Society, Culture & Health Care system

Dr. Babar T Shaikh

The Aga Khan University, Karachi
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 New doctors advise that colostrum should be given. It is essential. Our elders say that colostrum should be disposed off, therefore, we practice what our elders advise us to do.
Mothers focus group

Rural Sindh, Pakistan.

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Health System
a set of cultural beliefs and practices;

the institutional arrangements; and

the socio-economic, political & physical context Health system includes environmental conditions, nutrition, water supply, education, housing, status of women, social structures, economic and political system
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Factors influencing health service utilization

Socio-demographic factors
Age/sex of child Family size/ parity

Education
Occupation
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Economic factors
Possession of household items

Possession of cattle
Possession of agriculture land

Type of residential house

Physical accessibility factor

Availability of the transport
Physical distance for Health Facility/Health Care Provider Time taken to reach Health Facility/Health Care Provider
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Financial accessibility factors

Fare spent for one round trip to Health Facility/Health Care Provider

Total amount spent for treatment of last illness (excluding fare)

Health service factors

Attitudes of health provider Satisfaction with the treatment Received medicines from Health Facility/Health Care Provider Received prescription for medicines to be purchased from bazaar
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Mothers autonomy
Freedom to visit HF alone

Permission to spend money on health

Decision power in emergency situation
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Conceptual framework of Kroeger

Socio-demographic factors Age/sex of child Family size/ parity Education Occupation Economic factors Possession of household items Possession of cattle Possession of agriculture land Financial accessibility factors Fare spent for one round trip to HF/HCP Total amount spent for treatment of last illness (excluding fare) Mothers autonomy

Freedom to visit HF alone

Govt./ Private HF/HCP

Permission to spend money on health Decision power in emergency situation Health service factors

Type of residential house

Physical accessibility factor Availability of the transport

Attitudes of health provider

Satisfaction with the treatment Received medicines from HF/HCP Received prescription for medicines

Physical distance for HF/HCP

Time taken to reach HF/HCP

to be purchased from bazaar 10

Challenges
Knowledge of illness/wellness and of services available Perceptions of services/service providers Risk/symptoms assessment Cultural prescriptions Social barriers/social pathways to care Etc
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Changing disease patters Advances in biomedical/ clinical sciences Health Sector Reform

Health Sector Change Agents

Global perspectives on health and health care New specializations/ professions Ethical issues: New dimensions Information/ Communication revolution Globalization
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PROVISION OF HEALTH CARE

Focus on Life-styles Focus on the Environment Shift focus from individuals to populations

Cost-effective health care

PRODUCING HEALTH

Evidence-based decision/ policy Resources to sector that contribute to health

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HEALTH CARE SYSTEM: TYPES AND COMPONENTS

T R A D I T I O N A L

PRIMARY Physicians office Dispensaries NGO/Community Groups BHU/RHC SECONDARY Clinics/Maternity homes Tehsil Hospitals NGO-run clinics/hospitals

P R I V A T E

M O D E R N

TERTIARY
Distric Hospitals Large Urban Hospitals

P U B L I C

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Outreach/Communitybased activities [Immunization, malaria control, MCH, FP]

GOVT. (PUBLIC) HEALTH DELIVERY SYSTEM (4 TIERS)

PHC Facilities (OPD)

TEHSIL & DISTRICT HQ. Hospitals

Tertiary Care Hospitals

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1 - 2 Million Pop

DISTRICT HQ HOSPITAL (80 - 100 Beds)

50,000-1 ml. Pop PUBLIC HEALTH DELIVERY SYSTEM 25-50,000 Pop

TEHSIL HQ HOSPITAL (40 - 50 Beds)

RURAL HEALTH CLINICS (Extensive OPD; 10-20 Beds)

10-20,000 Pop

BASIC HEALTH UNITS (Preventive & Curative; mostly OPD)

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IMMUNIZATION PROGRAM

MCH SERVICES
PREVENTIVE HEALTH SERVICES

FP SERVICES

LHW PROGRAM [45,000 LHW /2000; Target 1:1,000 Pop]

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Insufficient focus on Prevention/Promotion Gender Imbalances

GOVT. HEALTH SERVICES: WEAKNESSES

Excessive centralization of management

Political Interference Lack of openness Weak human resource development Lack of integration Lack of Healthy Public Policy
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Problem areas
POVERTY

ILLITERACY

PROBLEM AREAS

LOW STATUS OF WOMEN

INADEQUATE SANITATION & WATER SUPPLIES

POOR QUALITY OF HEALTH SERVICES

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Income influences health

People in the top income bracket are healthier than middle income earners Middle income earners are, in turn, healthier than people with low income This means that the poorer people are, the less healthy they are likely to be.
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Social status affects health

It affects health by determining the

degree of control people have over life circumstances

It affects their capacity to act and make choices for themselves Higher social position and income somehow act as a shield against disease.
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Gender influences health

Gender is linked more to the roles, power and influence society gives to men and women, than it is to their biological differences.

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Culture influences health

Culture and ethnicity influence how people link with health system, their access to health information and their lifestyle choices. Dominant cultural values largely determine the social and economic environment of communities. Result:
Marginalization Loss/devaluation of culture and language

Lack of access to culturally appropriate health services

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Health Care system 25% Biological endowment 15% Physical environment 10% Socio-economic environment 50% Estimated Health Impact of Determinants of Health on Population health Status: CIAR 1997

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Population Health Approach

Focuses on the entire range of individual and collective factors (income and social status, education, employment and working conditions, social environment, physical environment, gender, culture, personal health and coping skills, healthy child development, health services)
The interaction among these factors
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Population Health Approach

Health is determined by the complex

interactions between individual characteristics, social and economic

Strategies to improve population health must

address the entire range of factors that determine health

Important health gains can be achieved by

focusing interventions on the health of the entire population/significant sub-populations rather than individuals

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Population Health Approach

Improving health is shared responsibility

that requires the development of healthy public policies in areas outside the traditional health system
The health of a population is closely

linked to the distribution of wealth across the population

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Creating a Healthy Community

Community Economy

Environment

Based on a model from: Hancock, Trevor. 1993, heath, human development and community ecosystem: three ecological models

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Health Services
move towards broader resources to support well-being

the design: services to maintain and promote health, to prevent disease, and to restore health system functioning to contribute towards population health.

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