The size of the pie

From the WEF  report last year on non communicable diseases, I retrieve the size of worlwide health expenditure in 2009:

World expenditure on health in 2009 totalled US$ 5.1 trillion (US$ 754 per capita)13, of
which 61% was spent by public entities. The vast majority of this expenditure (US$ 4.4 trillion) took place in high-income countries, where spending per capita was US$ 3,971 and the share of public spending was 62% of the total. At the other end of the spectrum, low-income countries spent an average of US$ 21 per capita, of which 42% was supplied by public entities.

As far as we need to know the value created from such resources devoted to health care, the European Commission said recently in this document Investing in Health. Accompanying the documentCOMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS:

Increasing the return on health investments requires a solid assessment of the efficiency and effectiveness of spending. Such an assessment faces three main methodological challenges.
The first is to verify that the evidence of efficiency gains and improvements in health obtained through better use of healthcare budgets remains valid when different definitions of health outcomes are used. A major problem is that much of the evidence focuses on crude measurements such as life expectancy, failing to consider the quality of the years of life gained. This is more clearly brought out by concepts such as Disability Adjusted Life Years (DALY), or Healthy Life Years (HLY).
The second challenge is to disentangle the relative influence of health systems on health outcomes from the impact of other determinants of population health, especially living and working conditions, income, education and the most common lifestyle-related risk factors
The third is the time lags between policy changes and their impact on health outcomes, a problem that may involve ‘false savings’ because they may lead to increased costs or other unintended consequences in the long term.
Further assessment of the efficiency of health systems therefore requires a refined analytical framework, structured along three axes:
(1) the definition of sound, reliable indicator(s) of health outcomes, building on the existing European Community Health Indicators,
(2) a better understanding of the effects of health systems on health outcomes, as distinct from the impacts on health of other factors such as health determinants and lifestyles, and
(3) a better understanding of the mechanisms, and therefore the timing, of how health policies affect health outcomes.

Sounds familiar.

The Dahlgren and Whitehead model 30 years after

 The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows

From the authors review:

Reflection on the past 30 years has helped us identify where to go from here, to develop the model so that it is adapted to the burning issues of the day. First, we need to find ways to better illustrate the vertical links between the social, economic and cultural determinants of health and those of lifestyle. This is needed to reinforce the point that many lifestyles are structurally determined. There is a  common, flawed assumption that the lifestyles of different socio-economic groups are freely chosen, ignoring the reality that lifestyles are shaped in important ways by the social and economic  environments in which people live.

Second, there is a current debate about the importance of the commercial determinants of health and whether they have been neglected by the public health community, including a critique of these not being given sufficient prominence in the Dahlgren and Whitehead model (Maani et al., 202015). By ‘commercial determinants’, Maani and colleagues refer to factors that adversely influence health, which stems from the profit motive; the examples they give concentrate on the strategies of tobacco, alcohol and food and beverage producers to promote their products. While we acknowledge that the impact of commercial interests should always be analysed, we deliberately do not define ‘commercial interests’ as a determinant in its own right to be included in the  rainbow model. In a rebuttal to Maani and colleagues, we explain how we consider profit-driven commercial interests as ‘driving forces’ that are related to almost all determinants of health except genetic factors.

 

Què hem de fer davant el creixement desaforat de la medicalització?

The Perils of Medicalization for Population Health and Health Equity

Possiblement el que cal és començar pel principi. Per afrontar la medicalització hem de saber de què estem parlant. Aquest article ajuda en primer lloc a això, i diu:

medicalization—the process by which personal, behavioral, and social issues are increasingly viewed through a biomedical lens and “diagnosed and treated” as individual pathologies and problems

I després posa els exemples i les estratègies:

First, medicalization and its negative aspects need to be better recognized and resisted. There are many audiences in need of a deeper understanding and appreciation of the dangers of the current overly medicalized view of population and public health and the conflation of health with health care. This includes physicians and other types of clinicians, along with health care administrators, executives, and analysts.

