health beyond hospitals (lecture for ramathibodi clinical fellows)

Health Beyond Hospitals

Nawanan Theera-Ampornpunt, M.D., Ph.D.Department of Community Medicine

Faculty of Medicine Ramathibodi HospitalMahidol University

May 14, 2014

Introduction

2003 Doctor of Medicine (1st-Class Honors), Ramathibodi2009 M.S. (Health Informatics), University of Minnesota2011 Ph.D. (Health Informatics), University of Minnesota

Currently• Lecturer, Department of Community Medicine• Deputy Executive Director for Informatics

Chakri Naruebodindra Medical Institute

[email protected]/Nawananwww.tc.umn.edu/~theer002

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Outline• “Health” & Its Determinants• Health Systems & Healthcare Systems• Functions & Components• Characteristics of a Desirable Health System• Models of Healthcare Systems• Thailand’s Context• Major Issues in Health Care

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“Health” & Its Determinants

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Class Discussion:

What Is Health?

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Health• Health vs. Illness and Disease

• Medical Model:Health = Absence of Illness or Disease

• So what’s the problem with this model?

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Problems with the Medical Model• Emphasis on treatment of illness/disease

• Promotion and Prevention deemphasized

• Not true sense of the word “Health” but rather just “Lack of ill health”

• So what’s a better model of health?

Shi & Singh (2004)

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The WHO Model & Definition

• “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

WHO Constitution (1948)

• Also known as biopsychosocial model of health

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Holistic Health• The well-being of every aspect of what makes a person whole and complete

Shi & Singh (2004)

Holistic Health

Physical

Mental

Social

Spiritual

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The Epidemiology Triangle

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Host

EnvironmentAgent

Disease

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Determinants of Health

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Individual

Adapted from Leerapan B. Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

Environment

Health

Healthcare Systems

Biological- GeneticsPsychological (KAP)- Knowledge- Attitudes- Practice (Behaviors/Lifestyles)

- Physical- Chemical- Biological- Social, cultural, economic, political, technological

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Natural History of Disease

Adapted from Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta: U.S. Department of Health and Human Services; 1992 (Cited in http://www.cdc.gov/osels/scientific_edu/ss1978/lesson1/Section9.html)

Healthy

Health Promotion

Disease Prevention

Early Detection Prompt Treatment Rehabilitation/ Limitation of

Disability

Primary Prevention(Preventing Disease)

Secondary Prevention (Preventing Disability or Death)

Tertiary Prevention(Preventing More

Disability or Death)

Stage of Susceptibility

Stage of Subclinical Disease

Stage of Clinical Disease

Stage of Recovery, Disability or Death

ExposurePathologic Changes

Onset of Symptoms

Usual Time of Diagnosis

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Health Promotion Strategies: Ottawa Charter

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WHO (1986)

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Social Determinants of Health

• The circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.

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WHO (2008)

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Social Determinants of Health

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WHO (2008)

Health Systems & Healthcare Systems

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Health Systems• A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.

• Includes efforts to influence determinants of health as well as more direct health-improving activities.

• More than the pyramid of publicly owned facilities that deliver personal health services.

WHO (2007)

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Health Systems• Includes

• A mother caring for a sick child at home• Private providers• Behavior change program• Vector-control campaigns• Health insurance organizations• Occupational health and safety legislation.• Inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health. WHO (2007)

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Health Care• Health care: Activities and services performed to improve a person’s health and well-being, through prevention and treatment of illness.

• Similar terms• Healthcare services• Healthcare delivery

Adapted from Shi & Singh (2004)

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Healthcare Systems• An organization that delivers healthcare • In general, healthcare systems

• promote good health in populations• balance levels of actual care provided with the expectations of the population they serve

• Narrower definition than WHO’s “Health Systems”

20Adapted from materials developed by Oregon Health & Science University, funded by the Office of the

National Coordinator for Health Information Technology, U.S. Department of Health and Human Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

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Healthcare Systems• Different models of healthcare systems

• Purely public (care conducted by the state)• Purely private (care conducted by independent, privately funded organizations)

• Often a mixed model• In countries with state run healthcare system, a private system may coexist in parallel or offer services not available under the public system



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Healthcare Systems

• Privately owned, commercial organizations may also act as healthcare systems

• These organizations may serve a single area or multiple geographic locations

• Private healthcare systems may be:• Not-for-profit organizations (governed by principle of non-distribution) or

• For profit organizations (distribute surplus funds to shareholders or owners)



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Healthcare Systems

• Healthcare systems can be measured using benchmarks• One framework for assessment:

• Patient assessed value• Performance on clinical interventions• Efficiency



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Public Health

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“is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.“

(Winslow, C.E.A. 1920)

Adapted from materials developed by Oregon Health & Science University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human

Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).

