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Population Health 101, Modules 1-2 - Coggle Diagram
Population Health 101, Modules 1-2
Module 1: Introduction to Health Systems
What is a health system?
What are health systems meant to do?
According to the WHO: "Provide financial protection against the costs of ill-health: "rich and poor are treated alike, poverty is not a disability and wealth is not advantaged."
Most importantly, to improve the health of a population (health outcomes).
AND, "Respond to people's expectations - making new technologies for workers, shortening waiting times, and upholding a level of respect for individuals at all levels of the system.
In my own words, a health system is one made up of people, institutions, organisations (like hospitals) and resources (like technology or perhaps even PPE) that are all working together to improve the health of a population. According to the WHO: "All activities whose primary purpose is to promote, restore or maintain health."
How does the health system work?
Health services can be split into primary, secondary and tertiary care. These can often be a bit blurred, because it's defined based on the level of specialisation a healthcare job has.
There are three elements to health care: public health, primary, secondary and tertiary.
Public health is health care, not healthcare. It focuses on improving health outcomes, and reducing the determinants that lead to dis-ease. Activity is not always intervention, and not always clinical. It can be showing up to schools and teaching children how to brush their teeth. Epidemiology is also public health.
Primary care is where most medical interventions happen. It is less visible than secondary care but clinicians and others in primary care also provide a key "link" to secondary care. It is the first point of call if a patient recognises that something is wrong. It is essential that primary care is accessible and affordable.
Secondary care is specialised medical/surgical services and uncomplicated hospital care (outpatient and inpatient services). It includes most roles that a GP clinic (or other primary health care service) can refer you to. Generally, roles like general surgeons and dermatologists are considered secondary care. Usually secondary care is provided in a hospital setting, but sometimes these specialist services are also provided in the community.
Tertiary care is almost always highly specialised surgery, characterised by particularly expensive and high-tech machinery. It is the least accessible because there are few tertiary care professionals in New Zealand and in general. It's usually super expensive.
Areas in which health is
not
the primary purpose: Environment, nutrition (woah, what?), housing, education, peace vs conflict, sport and leisure, and transportation. Altogether, these aspects all have a big impact on health outcomes. Obviously.
How might we telll how well a health system is working, using population health and statistics?
First and foremost, no matter how you measure, you won't be able to do it perfectly. The effectiveness of a health system is tough to quantify. Okay. Now let's get into it. :warning:
Measuring the incidence (very important) and prevalence of non-communicable diseases (NCDs) are a really good way of looking at a population's health and how effectively the health system is running. This is because NCDs are common throughout the world, and many different stages of health care are required in order to reduce the frequency of them.
What are the typical broad aims of health systems?
There are three key elements that matter. These are quality, access, and efficiency (efficiency is sometimes known as cost).
Quality is about providing health care services that are of a high standard. There are two aspects to this.
"Clinical quality" refers to skill levels, correct diagnosis and treatment (i.e. effective and safe treatment, with the correct drugs, equipment and method). If your skill level is low, you may not be able to know what the correct method of curing a patient may be, which can be inefficient or downright dangerous.
"Service quality" means that amenities such as the food available and the design of the infrastructure/rooms, convenience (e.g. waiting times), interpersonal quality (e.g. politeness, provision of relevant information), and
interconnectedness between services.
Access means that people are able to make use of a service if they want or need to do so. What sort of things would make it hard to access healthcare?
Being too far away, physically.
The price being too high to afford.
Language barriers?
There's also kind of a fourth aim. That is "the experience of the health workforce" and the target of this aim is to reduce the burnout of healthcare workers. I say that shit is VERY important.
What is health?
The dominant Western view of health follows the biomedical health model. In this model, health is defined as the absence of injury and illness such as that caused by disease.
Typically, "disease" in the traditional biomedical model boils down to identifiable abnormalities of the body.
This model is rooted in certain beliefs of what is and isn't normal that have been set up by... Cisgender heterosexual white European males of the past. Several things are wrong with it.