 Second, because of the strong focus on individuals and personal responsibility in United States culture, it is critical to expand the capacity for the media to tell different types of stories. Journalists frequently draw from individual anecdotes and thus may require training or resources to effectively tell structural stories in compelling ways. A number of important efforts in this regard are underway 

Third, more health-related research funding is needed across a variety of domains to move beyond medicalized perspectives in research and policy recommendations. A host of behavioral and social science research at the micro, meso, and macro levels needs to be elevated in order to better understand and address the core issues that cut across health status outcomes

Fourth, public policy narratives and priorities for health need to be changed. The conflation of health policy and health care policy must be halted, along with a de-emphasis on health care policy as the main route to improved population health

i conclou:

 A medicalized view of health ignores the limited role that personal health care services and health insurance play in producing levels and distributions of health within communities and populations.Medicalization also has far-reaching negative effects on cultural and media representations of health and illness; on the allocations of funding for research, interventions, and public health infrastructure; and on agenda setting for the social policy reforms needed to address the fundamental drivers of social and health inequity

En qualsevol cas sorprèn que no faci referència al consumisme sanitari ni als determinants comercials de la salut. Hi ha més coses a fer, calen més estratègies que les que diu l'article. En parlarem un altre dia.

Parov Stelar

Models for population health

 Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream

The Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop on September 19, 2019 titled Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream. The term upstream refers to the higher levels of action to improve health. Medical services act downstream (i.e., at the patient level) in improving population health, while such activities as screening and referring to social and human services (e.g., for housing, food assistance) are situated midstream, and the work of changing laws, policies, and regulations (e.g., toward affordable housing, expanding healthy food access) to improve the community conditions for health represents upstream action.

The workshop explored the growing attention on population health, from health care delivery and health insurance organizations to the social determinants of health and their individual-level manifestation as health-related social needs, such as patients' needs. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. This publication summarizes the presentations and discussions from the workshop.

Digital health futures

 The Lancet and Financial Times Commission on governing health futures 2030: growing up in a digital world

The governance of digital technologies in health and health care must be driven by public purpose, not private profit. Its primary goals should be to address the power asymmetries reinforced by digital transformations, increase public trust in the digital health ecosystem, and ensure that the opportunities offered by digital technologies and data are harnessed in support of the missions of public health and UHC. To achieve these goals, we propose four action areas that we consider game-changers for shaping health futures in a digital world.

First, we suggest that decision makers, health professionals, and researchers consider—and address— digital technologies as increasingly important determinants of health. Second, we emphasise the need to build a governance architecture that creates trust in digital health by enfranchising patients and vulnerable groups, ensuring health and digital rights, and regulating powerful players in the digital health ecosystem. Third, we call for a new approach to the collection and use of health data based on the concept of data solidarity, with the aim of simultaneously protecting individual rights, promoting the public good potential of such data, and building a culture of data justice and equity. Finally, we urge decision makers to invest in the enablers of digitally transformed health systems, a task that will require strong country ownership of digital health strategies and clear investment roadmaps that help prioritise those technologies that are most needed at different levels of digital health maturity.

 Neus Martin, Galeria Barnadas

Navigating through data

The Health Data Navigator

Undertanding health system performance starts with the availability of data. Many sources are available, but beyond data you need a framework for the analysis. Since this week a new and healthful source is the Health Data Navigator, the outcome of the Euroreach research. The toolkit summarizes in one document the approach. It is a helpful resource. The institutional basis for performance is often a key neglected element in the analysis. They follow the WHO Building Blocks perspective, although there are other options.
Beyond OECD data, we have right now a new database to check. Unfortunately our country has not joined this initiative by now.

