Global Health introduction

Definition of global health

• Collaborative trans-national research and action for promoting health for all
• Achieving health equity by study, research and practice

Cost effectiveness is a very important aspect of Global Health.

Career in Global Health

• National representative
• Netherlands course in Global Health and Tropical Medicine, 28 months

Determinants of health

Health

• WHO: a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity → practically impossible to achieve
• S. van der Geest: the proper functioning of the body
• M. Hubert: the ability to adept and self-manage

Determinants

• Determinant: a factor that decisively affects the nature or outcome of something

Models of determinants of health are:

• Lalonde framework: assumes no interaction between determinants of health
• Skolnik model: more complex model used in this course

Different determinants influence each other. Health care has a relatively low impact on health status. Social determinants of health are particularly important for the wellbeing of patients.

According to epidemiologists Wilkinson and Pickett, “equality” in itself is a determinant of health.

Long and healthy life is a precondition for development, which stimulates participation in the society. Generally, high income relates to a good health status. Therefore, economic development is a precondition for a long and healthy life.

However, the Blue Zone Project shows that there are additional factors such as social cohesion and lack of stress that stimulate a long and healthy life.

Health indicators

Indicators

Indicator: measure that tells something about the state or level of something. Health indicators are often ratios or rates with a numerator and a denominator.

• Ratio: compares two measures of the same dimension
• Rates: compares two measures of different types

Key Health Status indicators:

• Life expectancy at birth: the number of years a newborn baby would live if subjected to the present mortality risks prevailing for each age group in the population
• Child mortality: low income countries have a high child mortality under 5 years due to malnutrition
  • Categories: perinatal, neonatal, postneonatal, infant, under 5 years
  • Infant mortality rate: the number of deaths of infants under age 1 per 1000 live births in a given year
  • Neonatal mortality rate: the number of deaths to infants under 28 days in a given year per 1000 live births in that year
  • Under-5 mortality rate: the probability that a newborn baby will die before reaching age 5, expressed as a number per 1000 live births
• Maternal mortality ratio: the number of maternal deaths per 100.000 live births
• Maternal mortality rate: the number of maternal deaths per woman of reproductive age per time period
• DALY: disability adjusted live year, YLD + YLL
  • YLD: years of life lost due to disability → number of incident cases, average duration, how severe the disability is
  • YLL: years of life lost due to death → number of deaths and age of death
• HALE: healthy life expectancy, average number of years that a person can expect to live in full health by taking into account years lived in less than full health due to disease or injury

Describing a population:

• Number of inhabitants
• Age distribution/median age
  • Median age: 50% of the population is older than this age, 50% of the population is younger than this age
• Male/female distribution
• Population pyramid
• Growth rate: can be caused by a higher birth rate or by migration trends
• Total fertility rate: TFR, the average number of children that would be born to a woman over her lifetime if:
  • She were to experience the exact current age-specific fertility rates through her lifetime
  • She were to survive from birth through the end of her reproductive life
• Age dependency ratios: the total number of people 0-14 and >65 divided through the total number of people 15-65
  • Can be high due to a high child age or old age → Jordan and Nepal have a low old age dependency ratio, while Japan has a very high one
  • Globally there is a tendency of increasing old age dependency ratio
• Crude birth rate: number of births per 1.000 population during one year
• Crude death rate: number of deaths per 1.000 population during one year
• Standardized/adjusted birth/death rate: corrected for the age distribution

Social Determinants of Health

Social Determinants of Health: social factors that influence our health.

For example what we decide to eat, which may be based on income, which is influenced by social determinants such as unemployment, education or disability. Bad eating habits may cause heart disease.

Information may be collected via surveys, social service or the judge system. This information can be given to health researches to examine health-related issues. Because the information is very confidential, it is made anonymous before being handed to researches.

By influencing social determinants and going beyond the health care system, the health and wellbeing of the population can be improved.

DALY explained

Definition

DALY: Disability Adjusted Life Years, a standardized quantitative measure of the burden of disease.

DALY is a single tool to combine the negative effects of early death and morbidity, a universally recognized and respected method to comprehensively quantify disease burden for a specific disease. DALY is a common metric with the following characteristics:

• Allows direct comparison of the burden across diseases
• Sums burden across diseases
• Permits comparing treated and untreated diseases
• Compares different disease interventions

Score

DALY = mortality + morbidity

• Mortality: life expectancy – age of death → YLL (years of lost life)
• Morbidity: disability rate x disability adjustment → YLD (years lived with disease)
  • Disability rate: 0 = fully healthy, 1 = 100% disabled
  • Disability adjustment: for how many years the disability is present

Discounting

Discounting: DALY estimates are adjusted for timing → future events are treated as having less value from today’s perspective. This can significantly reduce the DALY.

