information are available at official websites of WHO www.who.int and www.who.euro.int

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EUROPEA� CHARTER OF PATIE�TS RIGHTS

Despite their differences, national health systems in European Union countries place

the same rights of patients, consumers, users, family members, weak populations and ordinary people at risk.

The �ice Charter of Fundamental Rights is the basis of the declaration of the fourteen concrete patients’ rights currently at risk: the right to preventive measures, access, information, consent, free choice, privacy and confidentiality, respect of patients time, observance of quality standards, safety, innovation, avoidance of unnecessary suffering and pain and personalized treatment, and the right to complain and to receive compensation. These rights are also linked to several international declarations and recommendations, issued by both the WHO and the Council of Europe. They regard organizational standards and technical parameters, as well as professional patterns and behaviour. Each of the national health systems of the EU countries manifests quite different realities with respect to patients’ rights. Some systems may have patients’ rights charters, specific laws, administrative regulations, charters of services, bodies such as ombudspersons, procedures like alternative dispute resolution, etc. Others may have none of these. In any case, the present Charter can reinforce the degree of protection of patients/citizens’ rights in the different national contexts, and can be a tool for the harmonization of national health systems that favours citizens and patients rights. This is of the utmost importance, especially because of the freedom of movement within the EU and the enlargement process.

The Charter of Fundamental Rights, which will represent the first brick in the European constitution, is the main reference point of the present Charter. It affirms a series of inalienable, universal rights, which EU organs and Member States cannot limit, and individuals cannot waive. These rights transcend citizenship, attaching to a person as such. They exist even when national laws do not provide for their protection; the general articulation of these rights is enough to empower persons to claim that they be translated into concrete procedures and guarantees.

The fourteen rights illustrated below are also linked to other international documents and declarations, emanating in particular from the WHO and the Council of Europe. As regards the WHO, the most relevant documents are the following: - The Declaration on the Promotion of Patients Rights in Europe, endorsed in Amsterdam in 1994; - The Ljubljana Charter on Reforming Health Care, endorsed in 1996; - The Jakarta Declaration on Health Promotion into the 21 Century, endorsed in 1997.

As regards the Council of Europe, one must recall in particular the 1997 Convention on Human Rights and Biomedicine, as well as Recommendation Rec (2000)5 for the development of institutions for citizen and patient participation in the decision-making process affecting health care. All these documents consider citizens health care rights to derive from fundamental rights and they form, therefore, part of the same process as the present Charter. FOURTEE� RIGHTS OF THE PATIE�T This part proposes the proclamation of fourteen patients rights, which together seek to render the fundamental rights recalled above concrete, applicable and appropriate to the current transitory situation in the health services. These rights all aim to guarantee a “high level of human health protection, to assure the high quality of services provided by the various national health services. They must be protected throughout the entire territory of the

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European Union. With regard to the fourteen patients’ rights, some preliminary statements are called for: - The definition of rights implies that both citizens and health care stakeholders assume their own responsibilities. Rights are indeed correlated with both duties and responsibilities. - The Charter applies to all individuals, recognizing the fact that differences, such as age, gender, religion, socio-economic status and literacy etc., may influence individual health care needs. - The Charter does not intend to take sides on ethical issues. - The Charter defines rights as they are valid in contemporary European health systems. It shall therefore be reviewed and modified to allow for their evolution, and the development of scientific knowledge and technology. - The fourteen rights are an embodiment of fundamental rights and, as such, they must be recognized and respected independently of financial, economic or political constraints, taking the criteria of the appropriateness of care into consideration. - Respect for these rights implies the fulfillment of both technical / organizational requirements, national health systems operate. - Each article of the Charter refers to a right and defines and illustrates it, without claiming to foresee all possible situations. 1-Right to Preventive Measures Every individual has the right to a proper service in order to prevent illness.

The health services have the duty to pursue this end by raising people awareness, guaranteeing health procedures at regular intervals free of charge for various groups of the population at risk, and making the results of scientific research and technological innovation available to all. 2-Right of Access Every individual has the right of access to the health services that his or her health needs

require. The health services must guarantee equal access to everyone, without discriminating

on the basis of financial resources, place of residence, kind of illness or time of access to

services.

An individual requiring treatment, but unable to sustain the costs, has the right to be served free of charge. Each individual has the right to adequate services, independently of whether he or she has been admitted to a small or large hospital or clinic. Each individual, even without a required residence permit, has the right to urgent or essential outpatient and inpatient care. An individual suffering from a rare disease has the same right to the necessary treatments and medication as someone with a more common disease. 3-Right to Information Every individual has the right to access to all kind of information regarding their state of

health, the health services and how to use them, and all that scientific research and

technological innovation makes available.