PS. The six building blocks:
• Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources.
• A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).
• A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.
• A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
• A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or
impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.
• Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight,coalition-building,regulation,attention to
system-design and accountability

Climate and health

 Estimating The Costs Of Inaction And The Economic Benefits Of Addressing The Health Harms Of Climate Change

From Health Affairs issue on Climate and Health, first of all:

To accurately describe the health-related costs of climate change, it is important to distinguish between key terms. Climate-sensitive exposures (such as ozone smog air pollution, extreme heat, and extreme precipitation) and health outcomes include those with demonstrated responses to one or more meteorological variables or seasonal patterns.6,7 In recent years, statistical analyses have enabled detection and attribution of the influence of human-caused climate change on extreme weather and other climate-related exposures.8 These climate change–related impacts on the environment include incremental contributions to the frequency and magnitude of extreme rainfall during hurricanes8,9 and increased temperatures during heat waves,10 among others. It is not yet possible to apply analogous methods to directly quantify the attributable portion of climate-sensitive health outcomes to the incremental effects of climate change, as preexisting medical conditions, health vulnerabilities, and multiple exposures are among the many health determinants and causal factors involved. There is currently a knowledge gap that must be addressed for more complete understanding of climate change–related exposure-response relationships.´

Therefore, 

 Expanded valuation analyses of the costs of climate-sensitive health outcomes are urgently needed to inform public policy. The findings from such studies can be linked to provide a sense of the overall scope of health costs from climate change in communities, cities, states, regions, and countries.

At present, it is difficult to characterize the costs of health harms linked to climate-sensitive exposures in the US. Given the current inability to comprehensively track recent damage, there is limited understanding of the scope of projected future climate-sensitive health risks and costs. 

So, there is not any estimate of inaction so far. 

LATAM Health at a glance

Panorama de la Salud:Latinoamérica y el Caribe 2020

Health at a Glance: Latin America and the Caribbean 2020

This is a joint report by OECD and World Bank. It is a key reference to understand health in LATAM and Caribbean. You'll find:

Key indicators on health and health systems in 33 Latin America and the Caribbean countries. This first Health at a Glance publication to cover the Latin America and the Caribbean region was prepared jointly by OECD and the World Bank. Analysis is based on the latest comparable data across almost 100 indicators including equity, health status, determinants of health, health care resources and utilisation, health expenditure and financing, and quality of care. The editorial discusses the main challenges for the region brought by the COVID-19 pandemic, such as managing the outbreak as well as mobilising adequate resources and using them efficiently to ensure an effective response to the epidemic. An initial chapter summarises the comparative performance of countries before the crisis, followed by a special chapter about addressing wasteful health spending that is either ineffective or does not lead to improvement in health outcomes so that to direct saved resources where they are urgently needed.

Spain Health expenditure per capita 2.446 € , Cuba Health expenditure per capita 2.484 $ !!!

Understanding Population Health

Population Health and the Future of Healthcare

Contents:

Defining Population Health

The Road to Population Health: A Changing Society

The Road to Population Health: A Changing Healthcare System

The Roots of Population Health

Health Status and How to Measure It

The Social Determinants of Health and Illness

Paying the Piper: Health Disparities

Population Health and Healthcare Delivery

Population Health and Public Policy

Traditional Approaches to Community Health Data

Data Needs for the Population Health Model

The Role of the Community in Population Health Improvement

Our health and its determinants (2)

The Relative Contribution of Multiple Determinants to Health Outcomes

There are five major categories of health determinants: genetics, behavior, social circumstances, environmental and physical influences, and medical care. If this is so, do we know the relative importance of each factor?
Last February I posted in this blog a figure by Kindig that explains their contribution. Now a Health Affairs brief summarises different views. Check Exhibit 1, and you'll see there that behaviour represents 35-50% of health status according to different estimates.
The message is clear in our current evironment of mostly non-communicable diseases, we have to find better ways to change behaviour towards healthier people. Decisions and actions, short and long term, risk and responsibility, costs and benefits, trade-offs of every day life.

PS. Must read:  The Ethics of Ebola.

