I la "salut a totes les polítiques", on ha anat a parar?

MAKING HEALTH PUBLIC. A Manifesto for a New Social Contract

Lessons from the demise of Public Health England: where next for UK public health? 

A Anglaterra després de la pandèmia, l'agència de salut pública en va sortir perjudicada per tot el que havia passat. Va desaparèixer i en van crear dues: UK Health Security Agency and the Office for Health Improvement and Disparities. Però en Peter Littlejohns et al. en un llibre acabat de sortir ens expliquen que caldria una alternativa diferent, caldria bastir un nou contracte social.

Al llibre primer repassen com han arribat fins aquí, i aquest gràfic ho resumeix:

i com diferents determinants de la salut es dilueixen en moltes agències:

i precisament per això cal revisar en profunditat l'organització i la coordinació.

I acaba així:

Unless our broken political and governance system, with its numerous systemic failings, is confronted, then attempts to tackle complex problems like public health, which requires long- term commitment, proper investment and a relentless focus on delivery, will fail.

Tinc la impressió que els britànics han fet marxa enrera els darrers anys en moltes de les polítiques de salut, i no només en els resultats, també en les idees i la capacitat de dur-les a la pràctica. Ara bé tenen una capacitat d'explicar-ho i criticar-ho que no tenim aquí. Una reflexió sobre l'organització que tenim de la salut pública seria especialment desitjable. Es precisament aquest pensament crític el que crec que ens convindria replicar.

El Pla Interdepartamental i Intersectorial de Salut Pública (PINSAP) de la Generalitat de Catalunya era una iniciativa pionera alineada amb les recomanacions de l’Organització Mundial de la Salut (OMS) per impulsar la salut des de tots els àmbits de l’acció del Govern i la societat, és a dir “salut a totes les polítiques” i va desaparèixer de les prioritats governamentals d'aquí el 2020, i ningú ha dit res al Parlament a hores d'ara. Ara farà una dècada que va començar i no he sabut veure cap avaluació recent de l'impacte. Molt trist tot plegat, podem fer desaparèixer prioritats i polítiques sense dir res, i no passa res. Després de tants esforços, ha anat a parar a la paperera de la història?

PS. Si voleu donar pistes a la nova ministra sobre com posar en marxa l'agència de salut pública o com no fer-ho, l'informe original en pdf és de fet millor que el llibre. El títol de llibre té atractiu, però el contingut del contracte social és imprecís.

Ara la prioritat ha de ser l'accés als serveis de salut

 A Population Health Impact Pyramid for Health Care

Aquest abril passat va fer 100 anys que es publica el Milbank Quarterly, revista de referència absoluta en política sanitària. I van preparar un especial d'obligada lectura per a tots aquells que els preocupa la salut poblacional. Avui destacaré un article tant sols.

El missatge de l'article és que cal més pensar en polítiques de salut poblacional que en polítiques d'assistència sanitària. Fins aquí, res de nou. Proposen un esquema per fer-ho operatiu. Es tracta de la Piràmide d'impacte en la salut poblacional:

Fixeu-vos per on comença, amb la formació de les professions sanitàries. Elemental, claríssim. Si no hi ha la formació en la qualitat i quantitat necessària de professionals difícilment tindrem millora en la salut. 

I si hi ha un embús en l'accés als serveis perquè no hi ha professionals o la seva productivitat és baixa, aleshores tenim molts més problemes en cascada.

A UK la llista d'espera és de 7,75 milions de persones, a Espanya és de 4,8 milions de persones (quirúrgica i ambulatòria, sense comptar l'espera per proves diagnòstiques), a Catalunya 844.255 persones esperant a data de juliol 2023 (186.665 per cirurgia, 476.623 per consultes i 180.967 per proves). El 10,6% de la població catalana està esperant per a ser atès al sistema de salut. A UK l'11,5% de la població està esperant. A Espanya el 10,1% de la població segueix també esperant.

Podem parlar de determinants socials, comercials i polítics de la salut, però el problema el tenim al capdamunt de la piràmide. Aquesta és la qüestió de fons a la que tantes vegades m'he referit i que no es resol estrictament amb diners. Cal reforma organitzativa, del context de l'assistència sanitària (també a la piràmide).

Com podeu veure amb el meu comentari he girat la orientació de la fletxa, perquè crec sincerament que l'ordre dels factors és erroni. Malgrat considerem la importància dels determinants socials i de l'entorn, si hi ha el 10% de la població esperant perquè no pot accedir als serveis, aleshores allò de que l'atenció sanitària influeix menys que altres factors en l'assoliment de la salut no se sosté. I no se sosté perquè si no hi ha accés no hi ha atenció. Així de clar. Quan es parla dels determinants de la salut, la premisa és que l'atenció sanitària existeix, però quan hi ha llistes d'espera d'aquesta magnitud i sense prioritzar, aleshores ja som en un altre entorn. Un entorn indesitjable on parlar de determinants socials està bé, però que primer caldria reduir fonamentalment aquest 10% de la població que espera massa temps per ser atesos.

