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Dr. Babar T Shaikh

The Aga Khan University, Karachi

Society, Culture & Health Care system

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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

•Age/sex of child

•Family size/ parity

•Education

•Occupation

Socio-demographic factors

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•Possession of household items

•Possession of cattle

•Possession of agriculture land

•Type of residential house

Economic factors

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•Availability of the transport

•Physical distance for Health Facility/Health Care Provider

•Time taken to reach Health Facility/Health Care Provider

Physical accessibility factor

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

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

Financial accessibility factors

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•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

Health service factors

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•Freedom to visit HF alone

•Permission to spend money on health

•Decision power in emergency situation

Mother’s autonomy

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Conceptual framework of KroegerSocio-demographic factors

•Age/sex of child

•Family size/ parity

•Education

•Occupation

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 HF/HCP

•Time taken to reach HF/HCP

Financial accessibility factors

•Fare spent for one round trip to HF/HCP

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

Health service factors

•Attitudes of health provider

•Satisfaction with the treatment

•Received medicines from HF/HCP

•Received prescription for medicines

to be purchased from bazaar

Govt./ Private HF/HCP

Mother’s autonomy

•Freedom to visit HF alone

•Permission to spend money on health

•Decision power in emergency situation

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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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Health SectorChange Agents

Changing disease patters

Advances in biomedical/ clinical sciences

Health Sector Reform

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

PRODUCING HEALTH

Focus on Life-styles

Focus on the Environment

Shift focus from individuals to populations

Cost-effective health care

Evidence-based decision/ policy

Resources to sector that contribute to health

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HEALTH CARE SYSTEM: TYPES AND COMPONENTSTRADITIONAL

MODERN

PRIVATE

PUBLIC

PRIMARY

Physicians’ office Dispensaries NGO/Community Groups BHU/RHC

SECONDARY

Clinics/Maternity homes Tehsil Hospitals NGO-run clinics/hospitals

TERTIARY

Distric Hospitals Large Urban Hospitals

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

Outreach/Community-based activities [Immunization, malaria control, MCH, FP]

PHC Facilities (OPD)

TEHSIL & DISTRICT HQ. Hospitals

Tertiary Care Hospitals

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PUBLIC HEALTHDELIVERY SYSTEM

DISTRICT HQ HOSPITAL (80 - 100 Beds)

TEHSIL HQ HOSPITAL (40 - 50 Beds)

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

BASIC HEALTH UNITS (Preventive & Curative; mostly OPD)

10-20,000 Pop

25-50,000 Pop

50,000-1 ml. Pop

1 - 2 Million Pop

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PREVENTIVE HEALTH SERVICES

IMMUNIZATION PROGRAM

MCH SERVICES

FP SERVICES

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

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GOVT. HEALTHSERVICES:

WEAKNESSES

Insufficient focus on Prevention/Promotion

Gender Imbalances

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

LOW STATUS OF WOMEN

INADEQUATE SANITATION & WATER SUPPLIES

POOR QUALITY OF HEALTH SERVICES

Problem areas

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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 healthCulture 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 Caresystem 25%

Biologicalendowment 15%

Physicalenvironment 10%

Socio-economicenvironment 50%

Estimated Health Impact of Determinants of Health on Population health Status: CIAR 1997

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• 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

Population Health Approach

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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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