The first three doses of ZMapp were administered to the American medical missionaries Kent Brantly and Nancy Whitebol, who have recovered, and the Spanish priest Miguel Pajares, who has since died. Some offered a practical justification for the widely criticized selection of Brantly and Whitebol: It makes sense to treat health workers first, so that they can continue to help others. But this argument largely fell apart with the selection of the 75-year-old Pajares.

PS.  "Only four companies today make vaccines, compared to 26 companies 50 years ago.". My concerns about a future systemic drug industry are closer than expected (at least in vaccines).

The tough figures of worldwide health spending

Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

We live in a disparate world, and the range of health care expenditure per capita goes from $33 in Somalia to $9.267 in USA. These are tough figures, while in Somalia you'll understand that access is the problem, in USA disparity is inside, waste and access at the same time are the problems. The Lancet article shows the reality of world health expenditure. It worths reading it.

The availability of prepaid resources for health, such as government spending, is one of many determinants of access to health care, and can lead to population health gains. Economic development is associated with an increase in spending and specifically an increase in prepaid resources. This is at the core of the pursuit for universal health coverage. This research also points to countries that deviate from the trends, spending more or less than expected, based on their level of economic development. This information is valuable to planners assessing funding gaps and financing opportunities, and can be used to provide insight into what future health financing challenges are likely. Tracking changes in health financing patterns across time and benchmarking against global trends is vital to addressing missed opportunities, ensuring access to medicines and high quality services, and the pursuit of universal health coverage.

Gorgeous new album by Joan Miquel Oliver. Atlantis

The public option for population health improvement

Addressing Social Determinants to Improve Population Health
Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
The Public Option How to Expand Freedom, Increase Opportunity, and Promote Equality

This is what JAMA article says about population health

While health care organizations may not be equipped to address each of the root causes of their patients’ conditions, they need to broaden their perspective on how to address social determinants of health and use their expertise to influence initiatives on education, housing, employment, and other important health related social issues that take place beyond their immediate clinical purview.

"Need to broaden their perspective", this is the message for health care organizations according to the articoe. I'm not so sure about it. The message is not only for health care organizations, it is for public policies. This is much more difficult to address when there is not a public option for the whole population. A new book sheds light on this topic for the US policy.

PS. The Limits of Private Action: What the Past 40 Years Taught Us About the Perils of Unregulated Markets
PS. There Should Be a Public Option for Everything

Els determinants comercials de la salut

 Unravelling the commercial determinants of health

Achieving health for all requires action on the economic and commercial determinants of health

Fa cinc anys vaig parlar dels determinants comercials de la salut. Llavors va ser el Milbank, i ara el Lancet que publiquen articles sobre la qüestió. Cal dir que el Lancet ja ho havia tractat també el 2016. I de sobte, un pot pensar, això va contra alguns negocis, doncs no va a favor de la salut. Millorar la salut és millorar el capital humà i social.

The conflict between profits and health equity is not new. The global health community fought for decades to provide access to antiretrovirals for patients with HIV/AIDS in less-resourced settings. Many commercial actors attempt to negatively influence national and international policies, undermine science, or to directly attack individuals calling out their actions. The recent Lancet Series on breastfeeding showed how an extensive network of lobbying by formula milk companies has derailed progress on breastfeeding education.

Cal esperar ara a l'informe de la OMS del 2024 sobre la qüestió i veurem si serveix per alguna cosa. Per ara molt de renou per a no res.

 

 

Political determinants of health

 The Political Determinants of Health

In this book, Daniel E. Dawes argues that political determinants of health create the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, and lack of healthy food options—that affect all other dynamics of health. By understanding these determinants, their origins, and their impact on the equitable distribution of opportunities and resources, we will be better equipped to develop and implement actionable solutions to close the health gap.

Cost-effectiveness of public health interventions

The case for investing in public health

The evidence shows that a wide range of preventive  approaches are cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening. The evidence in this report shows that prevention is cost-effective in both the short and longer term. In addition, investing in públic health generates cost-effective health outcomes and can contribute to wider sustainability, with economic, social and environmental benefits.

