Health inequality 0315 r

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Health inequality 0315 r

  1. 1. Social Inequalities in HealthYawen Cheng, ScD Associate Professor Institute of Health Policy and Management, College of Public Health, National Taiwan UniversityEssentials of Global HealthMarch 15, 2013 1
  2. 2. Study Objectives1. Concept of “health equity” and “health rights”2. Health inequalities  Evidences and extent  Causes?3. A historical review on collective actions for achieving health equity  The role of public health policies  On health care systems  On overall living environment (social determinants of health) 2
  3. 3. Public Health Public health is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society. Goal: to promote biological, physical and mental well- being of all members of society. 3 major disciplines  Biological and medical sciences  Environmental and occupational health sciences  Health policy and management 3
  4. 4. Core values Definition of health equity – absence of unfair and avoidable or remediable differences in health among social groups. Primary responsibility for protecting health equity rests with government (importance of state role). Human right – Are health and health care parts of human rights?  1948 UN declaration  1966 ICESCR  2000 Human Right to Health  What are human rights? The story of human rights https:// www.youtube.com/watch?v=oh3BbLk5UIQ (9:51) Empowerment of disadvantage communities 4
  5. 5. Health inequalities? Are there systematic differences in health outcomes? Are these differences unnecessary, avoidable by reasonable action, and are considered unfair or unjust (moral judgment)? 5
  6. 6. Inequalities in Mortality according tooccupational grade in British civil servants(the Whitehall Study) Source: Marmot (2006) Health in an unequal world, Lancet 368, 2081-2094. 6
  7. 7. 7
  8. 8. Age-adjusted Morbidity by Employment Grade: The Whitehall II Study (Marmot, et al. Lancet 1991; 337:1387-93) 25 Pre-menstrual syndrome 20 15 Cough with phlegm % 10 Ischaemia 5 Hypertension Diabetes 0 1 2 3 4 5 6 empl oy ment gr ade 8
  9. 9. Difference in cardiovascular mortalities by income level 9
  10. 10. Cumulative Economic Hardship and Physical, Psychological, Cognitive and Social Functioning (Lynch & Kaplan, NEJM 1997; 337: 1889-95) 5 4Odds Ratio* 3 2 1 0 Dif ficulty DSM-II I-R Lack of Cognitive Social with IADL Depression optimism difficulties isolation Once below 200% poverty (1965, 1974, 1983) Twice All 10 * Adjusted for age, sex, BMI, pack-years of smoking, alcohol intake, and physical activity
  11. 11. 11
  12. 12. Life expectancy of aborigines and HanChinese in Taiwan ( 2000 )Ethnic Group Male FemaleTaiwanese 73 79Plain Aborigine 62 (-11) 72 (-7)Mountain Aborigine 58 (-15) 69 (-10) 12
  13. 13. What are the causes of health differencesacross population? Health care services Factors outside of health care sector – social environment  Living conditions  Working condition  Exposure to environmental hazards  Social control  Social security  Psychosocial stress  … 13
  14. 14. The role of “social determinants of health” 14
  15. 15.  In Sickness and wealth: health in America (from Unnatural causes) (4:38) https:// www.youtube.com/watch?v =w98GSXBEyQw&list=UUt1Df8qkClmfBpctQMoF 15
  16. 16. What are the “structural drivers” ofunhealthy social environment? Source: Solar and Irwin (2007). A conceptual framework for action on social determinants of health. WHO CSDH Report. 16
  17. 17. A historical review on major interventionsfor the improvement of population health Provision of medical and health cares Improvement of living conditions 17
  18. 18. PH Law (1848) New Poor Law (1834)Poor Law (1601) Factory Law (1802) Essay on Populations (Malthus, 1798) 18 Source: http://www.gresham.ac.uk/uploads/Demography(1).ppt