Per tant el missatge avui hauria de ser hem de pensar el polítiques de salut poblacional però si no hi ha accés, aleshores la prioritat són les polítiques d'assistència sanitària, i per sobre d'això la formació de professionals i la disponibilitat de recursos i infraestructures. Ens trobem a prop d'una emergència sanitària. O potser ja hi som i no ens n'hem adonat.

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

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.

 

 

IA pertot arreu

Multimodal biomedical AI

En aquest blog he anat explicant darrerament els avenços en la intel·ligència artificial i els podeu trobar en aquestes entrades. La innovació és tan ràpida que costa molt estar atent al que està passant. Per aquest motiu us suggereixo una ullada a l'article que parla de la intel·ligència artificial multimodal en biomedicina, recullo una frase:

The development of multimodal AI models that incorporate data across modalities—including biosensors, genetic, epigenetic, proteomic, microbiome, metabolomic, imaging, text, clinical, social determinants and environmental data—is poised to partially bridge this gap and enable broad applications that include individualized medicine, integrated, real-time pandemic surveillance, digital clinical trials and virtual health coaches (Fig. 1). In this Review, we explore the opportunities for such multimodal datasets in healthcare; we then discuss the key challenges and promising strategies for overcoming these. 

I un gràfic: 

 

i el que són els foundation models:

Bommasani R et al, arXiv, July 2022

i si voleu saber l'última informació sobre "multimodal ai", la trobareu aquí.

I jo em pregunto, hi ha algú aquí aprop que estigui a l'aguaït de tot això? Es tant important que convindria no perdre passada i em temo que fem tard.

PD. Avui  a WSJ i al NYT 

"This is going to change everything about how we do everything. I think that it represents mankind’s greatest invention to date"

Els riscos d'un estil de vida sedentari

 Step Up! Tackling the Burden of Insufficient Physical Activity in Europe

Els hàbits i comportaments són determinants per la salut, ho sabem tots i alhora sovint fem com si sentíssim ploure. El més difícil de tot és que una vegada tenim consciència del risc adoptem l'actitud acurada per prevenir les conseqüències del nostres hàbits i comportaments. Al principi hi ha tenir la consciència del risc, sense això ben poc hi pot haver després. Fa temps que en vaig parlar i allà insistia en la importància de la comunicació de riscos a nivell poblacional. Això no s'improvisa, i els anys passen i podem veure que s'ha fet ben poc al respecte.

Ara que l'OCDE i l'OMS han publicat un bon informe sobre el sedentarisme, convé impulsar totes les polítiques de salut pública per afrontar-lo. Altrament ja us puc assegurar que davant l'obesitat creixent, l'opció que alguns ja entreveuen és combinar sedentarisme amb fàrmacs per aprimar. Un estil de vida privat que acabarà fent-se càrrec el finançament públic, és clar. Hi som molt aprop.

Altrament per passar a l'acció, cal llegir el capítol 4 on explica quines són les tasques a fer des de la vessant política:

Despite many countries having stepped up their efforts to promote physical activity, there remain gaps in the policy response. For example, schemes to promote active travel to school or work are only present in 14 and 17 out of 27 EU Member States, respectively.

A wide range of policy options exist to increase population physical activity, which improve population health, as well as reduce health care expenditure, including:  setting-specific programmes, in schools, workplaces and the health care system, policies to increase access to sports facilities,  urban design, environment and transport policies,  communication and information policies 

As physical activity is a complex behaviour, a comprehensive package of policies is needed to target all its drivers at the same time, with sufficient and sustained funding and evaluation.

A policy package aimed at increasing physical activity, implemented in 36 countries, would save around EUR 14 billion in health cost by 2050 (equivalent to the total annual health care expenditure of Greece) and return EUR 1.7 for every EUR 1 invested.

Malauradament no trobareu Catalunya a l'informe de l'OMS, encara que financem una oficina a Barcelona amb els nostres impostos i no sabem què en rebem a canvi. Però aquí en teniu un sobre pràctica esportiva de l'any 2019, que va servir pel Pla d'activitat física i esport, mentre es van oblidar que hi havia una enquesta de salut on explica moltes coses d'això amb força detall. I és que la guia de prescripció de l'exercici físic per la salut és de l'any 2007... Això no es resoldrà fent Youtubes que han vist 500 persones al llarg de 6 anys! I tampoc es resoldrà si es confon l'activitat física amb activitat esportiva, com fa el Pla vigent. Una petita ullada a l'informe seria molt recomanable.