What is Public Health?• Private Health

• Clinicians, Health Practitioners

• Treat Individual Health Problems

• Action usually taken after illness/injury occurs

• Public Health• Agencies• Treat/Maintain Health of

Populations• Actions include

Education, Policy, Research, Monitoring



Multiple Layers of “Health Systems”: A Health Systems Research Perspective

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Hoffman et al. (2012)

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10 Great Public Health Achievements –US, 1900-1999

• Vaccination• Motor-vehicle safety• Safe workplaces• Control of infectious diseases• Decline in deaths from coronary heart disease and stroke• Safer and healthier foods• Healthier mothers and babies• Family planning• Fluoridation of drinking water• Recognition of tobacco use as a health hazard


National Coordinator for Health Information Technology, U.S. Department of Health and Human Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).

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How Has Public Health Improved Healthcare?• Improvements in understanding disease

• Epidemiology is considered the basic science of public health and is• a quantitative basic science• a method of causal reasoning based on developing

and testing hypotheses pertaining to occurrence and prevention of morbidity and mortality

• a tool for public health action to promote and protect the public’s health



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• An example of epidemiology at work: • In 1854: epidemic of cholera in London, England• Cholera is a bacterial disease• Lack of sanitation and overcrowding led to the spread

of disease• Dr. John Snow linked the spread of disease to a

contaminated public water pump• Snow’s hypothesis: cholera was spread by

contaminated water



How Has Public Health Improved Healthcare?

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• Improvements in data collection • Original methods of data collection were crude• progressive improvement in methodology led to the use

of sophisticated scientific methods to collect data• cohort studies • randomized controlled trials




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• Improvements in data analysis (use of tools such as multivariate analysis and meta-analysis)

• Improvement in disease surveillance • Example: the Real-Time Outbreak and Disease

Surveillance (RODS) Laboratory at the University of Pittsburgh, Department of Biomedical Informatics




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• Improvement in training • Establishment of many schools of public health in the

early 20th century• Professional degrees such as Master of Public Health

(M.P.H.)• Improvements in infrastructure

• Federal• State• Local health departments




Functions & Components of Health Systems

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Functions of Healthcare Systems

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Healthcare Service Delivery

Health Insurance

Adapted from Shi & Singh (2004) by Theera‐Ampornpunt

Healthcare Payment

Healthcare Financing

Access

FundingFunding

Claims & Reimbursements

Governance, Policy &

Administration

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Components of Health Systems

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Cited in: Hoffman et al. (2012)

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Components of Health Systems

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WHO (2009)

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Healthcare Delivery

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• Healthcare is delivered in different placesInpatient facilities

• Hospitals• Institutions for treating sick or injured people• Historically places for shelter, almshouses

• Different types of hospitals• General medical and surgical hospitals• Specialty hospitals (orthopedic, pediatrics, women’s

services, psychiatric, neurological, infectious disease)


Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

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Healthcare Delivery

• Hospitals may be publicly or privately owned• Patients can be admitted to a hospital through

• Emergency room• An internal outpatient clinic• Directly admitted from an external physician’s office

• Depends on local practices



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Healthcare Delivery

• Nursing and residential care facilities• Can be short term facilities or long term facilities

• Long term care classified by level of care• Nursing homes gradually shifted from being part of the welfare system to being a part of the healthcare system



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Healthcare DeliveryOutpatient facilities • Hospitals in some countries provide ambulatory care through internal outpatient clinics

• Physicians offices (also known as private clinics)

• Primary care offices• Specialty care offices• Single specialty or multispecialty offices



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Healthcare Delivery• Dental offices

• General dentists or specialists• Medical and diagnostic laboratories• Pharmacies

• Internal pharmacies of hospitals• Private pharmacies

• Community health centers• Other ambulatory health services



U.S. Healthcare IndustryIndustry segment Employment Establishments

Total 100.0 100.0

Ambulatory healthcare services 42.6 87.3

Offices of physicians 17.0 36.0

Home healthcare services 7.2 3.7

Offices of dentists 6.2 20.4

Offices of other health practitioners 4.7 19.6

Outpatient care centers 4.0 3.6

Other ambulatory healthcare services 1.8 1.4

Medical and diagnostic laboratories 1.6 2.4

Hospitals 34.6 1.3

General medical and surgical hospitals 32.5 1.0

Other specialty hospitals 1.4 0.2

Psychiatric and substance abuse hospitals 0.7 0.1

Nursing and residential care facilities 22.8 11.4

Community care facilities for the elderly 5.2 3.5

Residential mental health facilities 4.1 4.0

Other residential care facilities 1.3 1.1

1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008.



