Determinants of health and the evolution of Primary Health Care

1. Determinants of health and the evolution of Primary Health Care by Steve Gloyd HServ/Epi 531 2007

2. Situational Analysis of Global Health Major determinants of health Poverty and inequality Inadequate primary health care systems Other factors Changing global environment, migration ID pandemics, transition/chronic diseases Militarism (wars and oppression) Different geographical mixes �.but most consequences ultimately fall on the poor Overwhelming poverty in the midst of the greatest accumulation of wealth in history. Gap between richest/poorest was 3/1 in 1900, now well over 100/1. Health care for the poor �(and education) - in many countries is worse that it was 30 years ago Overwhelming poverty in the midst of the greatest accumulation of wealth in history. Gap between richest/poorest was 3/1 in 1900, now well over 100/1. Health care for the poor �(and education) - in many countries is worse that it was 30 years ago

3. Death & Illness 2005 11 million children under five die each year from preventable causes In many African countries, 20% of children do not reach age five In 16 countries, more are dying now than 15 years ago 500,000 women die each year in childbirth 3m adults die from AIDS, 2m Tb

4. Under-5 mortality 2004

5. Mortality rates - 2006

8. Severe malaria occurs mostly in Africa

9. HIV prevalence is very high in Sub-Saharan Africa

10. The Disability Adjusted Life Year or DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of �healthy� life lost by virtue of being in states of poor health or disability (1). The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of �healthy� life and the burden of disease as a measurement of the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability. DALYs for a disease or health condition are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition: The years of life lost (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: The Disability Adjusted Life Year or DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of �healthy� life lost by virtue of being in states of poor health or disability (1). The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of �healthy� life and the burden of disease as a measurement of the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability. DALYs for a disease or health condition are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition: The years of life lost (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:

13. What are the principal factors associated with high mortality? Education Nutrition Family income Water, Sanitation Health Care Inequality ************ Common denominator: Poverty and Disparity

14. How important is parental education? Greater than income and access to health services combined Accounts for most of the rural/urban, family size mortality associations Maternal is more important than paternal education Primary to secondary is more important than literacy to primary Maternal education overrides the effect of decreased nursing, earlier weaning

16. Educated mothers� children are healthier

18. Gender equalitythe role of women and child survival women are the keys to the health of their children women�s reproductive health is important to subsequent child health women�s education is the most important factor affecting overall health in developing countries gender equality means improving conditions and status of women for themselves

21. Progress in Nutrition

22. Distribution of family income < $2/day

23. Impact of family assets (income)

25. BBC News Headline, Sept 28 2006 �Dirty water 'kills 1.5m children'

28. Medicine does make a difference

29. But, over 5m people worldwide are dying without access to AIDS, TB, malaria treatmentBut, over 5m people worldwide are dying without access to AIDS, TB, malaria treatment

30. Inequality

37. Overview of Mortality and Morbidity Non-homogeneous (regions of 3w, urban-rural, rich-poor, male-female) Most deaths in children Aggregate data obscures extreme differences Tropical vs. �tropicalized� diseases Analogy with MRs in Europe, USA: 1850-1900, except� Industrialization era used cheap raw materials from colonies Debt & AIDS

38. The big picture � determinants of global health

39. How to improve child survival? Reduce poverty (improve family income) Improve education (especially girls) Improve nutrition, water, sanitation, housing Improve gender equality Improve access to quality health care Preventive and curative � common diseases AIDS treatment

40. Kerala and Sri Lanka � Equity oriented strategies Education - Universal and compulsory primary education Sri Lanka 1950 Kerala 1959 Land Reform Kerala Land Reform Act 1959 (50% got land) Sri Lanka Land Resettlement Program (1940�s) Housing, Water, Sanitation (targeted for poor) Major projects in both countries, 1950-1970 Simple health services Developed in both countries Common Denominator � all require government intervention

41. Kerala, Sri Lanka, and India: Changes in infant mortality(per 1000 live births)

42. Equity strategies and rapid growth Asian tigers 1945-1980 Taiwan, S.Korea, Singapore, Hong Kong Huge growth (7-10%), mortality reductions (8-10%) Protectionism, land reform, literacy campaigns, social net, good markets Newer Asian economies 1960 � 1990 Malaysia, Thailand, Indonesia Less growth (4-5%) less mortality reduction (2.5-5%) Female literacy - 80-92% Africa growth countries 1961-87 Botswana, Cameroon, Congo, Lesotho, Gabon, Kenya No relationship of U5MR reductions with growth Mixed literacy levels

44. Policy Evolution Vertical Programs: 1910 - 1960 (1977) Malaria, yellow fever, yaws, small pox, (polio) Era of optimism: 1960�s and 70�s Independence, decolonization Disillusion with clinical, vertical approaches China, Cuba social revolutions Kerala, Sri Lanka equity strategies Experiments in Africa

45. Success stories create optimism Health for All 2000 (1975) Primary Health Care (Alma Ata-1978) Millennium Development Goals 2000

46. Declaration of Alma-Ata (1978) Health is a fundamental human right & requires inter-sectoral action Existing gross health inequality unacceptable Improved health and peace require economic and social development based on a new international economic order (NIEO) Governments have responsibility to provide adequate health and social measures for health Primary health care is appropriate, accessible, acceptable, affordable and requires community participation (Specifies components of PHC) Governments need the will to formulate and implement PHC policies International cooperation is necessary HFA 2000 requires redirecting resources from military to social expenditures (including health)

47. �Essential components� of Primary Health Care Health education Environmental sanitation, especially food and water The employment of community or village health workers Maternal and child health programs, including immunization and family planning Prevention of local endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs Promotion of nutrition Traditional medicine

51. Why did PHC fail to take off? Inadequate national political commitment (and resource allocation) to overall goals of Alma-Ata Tertiary-primary care, private-public, urban-rural, doctor-nurse Western (US) resistance to social change governments (cold war excuse) Debt and structural adjustment programs � reduction of overall budgets Child survival programs �adjustment with a human face�

54. Global Distribution of Health Workers in Selected Countries

57. Private sector health organizations - Pakistan

58. Private hospital

59. Poorly maintained and equipped health facilities

61. Millennium Development GoalsUnited Nations 2000 Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria, other diseases Ensure environmental sustainability Develop a global partnership Poor achievement in sub-Saharan Africa

62. Poverty reduction � some progress, but not in Africa

63. Primary education progress everywhere except Africa

64. Gender equality in education is improving � except Africa

65. Africa lags behind in mortality reduction

67. Why is Africa* lagging behind? Debt, structural adjustment programs (SAPs), and crumbling public infrastructure Forms of foreign assistance War and militarism