PD. Aquí podeu veure què vaig dir el 2012 de l'oficina de la OMS a Barcelona. Una oficina cara, això és tot el que financem amb diners dels catalans, i algú sap si val la pena fer-ho?. Tot el que han fet durant l'any 2020 és un informe en anglès sobre la planificació sanitària catalana. Ho comentaré properament.

PD. El blog de l'OCDE

 

 

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

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.

Behavioral pandemics

 Human Behaviour in Pandemics. Social and Psychological Determinants in a Global Health Crisis

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

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.

 

Nudging and public policy

 Psychology and Behavioral Economics. Applications for Public Policy

This is a textbook on applied behavioral economics for public policy issues. In chapter 5 you'll find the health section and this is the summary:

Where people live, what they eat, how careful they are about taking their medications, and even what they do in their spare time are very much related to the quality of their lives and their health-related outcomes. While our genetic makeup accounts for a signifcant portion of our health outcomes, we know that health is also heavily infuenced by what are known as social determinants: education, wealth, neighborhood safety, housing, and health literacy, among many others. Throughout the day, we face many decisions that have a direct or indirect impact on our health and quality of life. Many of these choices can be infuenced toward healthier options by behavioral interventions.

This chapter presents behavioral insights and interventions that have a high potential to impact the health of community members, reduce disparities, and improve their overall quality of life. These insights and interventions range from increased medical adherence to improved nutritional choices using nudges, regulations, provision of information, or rewards for positive behaviors

 

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.

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.

Risk stratification, objective and subjective

 Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients

A proposal in two steps:

Step one involves sorting patients into one of three risk groups (high, medium, and low) based on objective data, which we take from claims or our electronic health record (EHR). We make our determinations based on the presence or absence of such factors as chronic conditions, advanced age, multiple comorbidities, physical limitations, substance abuse, a lack of health insurance, low health literacy, frequent hospitalizations or emergency department (ED) visits, recent major surgery or brain trauma, polypharmacy, or difficulty following a treatment plan. Some EHRs will calculate a risk score automatically based on this data. In either case, it is important to adjust the score based on additional, subjective considerations, which are the focus of step two.

In step two we assign each patient to one of six risk levels based on how physicians and staff answer the following questions:

• Is the patient healthy with no medical problems? If so, are his or her biometrics in or out of range?
• Does the patient have chronic conditions but he or she is doing well?
• Does the patient have chronic conditions that are out of control but without complications?
• Does the patient have complications of chronic disease or high-risk social determinants of health? (If you or your care team are unsure how to assess or address a patient's social determinants of health, the AAFP's EveryONE Project1 includes tools and resources.)
• Is the patient potentially in danger of dying or being institutionalized within the next year?

I missed any reference to morbidity and episode measurement. My impression is that objective measure is the first mandatory step through groupers, and risk stratification improves with subjective sources of information. And levels can be allocated through probabilistic fuzzy systems.

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. 

On healthcare and its contribution to decline in mortality

 The (Still) Limited Contribution of Medical Measures to Declines in Mortality

The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century

 “Medical measures appear to have contributed little to the overall decline in mortality in the United States since about 1900.” Readers might assume that this statement is from a recent research article or policy report featuring the social determinants of health. But no, it is from the 1977 seminal Milbank Quarterly article by John and Sonja McKinlay titled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century.”

 In the section of Milbank Quarterly Classics, David Kindig explains his favourite topic while reviewing the McKinlays 1977 article:

 “if they [medical measures] were not primarily responsible for it [the decline in mortality], then how is it to be explained?” They did not answer this question themselves, but referred back to McKeown, who had concluded that “the main influences were: (a) rising standards of living, of which the most significant feature was a better diet; (b) improvements in hygiene; and (c) a favorable trend in the relationship between some micro‐organisms and the human host.”2 However, in their conclusion they magnified this point, stating that “profound policy implications follow from either a confirmation or a rejection of the thesis. 

 For many years, I taught a session of my population health course featuring the two contemporary papers that frame what we know today—the first by McGinnis and colleagues, based on CDC surveys, argues that medical care is responsible for about 10% of preventable mortality, and the second an econometric analysis by David Cutler argues that medical care was responsible for 50% improvement in certain causes of mortality over the period of 1960 to 2000. When students are shocked by this range, I remind them that, in a world that still predominantly assumes the pre‐McKinlay reality of medical care being close to fully responsible for preventing or curing disease and death, it is still a profound statement to many that much more than medical care goes into the production of health.

A must read. There are still many unanswered questions.

Hopper

Determinants of change in life expectancy

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and −7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

 A must read article. This is the kind of messages that can inform policymakers and redefine priorities. Unfortunately, there is no similar study for my country.

PS. If you want the same study over two centurys, check here

Vaquero at Marlborough

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 $ !!!

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