Characteristics of a Desirable Health System

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WHO Framework

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WHO (2009)

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EQESAR Framework

• E - Equity• Q - Quality• E - Efficiency• SA - Social Accountability• R - Relevancy

45Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

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Equity

• Equal services for equal needs• Unequal services for unequal needs• Accessibility

• Physical• Psychological• Financial• Information

46Leerapan B. Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

Quality• Safety• Timeliness• Effectiveness• Patient-centeredness

Adapted from IOM (2001)

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Efficiency

• Cost-effectiveness• Output or outcome versus cost• Technical/operational efficiency• Allocative efficiency

48Adapted from Leerapan B. Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

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Social Accountability

• Good governance• Adequate oversight and monitoring• Transparency


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Relevancy

• Relevant to issues/problems in the context of interest

• Context-dependent


Models of Healthcare Systems

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Models of Healthcare Systems

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Model Financing ProviderOwnership

Example of Countries

Employer-based(market-based)

private insurance

Multipayer, voluntary

Private United States

National health insurance

Single-payer (general taxes)

Public/Private Canada

National health system

Single-pyaer(general taxes)

Public United Kingdom

Socialized health insurance

Employer-employee,mandatory

Private Germany

Hybrid Multiple models Public/Private Thailand

Adapted from Shi & Singh (2004)

Thailand’s Context

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Thailand’s Health Systems: Public• กระทรวงสาธารณสุข

• สํานักงานรัฐมนตรี

• สํานักงานปลัดกระทรวงสาธารณสุข (สป.)

• สํานักงานคณะกรรมการอาหารและยา (อย.)

• กรมการแพทย์

• กรมควบคุมโรค

• กรมพัฒนาการแพทย์แผนไทยและการแพทย์ทางเลอืก

• กรมวิทยาศาสตร์การแพทย์

• กรมสนับสนุนบริการสุขภาพ

• กรมสุขภาพจิต

• กรมอนามัย54

Thailand’s Health Systems: Publicราชการบริหารส่วนกลางใน สป.

• สํานักบริหารกลาง

• ศูนย์เทคโนโลยีสารสนเทศและการ

สื่อสาร

• สถาบันพระบรมราชชนก

• สํานักการพยาบาล

• สํานักตรวจและประเมินผล

• สํานักนโยบายและยุทธศาสตร์ (สนย.)

• สํานักบริหารการสาธารณสขุ (สบรส.)

ราชการบริหารส่วนภูมิภาคใน สป.

• สํานักงานสาธารณสุขจังหวัด (สสจ.)

• สํานักงานสาธารณสุขอําเภอ (สสอ.)

• โรงพยาบาลส่งเสริมสขุภาพตําบล

(รพ.สต.)

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Thailand’s Health Systems: Public• สถาบันวิจัยระบบสาธารณสุข (สวรส.)

• สํานักงานกองทุนสนับสนุนการสร้างเสริมสุขภาพ (สสส.)

• สํานักงานหลักประกันสุขภาพแห่งชาติ (สปสช.)

• สํานักงานคณะกรรมการสุขภาพแห่งชาติ (สช.)

• สถาบันรับรองคุณภาพสถานพยาบาล (สรพ.)

• องค์การเภสัชกรรม

• โรงพยาบาลบ้านแพ้ว (องค์การมหาชน)

• โรงพยาบาลของรัฐนอกสังกัดกระทรวงสาธารณสุข56

Thailand’s Health Systems: Publicสภาวิชาชีพ

• แพทยสภา

• ทันตแพทยสภา

• สภาการพยาบาล

• สภาเภสัชกรรม

• สภาเทคนิคการแพทย์

• สภากายภาพบําบัด

• สภาการแพทย์แผนไทย

• สภาการสาธารณสุขชุมชน

คณะกรรมการการประกอบโรคศิลปะ

• สาขาเทคโนโลยีหัวใจและทรวงอก

• สาขาการแก้ไขความผิดปกติของการสื่อความหมาย

• สาขากายอุปกรณ์

• สาขาการแพทย์แผนจีน

• สาขากิจกรรมบําบัด

• สาขารังสีเทคนิค

• สาขาจิตวิทยาคลินิก

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Thailand’s Health Systems: Public• กระทรวงศึกษาธิการ

• กระทรวงแรงงาน

• สํานักงานประกันสงัคม (สปส.)