The idea is that illness is coming from a SINGULAR part of the body that's not working how it ideally should. Focus is on "organic" illness (illness which only relates to one organ.)
It was believed that mental phenomena, such as emotional disturbances like depression, were completely separate from other disturbances of bodily function. There was no recognised connection in the health of one's mind and one's body.
Psychosomatic illness very much exists, so we know that isn't true.
The patient is a passive recipient of treatment, although cooperation with treatment is expected. Things just happen to them and they accept it.
The patient is a victim of circumstances with little or no responsibility for the presence or cause of the disease. If you have type 2 diabetes from eating cake and drinking soda every day, oh well. Guess it's the food's fault.
All diseases give rise to symptoms, even if not initially (fuck you if you're asymptomatic, you don't exist). Although other factors may influence the consequences of the disease, they are not related to its defvelopment or manifestations. If you've got lung cancer and smoking makes it worse, well... Obviously the smoke has nothing to do with it.
Under this model, for an illness to be counted as real, a cause must be identified. Sometimes the cause might be related to environmental conditions, such as place of work. Normally, the environmental conditions were ALSO physical, and not psychological or social.
Conversely, this model does not care for whether a patient is happy or sad or stressed or if it's their century.
Seatbelts are designed for biological men. The founders of the biomedical model had the health of men in mind well over the health of women. Other genders too. The injury rates for women in cars are so much higher as a result.
Insomma: exposures, risks, hazards. What is physically happening to the patient? What specific area of the body is affected?
Under this model, what would happen if you couldn't pinpoint someone's illness to just one organ?
You would say it's either psychosomatic (caused by or worsened by mental factors like stress) or idiopathic (arising out of nowhere from seemingly... Nothing).
Many illnesses that aren't "organic" will get ignored when viewed through a biomedical lens.
What is now known as chronic fatigue was once known as "yuppie flu." It takes a long time to diagnose chronic fatigue, because it is diagnosed by exclusion. That means other illnesses are ruled out one by one. Since it targets many different organs, that can take a while. It has an unknown "aetiology" aka cause. There are (likely) several different versions, however.
Endometriosis is another illness that affects the whole body. It is thought that 10% of women in NZ are affected by endometriosis, but it takes an average of 9 years to get diagnosed. That's ages. There should definitely be a more expidited pathway to diagnosis, but since endometriosis (and chronic fatigue) are both illnesses that mainly target women, not a lot of progress has been made.
The International Classification of Functioning, Disability and Health is a list of illnesses. It is still largely biomedical, but there are social and psychological factors included in some cases. It is a "list of things that can be wrong with someone['s health]."
The WHO looked at it and decided that it wasn't completely where they wanted it to be. They recognised that lots of different things can go on at once. Being well isn't just about not having an ailment. Instead of that, we wanted something slightly more positive looking. Something that defines health in a way that is more subjective, because largely that is what health is.
What are people able to do? What are people choosing to do? What is important to people? How easily can they do those things? Anyways, the WHO created a new definition for health. (Bolded, central).
In the newer, better, biopsychosocial model, biological, social, and psychological aspect of one's health are considered rather than solely their biological abnormalities.
l
Social wellbeing looks like: being able to be who you are in all settings.
As an alternative to the frankly stupid biomedical model, the biopsychosocial model of health was created in the 1970s. Defined by Wade and Halligan as a model that recognises that "psychological and social factors influence a patient's perceptions and actions and therefore the experience of what it feels like to be ill."
This model is most commonly discussed in primary care.
It recognises that people are not just machines, and that we all have different experiences.
The health system stopped asking "are you healthy or
not
healthy and started asking other questions such as, "what is affecting your mental state?" Causes of the causes were also being looked into a lot more.
Insomma, it is a model that treat's one's health as the quality of their physical, mental and social well-being. Hauora for atheists?
Patients were no longer seen as passive participants of illness and disease.
The social and psychological factors that influence perception of an illness are seen as important. They are looked at, and if they cannot be modified they are at least responded to.
The WHO defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease".