Averting

Treatment can reduce both the mortality and morbidity of a disease. The amount of DALY’s reduced by treated is the “averted” amount of years. Programs try to avert DALYs.

QALY

QALY: quality adjusted life years. Considers the same values as DALY, but from another perspective → quantifies health instead of disease burden. Therefore, bigger QALY values are better while smaller DALY values are better.

RC Measuring health around the world

Facts

Demographic composition: for example whether a population is very old or young.

Methods to measure health status in a LMIC:

• Censuses
• National household surveys (verbal autopsies)
• Data from health facilities
  • Are often paper-based records in LMIC, instead of electronic
  • Often there is missing information, or wrongly categorized information

Data from LMIC in general is a very rough indication of the real situation.

DALYs are subjective, the YLD is determined by experts who discuss about this.

Demographic transition

Major terminologies of the transition framework:

• Demographic transition: shift from a high to low fertility and mortality
• Epidemiological transition: shift in population growth due to change of disease patterns, for instance from infectious diseases to non-communicable diseases
  • Characteristics
    • Sudden and stark increase in population growth rates
    • Due to medical innovation in disease or sickness therapy and treatment
    • Followed by a re-leveling of population growth, declines in fertility rates
    • Change in disease patterns
  • Historically there are 3 stages
    1. Age of pestilence and famine: started 10.000-1.000 years age
    2. Age of receding pandemics: started 200 years ago
    3. Age of chronic diseases: started 50 years ago

These transitions have 4/5 phases which all have an impact on health, and which can be displayed in a demographic transition model. Often these models are based on the fact that there is no immigration in a population.

Double burden of disease

Many LMIC suffer from both non-communicable diseases and infectious diseases. Some groups claim that there is a triple burden of disease in LMIC, adding injuries to the burden.

Development measured by HDI

The HDI is an index of development, not only of health. The HDI is developed by the World Bank and consists of several elements:

• Health: measured by life expectancy at birth
  • Morbidity is not taken into account
• Education: measured by the mean years of schooling and the expected years of schooling
• Living standards: measured by the gross national income per capita
  • Different countries can be compared by converting currencies into international dollars, correcting to what you can buy in a country and taking inflation into account

Atlas method

Atlas Method: corrects for exchange rates between different currencies

Purchasing Power Parity

Purchasing Power Parity: what you can actually buy with an international dollar. An international dollar has the same purchasing power over the GNI as a US dollar.

Trends

The HDI had a trend of increasing globally over time. The progress of the HDI since 1990 has not always been steady, but the general tendency is an increase in de HDI. Some countries suffered reversals due to conflicts, epidemics or economic crises.

Inequality between countries

A country can be very high in the non-corrected HDI, but low on the corrected HDI. The corrected HDI takes inequality into account. Countries with a low corrected HDI have very high rates of inequality in schooling, income and access to health.

GINI Index

GINI index: measures the extent to which the distribution of income or consumption expenditure among individuals or households within an economy deviates from a perfectly equal distribution. It ranges between 0-1. If the GINI-index is 0, there is complete perfect equality within the population. If the GINI-index approaches 1, there is a lot of inequality in different groups. A Lorenz curve plots the cumulative percentages of total income received against the cumulative number of recipients, starting with the poorest individual or household. The GINI-index measures the area between the Lorenz curve and a hypothetical line of absolute equality.

Gender Inequality Adjusted HDI

GII: an index for measurement of gender disparity.

SDI

SDI: Social Demographic Index, an index to measure the overall development and wellbeing without taking health into account. It takes the following factors into account:

• Average income
• Fertility
• Education

Global Income Distribution

Gapminder: the size of the bubble indicates the size of the population

Hans Rosling: the founder of Gapminder. He divided the world into 4 income levels:

• Level 1: <$2 a day
• Level 2: $2-$8 a day
• Level 3: $8-$32 a day
• Level 4: >$32 a day

When put in a graph, this displays the Global Income Distribution.

Global child mortality

The under-5 child mortality (U5M) is a very important indicator to look at global health. The trend of under-5 child mortality is very good. However, this trend is not equally distributed among the countries. Countries in Eastern and South-Eastern Asia have made the most progress, with an 80% decline in under-5 deaths. Sub-Saharan Africa is worse off → these countries are also called the bottom 20%.

Building blocks of a health system

A health system has 6 building blocks:

• Leadership/governance
• Health care financing
• Health workforce
• Medical products and technologies
• Information and research
• Service delivery

Goals and outcomes of these building blocks are:

• Improved health
• Responsiveness
• Financial risk protection
• Improved efficiency

Insufficient numbers of health care workers

Factors responsible for the insufficient numbers of health care workers in LMIC:

• Shortness of HCW and a limited number of training facilities
• Unequal distribution of HCW within countries
• Migration of HCW to high-income countries → “brain drain”
• Migration of HCW to better paying private sectors or NGO’s

Development

Definition

Development: the desired change from a life with many sufferings and few choices to a life with satisfied basic needs and many choices, made available through the sustainable use of natural resources.