Health care services, providers and professionals have to provide patient-tailored information, particularly taking into account the religious, ethnic or linguistic specificities of the patient. The health services have the duty to make all information easily accessible, removing bureaucratic obstacles, educating health care providers, preparing and distributing informational materials. A patient has the right of direct access to his or her clinical file and medical records, to photocopy them, to ask questions about their contents and to obtain the correction of any errors they might contain.

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A hospital patient has the right to information which is continuous and thorough; this might be guaranteed by a tutor”. Every individual has the right of direct access to information on scientific research, pharmaceutical care and technological innovations. This information can come from either public or private sources, provided that it meets the criteria of accuracy, reliability and transparency. 4-Right to Consent Every individual has the right of access to all information that might enable him or her to

actively participate in the decisions regarding his or her health; this information is a

prerequisite for any procedure and treatment, including the participation in scientific

research.

Health care providers and professionals must give the patient all information relative to a treatment or an operation to be undergone, including the associated risks and discomforts, side-effects and alternatives. This information must be given with enough advance time (at least 24 hours notice) to enable the patient to actively participate in the therapeutic choices regarding his or her state of health. Health care providers and professionals must use a language known to the patient and communicate in a way that is comprehensible to persons without a technical background. In all circumstances which provide for a legal representative to give the informed consent, the patient, whether a minor or an adult unable to understand or to will, must still be as involved as possible in the decisions regarding him or her. The informed consent of a patient must be procured on this basis. A patient has the right to refuse a treatment or a medical intervention and to change his or her mind during the treatment, refusing its continuation. A patient has the right to refuse information about his or her health status. 5-Right to Free Choice Each individual has the right to freely choose from among different treatment procedures and

providers on the basis of adequate information.

The patient has the right to decide which diagnostic exams and therapies to undergo, and which primary care doctor, specialist or hospital to use. The health services have the duty to guarantee this right, providing patients with information on the various centres and doctors able to provide a certain treatment, and on the results of their activity. They must remove any kind of obstacle limiting exercise of this right. A patient who does not have trust in his or her doctor has the right to designate another one. 6-Right to Privacy and Confidentiality Every individual has the right to the confidentiality of personal information, including

information regarding his or her state of health and potential diagnostic or therapeutic

procedures, as well as the protection of his or her privacy during the performance of

diagnostic exams, specialist visits, and medical/surgical treatments in general.

All the data and information relative to an individuals state of health, and to the medical/surgical treatments to which he or she is subjected, must be considered private, and as such, adequately protected. Personal privacy must be respected, even in the course of medical/surgical treatments (diagnostic exams, specialist visits, medications, etc.), which must take place in an appropriate environment and in the presence of only those who absolutely need to be there (unless the patient has explicitly given consent or made a request). 7-Right to Respect of Patients Time Each individual has the right to receive necessary treatment within a swift and predetermined

period of time. This right applies at each phase of the treatment.

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The health services have the duty to fix waiting times within which certain services must be provided, on the basis of specific standards and depending on the degree of urgency of the case. The health services must guarantee each individual access to services, ensuring immediate sign-up in the case of waiting lists. Every individual that so requests has the right to consult the waiting lists, within the bounds of respect for privacy norms. Whenever the health services are unable to provide services within the predetermined maximum times, the possibility to seek alternative services of comparable quality must be guaranteed, and any costs borne by the patient must be reimbursed within a reasonable time. Doctors must devote adequate time to their patients, including the time dedicated to providing information. 8-Right to the Observance of Quality Standards Each individual has the right of access to high quality health services on the basis of the

specification and observance of precise standards.

The right to quality health services requires that health care institutions and professionals provide satisfactory levels of technical performance, comfort and human relations. This implies the specification, and the observance, of precise quality standards, fixed by means of a public and consultative procedure and periodically reviewed and assessed. 9-Right to Safety Each individual has the right to be free from harm caused by the poor functioning of health

services, medical malpractice and errors, and the right of access to health services and

treatments that meet high safety standards.