Our own perceptions of health and its impact on our overall health and wellbeing may also be important. This can include everything in the WHO ICF (International Classification of Functioning) and any expansions on it. This is probably not classifiable, except with a very broad, subjective, non-health measure like quality of life or life satisfaction.
Traditionally it has mostly been about the absence of illness, and sometimes about the capacity to function. Generally it has not been about complete wellbeing. But that is changing!
How can we tell a system is working effectively?
See pink for the broad aims that should be met.
Module 2: Health Professionals
People at every level of the lens need to do their part to ensure a successful health system
Special Topics
NZ HEALTH SYSTEM ORGANISATIONS. This lecture is about learning to identify major organisations within New Zealand's historic DHB health system.
The key players of the DHB system are the Ministry of Health (the leader) DHBs, PHARMAC, ACC, primary care, urgent care, Saint John, and others.
The
ministry of health
governs the direction of the health system that is put in place. Most of the funding for New Zealand's health system is currently done through the ministry of health, but will soon instead be coming from Te What Ora.
Public health and Maternity Services are both centrally funded by the MOH, because they are both considered essential services. Central funding ensures that all New Zealanders have access to those services, regardless of their location or ability to pay for them.
Under the Ministry of Health (MOH) were the DHBs. DHBs were accountable to a combination of publicly elected (7) and MOH-appointed (4) members. The DHBs themselves realised and recognised that the system had inefficiencies in there, so they worked together to provide and plan within some "regional alliances" of 4-6 DHBs each. This allowed intra-regional sharing of "back-room function" AKA behind the scenes work.
Also under the MOH is PHARMAC. This is a public sector organisation, run by a MOH-appointed Board. It is funded with tax money (funded by taxation). It functions as a "payer": that is, it decides what pharmaceuticals the government will pay for, and then negotiates what they will pay for them.
Budget wise, PHARMAC didn't used to have a firm budget; for a long time, their budget was top-sliced from the DHB budget. X percent of the DHB budget went to PHARMAC. In the recent past (pre Te Whatu Ora and low-key also now) it got a budget that was defined as a separate line item in the DHB budget. Simplified: That means it gained some "purchasing power". Before, they were buying smaller quantities and thus getting less bang for their buck. Now, they can buy more stuff at once, and just like your mom's bulk shopping, they get themselves a deal.
Its role: which pharmaceuticals should NZ get? How much of it will we buy? How much will we as New Zealanders pay for those medications?
By the way, we don't get to see those prices because they're "commercial things." Thanks Richard.
A figure gets given, and gets provided on the pharmaceutical schedule. Then there's usually a large rebate (a large cut-down on what the government will actually be paying for them drugs) (a discount lol). The rebate is done so that it's not clear what price was paid, and so cheap prices don't cause a problem in New Zealand's
NOTE: budget for non-hospital pharmaceuticals is set by the Minister of Health.
PHARMAC has a role in public hospitals on which medicines are used and with negotiating national contracts for devices.
Fun fact, PHARMAC is the only agency in the world which
Decides what medicines to fund and 2. Manages a fixed budget for purchasing them. We USED to bargain like Asians (over the the last 10 years our stubbornness has saved us about 7.2 billion dollars) but we've simmered down a bit. This means that pharmaceuticals in NZ are cheaper than other places. What they DON'T do is approve of medicines. That job is for Medsafe.
PHARMAC also buys breast pumps and pregancy tests, and other medical things that aren't directly medicine itself.
Now, if you thought PHARMAC was unique, wait till you bloody hear about our Accident Compensation Corporation (ACC).
The public is covered by the ACC for all accidents. In return, the public give sup the right to sue medical practicioners (OH! HOLY SHIT! THAT'S WHY? WOW.) It's smart, because all that added cost of litigation (lawsuits and such) is gone, and it goes instead to funding the health system. Plus, healthcare workers don't have to face the pressure of potentially getting sued, which reduces the toll on them.
The ACC is another public sector organisation run by a Board, this time appointed by the Minister of Accident Compensation, rather than by the entire MOH.
Funding: the ACC is funded by employer levies (separate from general tax, and also, the employers have to do the math there, not the employees), taxation and vehicle registration.