Cost-effectiveness studies  are usually focused towards treatments. This report shows some examples related to public health. Unfortunately,  this is not so common. Up to now my reference on this tòpic was this article. Now I'm adding this report by WHO Euro. And the question remains: if these interventions are so cost-effective, why are we waiting for their implementation?

It is recognized that a comprehensive strategy needs to include a combination of population and targeted individual preventive approaches, but it should be noted that, on average, individual-level approaches were found to cost five times more than interventions at the population level (WHO, 2011a). In general, evidence also shows that investing in upstream population-based prevention is more effective at reducing Health inequalities than more downstream prevention (Orton et al., 2011). Meanwhile, the National Institute for Health and Care Excellence in the United Kingdom found thatmany public health interventions were a lot more cost-effective than clinical interventions (using cost per QALY), and many were even cost-saving (Kelly, 2012).

The right to healthcare access

 Population Health and Human Rights

From NEJM article:

The study of population health encompasses two main objects of analysis: the health conditions affecting a population (the frequency, distribution, and determinants of diseases and risk factors) and the organized social response to those conditions, particularly the way in which that response is articulated in the health system, including the principles and rules that determine who has access to which services and at what cost to whom. These services include both clinical and public health interventions. Since the 19th century, national health systems have sought to provide health services to an increasing proportion of the population, using four eligibility principles: purchasing power, poverty, socially defined priority, and social rights. Reliance on purchasing power means that access is  determined by ability to pay, with governments limiting their role to basic regulation. Because this principle excludes many people, governments have historically intervened to expand access, either through public assistance programs covering families with incomes below a predetermined level or through social insurance schemes for prioritized groups (e.g., the armed forces, industrial workers, civil servants, or older adults). All these eligibility principles result in only  partial coverage, but the ideal of universality has influenced public policy in most countries, though the design and performance of health systems vary widely.

El camí cap a la integració assistencial (2)

Primary Care and Public Health: Promoting Integration to Improve Population Health

Des de l'altra banda de l'Atlàntic, l'IOM ens ofereix més elements sobre la integració assistencial, aquesta vegada enfocant l'atenció primària i la salut pública. L'informe va enfocat a com millorar la salut poblacional:

Improving population health will require activities in three domains: (1) efforts to address social and environmental conditions that are the primary determinants of health, (2) health care services directed to individuals, and (3) public health activities operating at the population level to address health behaviors and exposures. There is abundant evidence for the benefit and value of activities in each of these domains for achieving the aim of better and more equitable population health

Dins hi trobareu case studies, de ciutats com Durham, que conec prou bé, o San Francisco, que també, ateses les destacades universitats que tenen en tema salut. Però quan ho llegeixo m'entra un cert dubte. Semblaria que els casos van per una banda i la realitat per una altra. I és que la integració té sentit quan més ampli és el seu impacte, si s'oblida de l'atenció especialitzada aleshores perd força. Allò que deiem ahir, un llarg camí per endavant.

PS. El dia 1 de maig toca anar a King's Fund:International Integrated Care Summit

PS. Qui et pot tornar 2 anys de la teva vida passats injustament a la presó?. Llegiu aquest relat. Mentrestant ahir veia delinqüents campant per la ciutat impunement.

 I com que l'exposició de Joan Miró, "L'escala de l'evasió" ja s'ha acabat, us resta l'oportunitat de veure escultures seves a Yorkshire, com aquesta que encapçalava el comentari de FT de fa uns dies.

Digital health transformation

Health in the 21st Century
Putting Data to Work for Stronger Health Systems

A new report by OECD highlights the potential digital health environment. We are still far from what they say. However, while reading it you'll be aware of its relevance. Chapter 5 is a must read:

Big data, and big data analytics, can be used at all three levels of health promotion and disease prevention – research, surveillance, and intervention – by:
-Allowing a more precise identification of at-risk populations, through a more comprehensive understanding of human health and disease, including the interaction between genetic, lifestyle, and environmental determinants of health;
-Enabling better surveillance of both communicable and non-communicable diseases; and
- Facilitating better targeted strategies and interventions to improve health promotion and
disease prevention.