Sustainable development goals

Sustainable development goals are 17 goals to transform the world. The UN aims to have achieved the sustainable development goals by 2030. Multiple countries have signed and are committed. Each goal has a different number of targets, which each have several indicators.

GNI

Gross national income: total domestic and foreign value added claimed by residents (GDP) + net receipts of primary income from nonresident sources.

The World Bank has categorized countries into low, middle and high income countries based on the GNI. Middle income countries can be split into low middle and high middle income.

RC Financing health in LMIC

Dutch health system

The Dutch health system:

• Is based on accessible, affordable, good quality care. Like the definition of UHC of WHO
• It developed as a private health system and introduced public health insurance during WWII → ziekenfonds
• It was reformed in 2006 towards private insurance with market incentives of patient choice and competition for contracts
• The government applies strict regulation and pays for long-term care, mental health, preventive care and epidemics such as COVID
• Virtually all health insurance companies are not-for-profit cooperatives and profits are added to the reserves to lower the premiums
  • There are 23 insurers, which bear risks for their operations and compete for clients

Dutch insurance system

The Dutch insurance system is a mix of public and private → the government sets the public requirements, which guarantee the social nature of private insurance:

• Individuals must purchase mandatory basic health insurance of around 1400 euros per year, are free to choose their own insurer and the own annual risk is 385 euros
  • This allows the government to mandate that the health insurance must accept all people under the policy
• Health insurers are required to accept persons under their policy, irrespective of age or state of health
• Premiums for a policy offered are equal for all policyholders, regardless of their health condition, age or background
• Health insurers have a duty of care of the basic package, but excluded are dental care, very expensive treatments of rare diseases and alternative medicine
• One can pay higher premiums to insure a larger package

The Dutch health system compared to LMIC

• Dutch
  • 80% private premium + 20% user fees = around 2000 euros per year
  • Overall financing is 77 billion per year → 5500 euros/person/year and 13% of the GDP
    • This average is above the UK (11%) and below the USA (18%)
• LMIC
  • Insurance is marginal and user fees are very high (30-80% of total health expenditures)
  • Overall financing is between 2% and 8% of the GDP

In short, Dutch inhabitants are well-protected against disease and costs. 24.000 people (0,2%) are not insured by choice or social cases, but hospitals do not refuse them. In LMIC most inhabitants are uninsured. In the USA 13% of the population is uninsured.

Micro and health economics

Economy of scale and scope

• Economy of scale: cost advantages are reaped by companies when production becomes efficient. Companies can achieve economies of scale by increasing production and lowering costs. This happens because costs are spread over a larger number of goods. Costs can be both fixed and variable. An institution benefits from the increase in volume of a single product
• Economy of scope: the production of one good reduces the cost of producing another related good. An economy of scope results in a decrease in the average cost of production.

Performance based financing

PBF is a health reform strategy. A health reform strategy can only be successful if fundamental economic laws are firmly applied.

Basis economic distribution systems

The 2 basic economic distribution systems are:

• The free market system: a form of economic organization in which resource allocation decisions are left to producers and consumers acting in their own best interest with a minimum of central government intervention
• The central planning economy: central decision makers tell people how to produce, what to produce and what to consume

In central planning, decisions on all production and pricing issues represent a gigantic task, means treating a phenomenal quantity of data in complex operations. This may in fact be impossible. Most countries now are in some form of a market economy.

Ideal system

The conditions for perfect competition (the ideal system) are:

• Numerous sellers and customers: rules out collusive arrangements whereby firms work together to fix prices
  • The government must stimulate the suppliers to be competitive and assure that there are no public or private monopolies or cartels → setting up one distribution system or only government health facilities is economically inefficient
    • A monopoly would be the worst possible situation
• Homogeneity of the product: the product is identical to that supplied by any firm and consumers do not care from which firm they buy
  • E.g. the prize for a pizza from a street corner or a seaside restaurant is different, but the product may be the same
  • The same counts for an OPD consultation from a nurse with limited diagnostic equipment or in an advanced clinic run by a doctor, yet in many countries, governments set the same price
• Freedom to enter or leave the market: new firms should be allowed to compete with existing firms → “creative destruction”, which stimulates new ideas or shifts in market opportunities
  • Example of COVID: should the government always invest to protect firms, or would the firm also survive under normal circumstances?
• Perfect information among suppliers and consumers: the government should promote information about:
  • Disease, prevention through government-approved google sites
  • Information about the quality of health facilities
  • Where to open new health facilities by engaging with potential new providers

Scarcity or shortages

If nobody influences consumers or providers, the price will always settle at the equilibrium. If the government intervenes, the price will become either too high or too low. If