To guarantee this right, hospitals and health services must continuously monitor risk factors and ensure that electronic medical devices are properly maintained and operators are properly trained. All health professionals must be fully responsible for the safety of all phases and elements of a medical treatment. Medical doctors must be able to prevent the risk of errors by monitoring precedents and receiving continuous training. Health care staff that report existing risks to their superiors and/or peers must be protected from possible adverse consequences. 10-Right to Innovation Each individual has the right of access to innovative procedures, including diagnostic

procedures, according to international standards and independently of economic or financial

considerations.

The health services have the duty to promote and sustain research in the biomedical field, paying particular attention to rare diseases. Research results must be adequately disseminated. 11-Right to Avoid Unnecessary Suffering and Pain Each individual has the right to avoid as much suffering and pain as possible, in each phase

of his or her illness.

The health services must commit themselves to taking all measures useful to this end, like providing palliative treatments and simplifying patients access to them. 12-Right to Personalized Treatment Each individual has the right to diagnostic or therapeutic programs tailored as much as

possible to his or her personal needs.

The health services must guarantee, to this end, flexible programs, oriented as much as possible to the individual, making sure that the criteria of economic sustainability does not prevail over the right to health care.

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13-Right to Complain Each individual has the right to complain whenever he or she has suffered a harm and the

right to receive a response or other feedback.

The health services ought to guarantee the exercise of this right, providing (with the help of third parties) patients with information about their rights, enabling them to recognize violations and to formalize their complaint. A complaint must be followed up by an exhaustive written response by the health service authorities within a fixed period of time. The complaints must be made through standard procedures and facilitated by independent bodies and/or citizens’ organizations and cannot prejudice the patients’ right to take legal action or pursue alternative dispute resolution. 14-Right to Compensation Each individual has the right to receive sufficient compensation within a reasonably short

time whenever he or she has suffered physical or moral and psychological harm caused by a

health service treatment.

The health services must guarantee compensation, whatever the gravity of the harm and its cause (from an excessive wait to a case of malpractice), even when the ultimate responsibility cannot be absolutely determined.

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I�TER�ATIO�AL RED CROSS

Mission, tasks and activities

The International Committee of the Red Cross (ICRC) mission is to protect and assist the

civilian and military victims of armed conflicts and internal disturbances on a strictly

neutral and impartial basis. Its tasks include: - visits to prisoners of war and civilian detainees; - searching for missing persons; - transmission of messages between family members separated by conflict; - reunification of dispersed families; - provision of food, water and medical assistance to civilians without access to these basic

necessities; - spreading knowledge of humanitarian law; - monitoring compliance with that law; - drawing attention to violations, and contributing to the development of humanitarian law.

Although the ICRC is the product of a private Swiss initiative, its work and scope are international. The organization has delegations and missions in some 80 countries around the world and employs a staff of over 11,000 people, most of them nationals of the countries in which it works. About 800 people work at the ICRC’s headquarters in Geneva, Switzerland, providing vital support to and supervision of field operations, and determining and implementing institutional policies and strategies. ICRC field delegations may cover one country or, in the case of regional delegations, several countries. They carry out a range of activities, depending on the situation and the needs in a particular country. Activities may include: - protecting and assisting the victims of existing or emerging armed conflict or violence

(civilians, people deprived of their freedom, dispersed families, the wounded and sick); - preventive action, cooperation with National Societies and humanitarian coordination and

diplomacy. The ICRC is a neutral, impartial and independent humanitarian organization. In most of

the countries in which it works, the ICRC has concluded headquarters agreements with the authorities. Through these agreements, which are subject to international law, the ICRC enjoys the privileges and immunities usually only granted to intergovernmental organizations, such as immunity from legal process.

Origins and history

The ICRC owes its origins to the vision and determination of one man: Henry

Dunant. The date: 24 June 1859. The place: Solferino, a town in northern Italy. The Austrian and French armies were locked in bitter battle and, after 16 hours of

fighting, the ground was strewn with 40,000 dead and wounded. That same evening, Dunant, a Swiss citizen, passed through the area on business. He was horrified by the sight of thousands of soldiers from both armies left to suffer for want of medical care. He appealed to the local people to help him tend the wounded, insisting that soldiers on both sides should be treated equally. On his return to Switzerland, Dunant published A Memory of Solferino, in which he made two solemn appeals: - for relief societies to be formed in peacetime, with nurses who would be ready to care for

the wounded in wartime; - for these volunteers, who would be called upon to assist the army medical services, to be

recognized and protected through an international agreement.

