Public P bli Health, H lth Community y Health and Hospitals

Public Health:

Overview

A shared responsibility for community

well-being through ongoing assessment, advocacy and assurance. advocacy, assurance The combination of science, practical skills and values (or beliefs) directed at skills, the maintenance and improvement of the ea t o of a all peop people. e health
Sources: J. Last. Public Health and Human Ecology. 1998. C.G. Sheps. Higher Education for Public Health. 1976.

Determinants of Population Health

SOURCE: The Future of the Publics Health (IOM 2003).

Vision: Healthy y People p in Healthy y Communities Mission: Promote Physical and Mental Health & Prevent Disease, Injury, & Disability
Public Health Prevents epidemics p and the spread p of disease Protects against environmental hazards Prevents injuries j Promotes and encourages healthy behaviors Responds to disasters and assists communities in recovery Assures the quality and accessibility of health services

Essential Public Health Services Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Inform, educate, and empower people about health issues Mobilize M bili community it partnerships t hi to t identify id tif and d solve l health h lth problems bl Develop policies and plans that support individual and community health efforts g that p protect health and ensure safety y Enforce laws and regulations Link people to needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public health and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and populationbased health services Research for new insights and innovative solutions to health problems
Source: Public Health Functions Steering Committee. July, 1995.

Source: Public Health Functions Steering Committee. July, 1995.

Ten Core Practices of Public Health

Assessment
1. Assess the health needs of the community 2. Investigate the occurrence of health effects & health hazards of the community 3. Analyze the determinants of identified health needs

Policy Development
4. Advocate for public health 4 health, build constituencies & identify resources in the community 5. Set priorities among health needs 6. Develop plans & policies to address priority health needs

Assurance

7. 8. 9. 10.

Manage resources & develop organizational structure Implement programs Evaluate programs & provide quality assurance Inform & educate the public
Source: Dyal, WW. American Journal of Preventive Medicine. 1995;11 (6 suppl):6-8.

Public Health Components

Epidemiology Biostatistics Health Services Environmental Social Behavioral Occupational Health

Determinants of health

Profile of our Current C Community i W Work k

Disease Specific HIV Tuberculosis Malaria

Basic Health Care for common illness

Water, Sanitation & Hygiene

Literacy & Education Formal, Nonformal, Vocational

Advocacy & Community Mobilization Thrift/Savings Micro-finance Income generation / Livelihood

Nutrition / Food security

Village health plan Micro birth plan

Advocacy

Community Analysis using 4 delays

Maternal Child Health

Community Based Monitoring

Capacity building

Service delivery

SHG role/support activities

Community l level l sensitization

Reproductive & Child Health

Reproductive & Child Health

Immunisation

Womens Women s literacy

Womens Women s literacy

Participatory Learning Exercise

Women Action Group

Womens Women s groups

Challenges g & choices

Shift from a hospital / disease focus to a community health focus focus.

Social Determinants Health of health P Promotion ti

Preventive Medicine

Primary Care

Secondary L Level lC Care

Rehabilitation

I t Integrated t d Programmes P
Continuum of care

Role of the hospital

Initiate the Community Project. Hospital reputation is important for entry in to the y community. Administrative support Technical resource persons
Health care Training a g

Facilities shared reducing overhead p expenses.

Role of the hospital

Important to support communities initiatives with critical / emergency care. Financing Accountability Provide a faith community and family support to community health programme staff. g with p partners Provide linkages

Disadvantages
Ownership Suspicion or mistrust Conflict C fli t of f interests i t t
sharing of resources

Attitudes of hospital staff Pre-conceived e co ce ed notions ot o s Different time frameworks Ghetto or mission mission compound compound mentality

A different drumbeat
Changes in the context

Non communicable Diseases

The new killers CVD, CVD Diabetes, Diabetes Mental Illness including substance abuse Injuries which include abuse, Accidents, RTA and Suicide, Asthma and COPD Dual burden of disease. Risk-reduction Ri k d i / b behaviour h i change h Need for integrated g continuum of care programmes

Health Care Financing -India India

82 82.4% 4% of health care expenditure occurs in the private sector of which 77.5% is from out-of out of pocket payments payments. Of the 5% of GDP spent on health care the government contribution is only 17 17.8% 8% which amounts to 0.9% of GDP. Health H lth care i in I India di i is th the most t privatized i ti d in the world

Medical expenses and impoverishment

Survey conducted in 3 districts in Gujarat and Andhra Pradesh - 85% of the households in Gujarat and 74% of those in AP health expenses was the main reason for their economic decline. World o d Bank a est estimates ates t that at OO OOP pus pushes es 2.2 % health users in poverty and 1in 4 g those hospitalised. p among

Catastrophic Health Expenditure

A adverse health condition that necessitates more than 10% of the household income in medical expenses (Pradhan 2002) Illness Ill l leads d to l loss of fi income and d significant i ifi extra expenditure. The combination pushes people in to poverty poverty. 9% of households in India experience catastrophic health expenditure Catastrophic health expenditure is more common in the low income group, but it can also effect the middle income group group.

Access to Essential / Life Saving drugs

WHO lists 270 drugs as essential take care of 95% of the health problems. 60,000 , to 80,000 , brands of various drugs g in India 10 of the top 25 drugs sold in the Indian market are non essential, , irrational or hazardous. 56% of the people in India still do not have access to essential drugs (WHO 2004) Deregulation of drug price control has led to spiralling of costs with profit margins being increased to 75-100%

Price variations in drugs

Medicine Brand Company Price in INR Difference

Ofloxacillin 200 mg Levofloxacillin L fl illi 500 mg

ZO Tarivid Levoflox

FDC Aventis Cipla

32 3.2 31 6.82 95 1.51 6 397% 1392% 969%

Amlodepine 5 mg

Travanic Aventis Amoloda c Zidus Amlogar d Pfizer

Income Inequalities

Disparities across income groups

Health Status Indicator Infant Mortality y Under 5 Mortality Childhood Underweight Total Fertility Rate (births/woman age:15 49) age:15-49) Poorest Quintile Richest Quintile Poor/ rich risk ratio

109 155 60 4.1

44 54 34 2.1

2.5 2.8 1.7 2.0

Social Disparities: IMR & U5MR

Can the principles of Primary Health Care be incorporated in to hospitals to synchronize them with community it b based d programmes? ?

Applying the Principles of Primary H lth care Health to t hospitals h it l

Demystifying y y g medicine strengthen g p patient education. Using patients to educate others in the community. Participation of the family and the larger community (volunteers) in caring for the patients. Using the community as gatekeepers for di ti services. directing i Community advisory committee in hospitals Making healthcare affordable affordable. Vertical equity differential pricing / cross subsidization

Applying the Principles of Primary H lth care Health to t hospitals h it l

Rational drug therapy Use of only appropriate/ cost-effective technology. technology

Conclusions
Hospitals can be a good launch pad for community based health programmes There are potential synergies in having community health programmes

Thank you for listening