  19. 19. Edwin Chadwick (1800-1890) Report of the Poor Law Commission (1832) New Poor Law (1834) Report on the Sanitary Condition of the Laboring Population (1842) Public Health Act (1848)  Sanitary idea - miasma theory  Drainage system  Central and local boards of health 19
  20. 20. Bismarcks social legislation (1884) 20
  21. 21. After WWII:Health Care Reform – Beverage model in UK On the way …  1911: National Health Insurance Act  1920: Dawson’s interim report - regionalization  1939: EMS  1942: Beverage report National Health Service  1944: NHS white paper - comprehensive and free  1946: NHS Act  1948: NHS inauguration 21
  22. 22. Changes in life expectancy in England80706050403020 1650 1700 1750 1800 1850 1900 1950 2000 22
  23. 23. 人口數(百萬) 0 5 10 15 20 25 1900 30 1905 1910 1915 1920 人口數 1925 1930 出生率 1935 1940 1945 死亡率 1950 1955 1960 1965 1970 Demographic Transformation (Taiwan)資料來源:行政院衛生署、內政部統計處、 Mirzaee (1979) 1975 1980 198523 1990 1995 2000 2005 2010 0 10 20 30 40 50 60 出生率與死亡率( /1000 )
  24. 24. Changes in life expectancy in Taiwan:comparisons of Han Chinese and Aborigines 90 Han Chinese(Male) Han Chinese(Female) 80 Aborigines(Male) Aborigines(Female) 70Life Expectancy at Birth (years) 60 50 40 30 20 10 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 24
  25. 25. THE BIRTH OF TAIWAN’s NHI Full Congress Election Democratic Progressive Party US De-RecognitionWithdraw from UN NHI Law President Election 25 25 Slide made by Prof. Tung-Liang Chiang
  26. 26. Historical Evolution of Public Health Social environment 1848 UK-Public Health Act 1884 Koch’s Postulates 1974 Lalonde Report 1928 Penicillin 1978 Alma Ata Declaration 1948 WHO 1986 Ottawa Charter 1964 SG Report 2005 WHO CSDH Traditional Public Health New Public Health 1971 Canada-NHI 1961 Japan-NHI 1989 Korea-NHI Medical care systems 1948 UK-NHS 1995 Taiwan-NHI 1911 Germany-RVO1883 Germany-SI 2001 Thai-Mix Laissez-faire Equity in Access Cost Control Efficiency 26 Slide made by Prof. Tung-Liang Chiang, NTU
  27. 27. 3 legs for public health policy Knowledge base (scientific evidences and social strategies) Public Health Policy Politics Social values/(power struggle) Attitude/ethics 27
  28. 28. 28Source: Solar and Irwin (2010). A conceptual framework for action on social determinants of health.WHO CSDH Report.
  29. 29. Interventions on “social determinants ofhealth” US Federal Indian Policies and Health (2:39) https:// www.youtube.com/watch?v =i4ExGtLxb_w&list=UUt1Df8qkClmfBpctQMoFFfA&index=20 An US governmental video, give examples of possible interventions for improving ‘social environment’ https://www.youtube.com/watch?v=5Lul6KNIw_8 (5:12) Michael Marmot, the chair of CSDH on social determinants of health, 4:47) https://www.youtube.com/watch?v=kXUsYrzUKyU Ichiro Kawachi - Advice to the Next President: 7 Ways to Fight Health Inequities http://www.youtube.com/watch?v=Vh8XcosZzTo (2:20) 29
  30. 30. Actors State  The role of researchers Private sectors Civil society (NGOs) 30
  31. 31. Two questions for small group exercise1. Do you agree that all people should be entitled to medical care, regardless of their ability to pay? Or do you think medical care services should be treated as “commodities”, and the extent of services we receive will depend on how much you pay? What are the situations in your home countries?2. Identify a health problem, and suggest a policy level intervention strategy, targeting on its social determinants (instead of individual risk factors). 31
  32. 32. Some hints for the discussion session Childhood obesity – regulations on infant formula/ on advertisement of fast food or unhealthy products Mental health problems among the unemployed – expanding social welfare/unemployment security Road injuries – mass transportation system, policy and enforcement on helmet wearing… 32
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