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In 1863 a five-member commission was set up to consider how Dunant’s ideas could be made a reality and the International Committee for Relief to the Wounded, which later became the International Committee of the Red Cross (ICRC) was founded. the distinctive emblem – a red cross on a white background, the reverse of the Swiss national flag – was adopted and the Red Cross came into being. Fundamental Principles The International Red Cross and Red Crescent Movement is present and active in almost every country and comprises around 100 million members and volunteers. It is united and guided by the seven Fundamental Principles – humanity, impartiality, neutrality, independence, voluntary service, unity and universality. Humanity

- to bring assistance without discrimination to the wounded on the battlefield, - to prevent and alleviate human suffering wherever it may be found, - to protect life and health, - to ensure respect for the human being. Impartiality

- It makes no discrimination as to nationality, race, religious beliefs, class or political opinions.

- It endeavours to relieve the suffering of individuals, being guided solely by their needs, and to give priority to the most urgent cases of distress.

�eutrality

- the Movement may not take sides in hostilities or engage at any time in controversies of a political, racial, religious or ideological nature.

Independence

- The National Societies must always maintain their autonomy so that they may be able at all times to act in accordance with the principles of the Movement

Voluntary service

- It is a voluntary relief movement not prompted in any manner by desire for gain. Unity

- There can be only one Red Cross or Red Crescent Society in any one country. - It must be open to all. - It must carry on its humanitarian work throughout its territory. Universality

- The International Red Cross and Red Crescent Movement, in which all Societies have equal status and share equal responsibilities and duties in helping each other, is worldwide.

Roles and responsibilities The Movement is made up of: - the International Committee of the Red Cross (ICRC)

o is the Movement’s founding body, o is the promoter and custodian of international humanitarian law, o is the guardian of the Fundamental Principles.

- �ational Societies

o embody the work and principles of the Movement in more than 180 countries, o provide a range of services including disaster relief and health and social programs, o in wartime assist the affected civilian population and, where appropriate, support the

army medical services. - the International Federation of Red Cross and Red Crescent Societies (International

Federation)

o works on the basis of the Fundamental Principles,

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o directs and coordinates international assistance of the Movement to victims of natural and technological disasters, to refugees and in health emergencies,

o acts as the official representative of its member societies in the international field and promotes cooperation between National Societies.

Emblems of humanity From the very beginning, the ICRC’s founders recognized the need for a single,

universal and easily recognizable emblem familiar to all. To their mind, the emblem had to protect not only people wounded in battle but also those bringing them aid. It was also to protect all medical units, including those of the enemy. The idea was that the mere sight of it would prompt combatants to show restraint and respect. The red cross on a white

background (the reverse of the Swiss national flag) was adopted by the International Conference of 1863. However, in 1876, the Ottoman Empire decided to use a red crescent instead of the red cross. Several States followed suit and in 1929 the red crescent in turn was granted official recognition, along with the Iranian red lion and sun (not currently in use).Over the years Some Societies that wished to join the Movement were not comfortable with either of the existing emblems. To solve these problems, the Diplomatic Conference of December 2005 brought together the States party to the Geneva Conventions and adopted Additional Protocol III, creating a new emblem, the red crystal. This emblem, free from any religious, cultural or political connotations, gives States and National Societies greater flexibility in the use of the emblems and puts an end to the question of proliferation of emblems.

Use of the emblem as a protective device is the visible manifestation of the protection

accorded by the Geneva Conventions to persons (members of army medical services, National Society volunteers, ICRC delegates, etc.), medical units (hospitals, first-aid posts, etc.) and means of transport. Use of the emblem as an indicative device shows that a person or object has a connection with the Movement. To avoid confusion with the emblem used as a protective device, the red cross, red crescent and red crystal used for indicative purposes are smaller in size. More information are available at official website of ICRC http://www.icrc.org/

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U�ITED �ATIO�S MILLE�IUM DEVELOPME�T GOALS

PRIORITIES I� GLOBAL HEALTH

Poverty and disease are interactive. Sick people have reduced or no capacity to perform well economically. Health is not a development goal, but also a means to promote development. The eight United Nations Millennium Development Goals agreed upon by all the countries of the world target the poor form all over the world with a community-based bottom-up approach as well as national targeted programs which must be integrated at the community level. Three of the eight Millennium Development Goals directly address health, and all the others are intricately linked to health. Inadequate levels of health spending by the world’s poorest countries are a major factor in continuance of the vicious cycle of poverty and illness. The Millennium Development Goals (MDGs) represent an effort by the international community to address the various pressing issues in the world as a global village in which problems of one country cannot be seen in isolation. The Goals represent human needs and basic rights that every individual around the world should be able to enjoy—freedom from extreme poverty and hunger; quality education, productive and decent employment, good health and shelter; the right of women to give birth without risking their lives; and a world where environmental sustainability is a priority, and women and men live in equality (Box 1). With 2015 approaching, an MDG monitoring system has been established to help track the progress of individual countries, to learn about new challenges, and to support organizations worldwide working on the MDGs. Progress towards the eight Millennium Development Goals is measured through 21 targets and 60 official indicators. Most of the MDG targets have a deadline of 2015, and 1990 is the baseline against which progress is gauged (UN, 2010).