• กรมสวัสดิการและคุ้มครองแรงงาน (occupational health & safety)

• กระทรวงการคลัง

• กรมบัญชีกลาง (สิทธิข้าราชการ)

• กระทรวงการพัฒนาสังคมและความมั่นคงของมนุษย์

• กรมพัฒนาสังคมและสวัสดิการ

• สํานักงานส่งเสริมสวัสดิภาพและพทิกัษเ์ด็ก เยาวชน ผู้ด้อยโอกาส คนพิการ และผู้สงูอายุ

• สํานักงานส่งเสริมและพฒันาคณุภาพชีวิตคนพิการแห่งชาติ58

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Thailand’s Health Systems: Public• กระทรวงเกษตรและสหกรณ์

• กรมปศุสัตว์ (Zoonosis & control of outbreaks)

• กระทรวงทรพัยากรธรรมชาติและสิ่งแวดล้อม

• กรมควบคุมมลพิษ (Environmental health)

• กระทรวงคมนาคม (เช่น เรื่องอุบัติเหตุจราจร)

• กระทรวงการต่างประเทศ (เช่น นโยบายสุขภาพระหว่างประเทศ)

• กระทรวงยุติธรรม (เช่น การฟื้นฟูสมรรถภาพผูต้ิดยาเสพติด)

• สํานักงานคณะกรรมการคุ้มครองผู้บริโภค (สคบ.)

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Thailand’s Health Systems: Private

• For-profit hospitals• Non-profit hospitals• Private clinics• Pharmacies• Private laboratories• NGOs• Media• etc.

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Thailand’s Hospitals (2010)

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Hospital Category Number of Hospitals

Percentage of All Hospitals

District hospitals (MOPH) 737 56.4%

General hospitals (MOPH) 68 5.2%

Regional hospitals (MOPH) 26 2.0%

Other hospitals under MOPH*

50 3.8%

Other public hospitals outside MOPH†

111 8.5%

Private hospitals 315 24.1%Total 1307 100.0%

*Including general and specialty hospitals under other departments within the Ministry of Public Health.†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state enterprises, and public hospitals under local governments.MOPH = Ministry of Public HealthSource: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).

Major Issues in Health Care

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• Public Policy & Healthcare Reform• Universal Health Coverage• Cost Containment• Quality & Patient Safety• Innovative Models of Healthcare Delivery & Financing

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• Evidence-Based Practice• Increased Expectations & Patient Volumes• Prevention vs. Treatment• Rise of Aging Population & Chronic Diseases• Legal Issues (e.g. Malpractice)• Patient engagement• Workforce: Shortages, maldistributions & evolving competency requirements

• Technological Advances 64

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• Globalization• Educated, engaged patients• Lifestyle changes• Challenges in control of disease outbreaks• Emerging field of “Global Health”

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Paradigm Shifts in Medicine

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• Physician-centric to patient-centric care• Individual to team-based care• Paper-based to electronic-based management of medical records

• Provider-kept to personal health records


Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1c).

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Summary

• Health Health care• There are “Health” issues beyond hospitals• There are key players of “Health” beyond hospitals

• Clinicians should learn to play collaborative roles with others within and outside hospitals for health of individuals and population.

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References• Centers for Disease Control and Prevention (CDC). Ten great public health

achievements--United States, 1900–1999. MMWR Morb Mortal Wkly Rep. 1999 Apr 2;48(12):241-3.

• Hoffman SJ, Rottingen JA, Bennett S, Lavis JN, Edge JS, Frenk J. A review of conceptual barriers and opportunities facing health systems research to inform a strategy from the World Health Organization. Geneva, Switzerland: World Health Organization; 2012. Available from: http://www.who.int/alliance-hpsr/alliancehpsr_backgroundpaperconceptualbarriersopportunities.pdf

• Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. 337 p.

• McKee M. Measuring the efficiency of health systems. The world health report sets the agenda, but there’s still a long way to go. BMJ. 2001 Aug 11;323(7308):295-6.

• Shi L, Singh DA. Delivering health care in America: a systems approach. 3rd ed. Sudbury (MA): Jones and Bartlett Publishers; 2004. 652 p.

• Winslow CE. The untilled fields of public health. Science. 1920 Jan 9;51(1306):23-33.

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References• World Health Organization, Commission on Social Determinants of

Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. Available from: http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

• Constitution of the World Health Organization. Geneva, Switzerland: World Health Organization; 1948. Available from: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf

• Everybody’s business. Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, Switzerland: World Health Organization; 2007. Available from: http://www.who.int/healthsystems/strategy/everybodys_business.pdf

• Systems thinking for health systems strengthening. Geneva, Switzerland: World Health Organization; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf

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health beyond hospitals (lecture for ramathibodi clinical fellows)

Health & Medicine