2nd National Scientific Conference on

Epidemiology
17 -19 October, Bandung

Epidemiology and Health Systems

Dr Nirmal Kandel , MBBS, MA (Anthropology), MPH, EMBA

Public Health Specialist

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

1|
 Outline

 Setting up the scenario – Epidemiology

 Skills of Epidemiology Trainings

 Uses of Epidemiology

 Health Systems and Framework

 System thinking

 Epidemiological Model for Health Systems

 Tree Model of Health System Framework

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
2|
 Epidemiology – What is this…
let me ask people around

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

3|
What do you mean by Epidemiology

is the study of skin disease

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

4|
 What do you mean by Epidemiology

Worst taught course in

Medical School

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

5|
 What do you mean by Epidemiology

the science of making

obvious obscure

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

6|
 What do you mean by Epidemiology

the science of long division and

provide a summary equation

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

7|
 BUT

The emphasis is not on statistics,

formulas, or computation, but on
epidemiologic principles and
concepts”.

Make statistics as simple as

possible…so that everybody can
absorb

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

8|
 Epidemiology
Epi (upon) + demos (people) + logy (study of)

WHO Define as:

Is the study of the distribution and

determinants of health-related states or
events in specified population and the
application of this study to the control of
diseases and other health problems.

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

9|
 Lets Analyze the Definition
 Study – it is the basic science of public health

 Distribution – Time, Place and Persons

 Determinants – search for the causes (all WH questions)

 Health Related states/events – whole spectrum of health – related

events

 Populations – Deals with Population rather than individual

 Control – Steers public health decisions on developing and evaluating

interventions
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
10 |
 Let’s come out from the box

Have a broader vision

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

11 |
 The evolving conception of epidemiology as a liberal art

The biggest CONFOUNDER is that

Epidemiology is often considered to be a biomedical science that relies on
a specific methodology and high-level technical skills.

 Its not only about diseases and outbreak investigation

 Its not only talk about statistical significance and regression analysis…

Infact, epidemiology in many respects also is “low-tech” science

that can be appreciated by those who don not specialize in this
field.

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

12 |
 Skills Acquired Through
Epidemiological Training

 Use of Interdisciplinary Approach

– Mathematics and biostatistics (for quantitative methods)
– History (for historical accounts of states/events and early epidemiological
methods
– Sociology (social determinants of states/events)
– Demography and geography (population structures and location of
states/events)
– Behavioral sciences (models of states/events, design of health promotion
programs)
– Economics (economic determinants of Health)
– Law (examining evidence to establish causality; legal based for health policy)

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

13 |
 Skills Acquired Through
Epidemiological Training

 Use of the Scientific Method

 Enhancement of Critical Thinking Ability

 Use of quantitative and Computer Methods

 Communications skills

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

14 |
 Briefly
Current Uses of Epidemiology

– Historical: study the history of the health of populations (epidemiological

transitions)
– Community health use: diagnose the health of the community ( to measure the
true dimensions and distribution of ill-health in terms of incidence, prevalence,
disability and mortality; to set health problems in perspective and define their
relative importance to identify groups needing special attentions.
– Health services use: study the working of health services (Operational
research and disease management)
– Risk assessment use: estimate individuals’ risks of disease, accident, or
defect)
– Disease causality use: search for the causes of health and diseases

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

15 |
 Application of Epidemiology on
Health Systems Development

 Health system strengthening has become a recognized priority for

achieving major public health goals such as those identified by disease-
specific global health initiatives, disease eradication, MDGs, universal
coverage etc.

 The most important single contribution that public health makes to

strengthening health systems is provision of relevant and
scientifically valid epidemiologic data upon which to base decisions
and policies affecting all aspects of the larger health system

 Providing the right kind of care to the right people in the right way at the
right time.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
16 |
 Health Systems
A health system 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.

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

17 |
 Health System Framework

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

18 |
 System Thinking in Health Systems

 Systems thinking is an approach to problem solving that view

‘problem’ as part of a wider dynamic system.

 Systems thinking involves much more than a reaction to

present outcomes or events.

 It demands a deeper understanding of the linkages,

relationships, interactions and behaviors among the elements
that characterize the entire system.