Box 1. Millennium Development Goals by 2015

1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria, and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

Source: The Millennium Development Goals Report 2010. New York: United Nations 2010. http//www.un.org/millenniumgoals /

The first MDG has two targets: to halve, between 1990 and 2015 the proportion of

people whose income is less than 1 USD a day; to achieve, full and productive employment

and decent work for all, including women and young people; and to halve the proportion of

people who suffer from hunter. The process evaluation method to track the work done in this regard is being done by the World Bank, UNICEF, WHO, and the Food and Agricultural Organization (FAO), using indicators such as underweight children under the age of 5 years and proportion of population with an income below 1 USD per day.

Progress on poverty reduction is still being made, despite significant setbacks due to the 2008-2009 economic downturn, and food and energy crises. The developing world as a whole remains on track to achieve the poverty reduction target by 2015. The overall poverty rate is still expected to fall to 15 per cent by 2015, which translates to around 920 million people living under the international poverty line—half the number in 1990. The fastest growth and sharpest reductions in poverty continue to be recorded in Eastern Asia.

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Deterioration of the labor market, triggered by the economic crisis, has resulted in a decline in employment. As jobs were lost, more workers have been forced into vulnerable employment. Since the economic crisis, more workers find themselves and their families living in extreme poverty.

The number of people who are undernourished has continued to grow, while slow progress in reducing the prevalence of hunger stalled—or even reversed itself—in some regions between 2000-2002 and 2005-2007. About one in four children under the age of five are underweight, mainly due to lack of food and quality food, inadequate water, sanitation and health services, and poor care and feeding practices. Children in rural areas are nearly twice as likely to be underweight as those in urban areas.

The second MDG has one target to ensure that, by 2015, children everywhere, boys

and girls alike, will be able to complete a full course of primary schooling.

Enrolment in primary education has continued to rise, reaching 89 percent in the developing world. But the pace of progress is insufficient to ensure that, by 2015, all girls and boys complete a full course of primary schooling. The biggest obstacle to education is poverty. Children remain out of school for a variety of reasons, including cost. Social and cultural barriers to education are also common. In many countries, educating girls is widely perceived as being of less value than educating boys. And children with disabilities across the world face far more limited opportunities than their nondisabled peers.

The third MDG’s target is to eliminate gender disparity in primary and secondary

education, preferably by 2005, and in all levels of education no later than 2015.

For girls in some regions, education remains elusive. Poverty is a major barrier to education, especially among older girls. In almost every developing region men outnumber women in paid employment. Women are largely relegated to more vulnerable forms of employment. Women are overrepresented in informal employment, with its lack of benefits and security. Top-level jobs still go to men — to an overwhelming degree.

The forth MDG is to reduce the 1990 under-5 mortality rate by two-thirds by 2015. Child deaths are falling, but not quickly enough to reach the target. This is primarily a measure of success in immunization and basic child nutrition. Causes of deaths among children under age five in 2008 are shown in Figure 1.

Figure 1. Causes of deaths among children under age five, 2008 (Percentage)

Source: The Millennium Development Goals Report 2010. New York: United Nations 2010. http//www.un.org/millenniumgoals /

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The fifth MDG has two targets: to reduce by three-quarters the maternal mortality

ration between 1990 and 2015; and to achieve, by 2015, universal access to reproductive

health.

Most maternal deaths could be avoided as it is seen in Figure 2. Giving birth is especially risky in Southern Asia and sub-Saharan Africa, where most women deliver without skilled care. More women are receiving antenatal care. Only one in three rural women in developing regions receives the recommended care during pregnancy. Progress has stalled in reducing the number of teenage pregnancies, putting more young mothers at risk. Poverty and lack of education perpetuate high adolescent birth rates. Progress in expanding the use of contraceptives by women has slowed. Use of contraception is lowest among the poorest women and those with no education. Inadequate funding for family planning is a major failure in fulfilling commitments to improving women’s reproductive health.