A healthy recession?

WSJ headlines announce a new economic slowdown. Concerns about the current state of worlwide economy and the financial sector are growing again. A special report by The Economist talks about the third great wave:

A third great wave of invention and economic disruption, set off by advances in computing and information and communication technology (ICT) in the late 20th century, promises to deliver a similar mixture of social stress and economic transformation. It is driven by a handful of technologies—including machine intelligence, the ubiquitous web and advanced robotics—capable of delivering many remarkable innovations: unmanned vehicles; pilotless drones; machines that can instantly translate hundreds of languages; mobile technology that eliminates the distance between doctor and patient, teacher and student. Whether the digital revolution will bring mass job creation to make up for its mass job destruction remains to be seen.

Some years ago  I explained how Iceland economic crisis had no negative effect on health. Now we can confirm the impact in our country in a new report and presentation. The quick answer is that unemployment and poverty have a clear impact on health. As far as the crisis implies raising both determinants, then the result is clear: poor and unemployed population are the target to monitor and improve health. You can discuss over the trend of one specific indicator or its significance. That's a minor issue. In general, average longevity and health is improving, although average doesn't mean everybody. The only way to have a good answer is a cohort study with microdata. I think that somebody should start doing it now, it's crucial.
This report is the best exercise one can do to introduce some common sense in any debate about the crisis and its impact on health: go to the facts and data. Therefore, if somebody talks about negative effects of the crisis on health, now you have to be precise, there is a selective impact.
Some months ago, I considered that what we need is a continuous monitoring of health status in any situation. As far as nobody knows if we are still in crisis, or how many years it will take to recover, monitoring is the right word.
My impression is that we had a crisis in 2008 and a new economic model has emerged. The current situation is unstable, uncertain and unpredictable. That's why the WSJ has anounced a new slowdown today. It's not a crisis, it's a new slowdown (again).

Research and results

The Biomedical Bubble: Why UK research and innovation needs a greater diversity of priorities, politics, places and people

More resources for research are needed. This is the usual mantra. However, what about outcomes?. Since this is not so easy to measure it really lies in an uncertain land. A new report tries to put things clearer, at least for UK. It explains the mismatch about research funding and what is needed to improve health. This is exactly what I consider the right approach. It is useless to ask for more money unless we explain and focus on the priorities for achieveing better health.

A biomedical bubble has developed, which threatens to unbalance the UK’s research and
innovation system, by crowding out the space and funding for alternative priorities. This
is not a speculative bubble, as developed for tulips in the 1630s, or dotcoms in the early
2000s; there is far too much substance in the biomedical sciences for this. But it is a social, political and epistemic bubble (similar to the ‘Westminster bubble’, or the ‘filter bubble’), in which supporters of biomedical science create reinforcing networks, feedback loops and commitments beyond anything that can be rationalised through cost-benefit analysis.

The biomedical bubble represents a risky bet on the continued success of the pharmaceutical industry, despite mounting evidence that this sector faces a deepening
crisis of R&D productivity, and is cutting its own investment. And it favours a particular approach to the commercialisation of science, based on protectable intellectual property and venture capital based spinouts – despite the evidence that this model rarely works. Our health and social care system is under growing strain, and as the NHS marks its 70th birthday this month, there is renewed debate about its long-term affordability. Too often, the biomedical bubble distracts attention and draws resources away from alternative ways of improving health outcomes. Only 5 per cent of health research funding is spent on researching ways of preventing poor health. And more than half is spent in three cities - London, Oxford and Cambridge - despite variations in life expectancies of up to eight years across the country. This paper argues for a more balanced distribution, aligned to what the evidence clearly shows are crucial social, economic, environmental and behavioural determinants of better health outcomes.

 Food for thought.

Shomei Tomatsu in Barcelona