Function: "Payer" like PHARMAC. "ACC is a compulsory insurance scheme. ACC contracts with providers for services to accident victims (and in doing so, drives policy in this area)."
In terms of provision, the ACC often says yes to things that the DHBs often didn't. A high clinical quality is provided because it is well funded.
Here are some things ACC covers that DHBs don't, as per ChatGPT:
Rehabilitation services for people with injuries or disabilities caused by accidents
Primary healthcare services related to an injury or accident, such as physiotherapy, chiropractic, or acupuncture
Home and community support services for people with injuries or disabilities caused by accidents
Mental health and addiction services related to an injury or accident
Vocational rehabilitation services to help people return to work after an injury or accident.
The service quality of course has to be extra good, because otherwise the question of, "what was the point of giving up our rights to litigate?" Can arise. That is a pressure.
Primary care: general practices and medical centres.
Private, for-profit business.
Funded by both patient co-payments, and per head (AKA per capita) by Primary Healthcare Organisations (PHOs). It is not clear what is up with PHOs in the near future.
Function: Providers.
Urgent Care Clinics (most prominent in Auckland). Open during the day and during after-hours. They used to be known as accident and medical services. Lower rate medical services than the ED.
Private, for profit.
Funded by co-payments from patients; payments also come from ACC for treatment of accident victims. Is it per head or per dollar?
Function: provide walk-in general medical (primary) services; usually they have x-ray services.
They are "probably like some of the overcrowded Eds." It is good that minor injury/accident based work happens here, because that prevents overcrowding in EDs.
Other private not-for-profit providers
Tend to be found in health care services that aren't centred around medical professionals, such as mental health, newborn babies and infants, disability services (physical and intellectual disability). They may serve the needs of particular groups and communities, such as Maori and pasifika health providers.
St Johns Ambulance
NZ's response to COVID-19
Iff you can get the health right, you can get the economy right. Prioritising health over revenue was clearly the smarter move.
We had a relatively light set of restrictions throughout COVID overall.
From very early on...
We were built different.
More recently, our responses were less robust with more of an emphasis on maintaining social cohesion.
Favourable outcomes: deaths, some efficient processes (drive through), lower times in lockdown.
Health + economy, not health or economy
Commitment to stick with policy, even when facing criticism.
One set of guidelines across the country, rather than a lot of local policies that differ.
Clear and consistent Information, supported by medical professionals.
NZ was fortunate in its ability to react to COVID-19 but benefitted from very broad support.
There has not been a trade-off between economic growth and lives saved. We have had both between 2019 and 2022.
Where does this leave us now?
Hard to know how many countries are accurately counting numbers.
Long COVID - will have long term effects, and change the needs at primary care and some specialist services.
Other longer health effects, especially in mental health.
Loss of care/compassion for others?
How do changes to a health system get made?
Obviously, whilst much of the success of a healthcare system is determined by things that happen on a smaller level (e.g. every patient and health professional interaction) all the changes being made by the government happen at the macroscopic level. This means that people are not all going to be happy, because there are so many perspectives.
"Few politicians are prepared to speak of the rationing of healthcare, but in reality all systems have finite resources, so planning decisions are as much about deciding what is
not
going to happen as what is."
The five control knobs of health system reform.
Financing: refers to how healthcare services are paid for and how the money is allocated across the healthcare system.
Payment: refers to how healthcare providers are reimbursed for the services they provide, and how payment systems can incentivize high-quality and efficient care.
Organization: refers to how healthcare services are structured and delivered, including the roles and responsibilities of different healthcare providers and organizations.
Regulation: refers to the rules and standards that govern the healthcare system, including quality and safety standards, licensing and accreditation, and regulations around the use of technology and drugs.
Behavior: refers to how healthcare providers and consumers behave within the healthcare system, including issues such as adherence to clinical guidelines, patient engagement and participation, and professional ethics.
By adjusting and improving these five control knobs, health-sector reformers can work towards creating a more effective and efficient healthcare system that better meets the needs of individuals and communities.