Figure 2 Causes of maternal deaths, developing regions, 1997/2007 (Percentage) Source: The Millennium Development Goals Report 2010. New York: United Nations 2010. http//www.un.org/millenniumgoals /

The sixth MDG is to stop by 2015 and begin to reverse the spread of HIV/AIDS, the

incidence of malaria and other major diseases; and to achieve, by 2010, universal access to

treatment for HIV/AIDS for all those who need it.

The spread of HIV appears to have stabilized in most regions, and more people are surviving longer. Many young people still lack the knowledge to protect themselves against HIV. Empowering women through AIDS education is indeed possible, as a number of countries have shown. In sub-Saharan Africa, knowledge of HIV increases with wealth and among those living in urban areas. The rate of new HIV infections continues to outstrip the expansion of treatment. Expanded treatment for HIV-positive women also safeguards their newborns.

Global procurement of more effective antimalarial drugs continues to rise rapidly. Children from the poorest households are least likely to receive treatment for malaria. External funding is helping to reduce malaria incidence and deaths, but additional support is needed. Tuberculosis prevalence is falling in most regions. Tuberculosis remains the second leading killer after HIV.

The seventh MDG has four targets which deal with sustainable environment,

reduction of biodiversity loss, sustainable access to drinking water and basic sanitation, and

improvement in housing. The four targets of eighth MDG are: to address the special needs of the least

developed countries; to develop further an open, rule-based, predictable, nondiscriminatory

trading and financial system; to deal comprehensively with developing countries’ debt; and in

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cooperation with the private sector, to make available the benefits of new technologies,

especially information and communications.

The interactions among poverty, population growth, and environmental degradation combine to adversely affect many developing countries and hundreds of millions of people globally. In many developing countries, economic stagnation and political instability compound these issues, causing an inability to address basic human needs and condemning more generations to ill health and early death. Although the effects of low income, lack of basic sanitation, and crowding in rural poverty or the slums of megacities cannot be overcome by health measures alone, the potential for raising the quality of life and survival rates by public health measures is very great. The leading causes of world disability (DALYs) and mortality are shown in Table 1 and the Figure 3 is presenting the burden of disease by broad cause group and region (Tulchinsky, Varavikova, 2009).

Table 1. Leading Causes of Mortality and Burden of Disease world, 2004

%

1. Ischaemic heart disease 12.2

2. Cerebrovascular disease 9.7

3. Lower respiratory infections 7.1

4. COPD 5.1

5. Diarrhoeal diseases 3.7

6. HIV/AIDS 3.5

7. Tuberculosis 2.5

8. Trachea, bronchus, lung cancers 2.3

9. Road traffic accidents 2.2

10. Prematurity, low birth weight 2.0

%

1. Lower respiratory infections 6.2

2. Diarrhoeal diseases 4.8

3. Depression 4.3

4. Ischaemic heart disease 4.1

5. HIV/AIDS 3.8

6. Cerebrovascular disease 3.1

7. Prematurity, low birth weight 2.9

8. Birth asphyxia, birth trauma 2.7

9. Road traffic accidents 2.7

10. Neonatal infections and other 2.7

Mortality DALYs

Source: Global burden of disease 2004 updates: selected figures and tables. Health statistics and informatics.

World Health Organization, 2004.

Figure 3. Burden of disease by broad cause group and region, 2004

Source: Global burden of disease 2004 updates: selected figures and tables. Health statistics and informatics. World Health Organization, 2004.

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Industrialized countries have overcome many of these problems but must cope with very substantial pockets of poverty, homelessness, violence, preventable diseases, environmental degradation, and limited assess to health care. The recognition that poverty and ill health are interactive led the industrialized nations to take an important step in mid-1990 to relive debt and provide aid-related loans to very poor countries. Despite this important step, most poor countries pay more on debt service than they do on health and education for their people. More information about The Millennium Development Goals are available at: http//www.un.org/millenniumgoals/

An Introduction to Social Medicine

MUDr. Michaela Kostičová, PhD. Doc. MUDr. Vojtech Ozorovský, CSc. Prof. MUDr. Ladislav Badalík, DrSc. JUDr. Gregory Fabian Vydalo: Vydavateľstvo Asklepios, Bratislava 2011 Vydanie: prvé Náklad: 200 výtlačkov Rozsah: 152 strán ISBN 978-80-7167-153-4