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

19 |
 System Thinking in Health Systems

Hence, system thinking includes:

– the nature of relationships among the building blocks
– the spaces between the blocks (and understanding what
happens there)
– the synergies emerging from interactions among the
blocks.

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

20 |
 Epidemiological Model for
Health Systems

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

21 |
 Development of Health Policy, Planning,
Strategies, Standards

Health Workforce Finance Information Health Services Medical Products, Governance/leadership

vaccine, technologies • Leaders and Managers
• Distribution & Need • Health Insurance • Types of Info • Types of Services
• System &
• Training & Capacity • User Fee • Info Generation • Distribution • Logistics Epidemiological
• Quantity and Quality • Costing and budgeting • Application • Other workforce • Technology & thinking
• Other workforce • Dissemination • Logistics Utilization • Strategic
• Management Implementation

Who, Where, • Mortality

• Morbidity
When, How, Population Needs - Health
Why, What • DALYS

• Distribution • The physical environment

• Type • Economic environment

• Risk Population
Population • Social Environment

• Marginalized • Life style/behaviour

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

22 |
 Monitoring of the health system,
organizational and programs
performance
with epidemiological techniques

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

23 |
 Epidemiology Defines Health System Needs by..

• Monitoring the population (demography)

• Distribution
• Type
• Risk Population
• Marginalized

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

24 |
 Epidemiology Defines Health System Needs by..

• Helping to determine
• The physical environment
• Economic environment
• Social Environment
• Life style/behaviour

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

25 |
 Epidemiology Defines Health System Needs by..

• Population needs based on the burden of

diseases/events
• Mortality
Who, where,
• Morbidity when, how, why,
what
• DALYS

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

26 |
Based on those needs Building Blocks function on

Health Workforce
• Distribution of different type of health
workforce (based on WH questions)
• Trainings and distribution
• How many, what types of health care
workers etc (Quantity and Quality)
• Other group of cadres not specialized in
health

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

27 |
Based on those needs Building Blocks function on

Finance
• How to pay for the service
• Health insurance (Social,
Community, Private)
• User fee mechanism
• Cost of the services (for local and
national planning) etc
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
28 |
Based on those needs Building Blocks function on

Information
• Types of information needed
• Mechanism of information generation
• Utilization at various levels
• Dissemination

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

29 |
Based on those needs Building Blocks function on

• Health Services (service delivery)

• Types of services implementation
(Immunization, mass campaign, clinical
facilities, prevention and health education and
list goes on)
• Where and how to distribute the services
• Who are going to deliver, rational distribution
of health workforce and other logistics
• Supporting services

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

30 |
Based on those needs Building Blocks function on

Medical Products,Vaccine and Technologies

• What are the essential list of medicine,
vaccines and equipment
• Need for new technology, innovation
and utilization
• Distribution and management of supply
chain etc

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

31 |
 Based on those needs Building Blocks
function on

Governance and Leadership

• System thinking or epidemiological thinking
capacity for managers and leaders
• Development of contextual policy as per the
need
• Centralization or decentralization

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

32 |
Based on those needs Building Blocks function on

Based on above we have to develop

• Health Policy
• Health Planning
• Health Strategies
• Health Standards

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

33 |
 The 3 Dimensions of Health Systems
(1) Health system building blocks

(2) Program/disease areas

(3) Performance drivers

• Inputs
• Policies & regulations
• Organizational Structures
• Behaviors of HS actors

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

34 |
 A “Cube” View of the Health System

© Abt Associates, 2001

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

35 |
 Inputs vs. Other Key HSS Performance
Drivers

© Abt Associates, 2001

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

36 |
 © Abt Associates, 2001

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

37 |
 Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
38 |
 Acknowledgement and References

1. All the available pictures downloaded from Google Image

2. Everybody’s Business – WHO Framework for Action (Accessed
from http://www.who.int/healthsystems/strategy/en/ )
3. World Health Organization – www.who.int
4. Dr Kenneth J. Rothman (his text books on epidmiology)
5. Ann Lion. Strengthening Health Systems - Moving Beyond
Supporting the Health System, Health Systems 20/20
Disclaimer: These references and contents are only used for teaching
purpose.
Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
39 |
 Thank You

Email
kandeln@gmail.com

Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist

40 |