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Sharing Responsibility Locally and Globally

Sharing Responsibility Locally and Globally. Reykjavík, October 9-11, 2005. Geir Gunnlaugsson Centre for Child Health Services Reykjavík, Iceland. Public Health— Shared Responsibility. Conference theme

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Sharing Responsibility Locally and Globally

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  1. Sharing Responsibility Locally and Globally Reykjavík, October 9-11, 2005 Geir Gunnlaugsson Centre for Child Health Services Reykjavík, Iceland

  2. Public Health—Shared Responsibility Conference theme Public health challenges cannot be tackled effectively unless the entire community works together and seizes opportunities that can help enhance the health of its citizens.

  3. Questions to address • How can the national level support the local level? • How can the local level coordinate resources to strengthen capacity in public health services? • Which strategies and models work in partnership building?

  4. What is a community? • Geographically bounded • Profession • Ethnic, cultural or religious • Group of nations • Virtual

  5. Downstream micro-level factors Upstream macro-level factors Midstream intermediate-level factors Government Health care system Access Availability Affordability Appropriate Utilization Physiological systems Endocrine Immune Polices economic,welfare health, housing transport, taxation Global forces Psychosocial factors Determinants of health (social physical, economic, environmental) Health Mortality Morbidity Life expectancy Quality of life Health behaviours Diet/nutrition Smoking/alcohol Physical activity Self-harm/addiction Preventive health care use Biological reactions Adrenalin Hypertension Blood lipid levels BMI, etc. Culture Culture Priority groups Low income/educ. Single parents Ethnic groups Unemployed Disabled Life-course stages Setting & contexts Work/employment Community/home Education/schools Community settings, eg Clubs, church NGOs Adapted from Queensland University of Technology School of Public Health, Australia Framework for socioeconomic determinants of health

  6. Early life experience Breastfeeding at 6 monthsSome European countries 1998-2000

  7. Early life experience Health PromotionBreastfeeding in Reykjavík 1970-1990 Thome M. Þróun brjóstagjafar í Reykjavík frá 1970-90. Hjúkrun 1993;69(3):11-23.

  8. Downstream micro-level factors Physiological systems Endocrine Immune Health Mortality Morbidity Life expectancy Quality of life Biological reactions Adrenalin Hypertension Blood lipid levels BMI, etc.

  9. Downstream factor: health 1821-1900 1901-2000 Infant mortalityIceland 1821-2000

  10. Downstream factor: health Infant Mortality RateNordic Countries 2001-03 NOMESCO 2005

  11. Downstream factor: health Mortality by external causesNordic children 0-17 years NOMESCO 2005

  12. Downstream factor: health Morbidity of school childrenIceland, 2005* Other (18%) Neurology (9%) Allergy (17%) 19% Obesity & endocrine (18%) Mental health (40%) School children 6-15 years old Chronic condition (n=5.690) *MHB. Data from national survey.

  13. Downstream factor: health Child mortality (<5 years) Countries in the human development aggregates Human Development Report 2005

  14. Downstream factor: health Causes of mortalityChildren <5 years Black RE et al., Lancet 2003;361:2226-34

  15. Downstream factor: health U5 Mortality and poverty Marmot M. Social determinants of health inequalities. Lancet;365:1099-1104.

  16. Downstream factor: health Life expectancyCountries in the human development aggregates Human Development Report 2005

  17. Medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged. Rudolf Virchow, 1848

  18. Downstream factor: health Log scale 160 125 1.2 times greater Social class 100 80 V - Unskilled 2.9 times greater 63 50 Average for working age men 40 30 I - Professional 25 1970- 1972 1979-1983* 1949- 1953 1930-32 1959- 1963 1991- 1993 Mortality and social class *1979-83 excludes 1981. England and Wales. Men of working age (varies according to year, either aged 15 or 20 to age 64 or 65) Note: These comparisons are based on social classes I & V only. Source: Office for National Statistics

  19. Midstream intermediate-level factors Health care system Access Availability Affordability Appropriate Utilization Psychosocial factors Health behaviours Diet/nutrition Smoking/alcohol Physical activity Self-harm/addiction Preventive health care use Culture Priority groups Low income/educ. Single parents Ethnic groups Unemployed Disabled Life-course stages Setting & contexts Work/employment Community/home Education Community settings, eg Clubs, church NGOs

  20. Midstream factor: health systems PHC programme elements Functional infrastructure Levels of service delivery Community involvement/ intersectoral collaboration Access Appropriate Available Affordable Tarimo E. Towards a healthy district: Organizing and managing district health systems based on primary health care. WHO, 1991

  21. Midstream factor: health systems Community based servicesHealth posts Boé, Guinea-Bissau

  22. Midstream factor: health systems Community based servicesAccess to drugs Boé, Guinea-Bissau

  23. Midstream factor: health systems Community based services Health education Boé, Guinea-Bissau

  24. Midstream factor: health systems Rational for user feesWorld Bank Policy 1987 • Improve efficiency and equity by increasing revenues • Increase quality and coverage by reducing frivelous demand • Shift patterns of care away from costly in-patient to low-cost primary healthcare services while protecting the poor through exemption. Save the Children. An Unnessary Evil? User fees for healtcare in low-income countries (2005)

  25. Midstream factor: health systems Health care services in IcelandFailure to seek care “Did you ever need to go to the doctor in the past six months, but postponed or cancelled the visit?” • Young people • Non-widowed • Economically troubled • People with inflexible schedules • Chronically ill • High out-of pocket health care costs • No discount card Vilhjálmsson R. Failure to seek medical care: Results from a national health survey of Icelanders. Soc Sci Med 2005;61:1320-30

  26. Midstream factor: health systems Private demand Lowest priority Highest priority Public health activities and other public goods Cost-effective package of basic health services with positive externalities (e.g. immunizations) Tertiary hospital care Private participation in financing the basic package ...? Highest priority Lowest priority Societal demand Expenditure on health

  27. Midstream factor Demand/Strain Psychosocial factors Stress Hostility Isolation Anger Depression Perceptions Self esteem Control Attachment Expectations Coping Networks Social support

  28. Midstream factor: behaviour Global trendsObesity “Corpulence is not only a disease itself, but the harbinger of others.” Hippocrates (460-370 BC) Hasiam DW and James WPT. Obesity. Lancet 2005;336:1197-1209

  29. Midstream factor: behaviour Obesity in Iceland9-year old children, 1938-1998 Boys Girls Overweight BMI >19,7 (both sexes); Obese BMI >22,6 for boys and >23,0 for girls Briem B (1999): Prevalence of overweight and obesity among 9 year old children in Iceland last 60 years.

  30. Midstream factor: behaviour SmokingChildren 15-16 years of age NOMESCO 2005

  31. Upstream macro-level factors Government Polices economic,welfare health, housing transport, taxation Global forces Determinants of health (social physical, economic, environmental) Culture Adapted from Queensland University of Technology School of Public Health, Australia

  32. Up- and midstream factor: culture Parents bring up a criminal Tímarit Morgunblaðsins, 17. október 2004

  33. Upstream factor Education Employment Occupation Working conditions Income Housing & area of residence Determinants for health(social, physical, economic and environmental)

  34. Upstream factor: determinant for health Short life Illiteracy Exclusion Material needs Poverty

  35. By necessities, I understand not only the commodities which are indispensably necessary for the support of life, but whatever the custom of the country renders is indecent for creditable people, even of the lowest order, to be without. Adam Smith, The Wealth of the Nations, 1776

  36. Upstream factor: determinant for health Poverty of children

  37. “In Iceland, the myth prevails that the Icelandic society is unique with regard to equality among its citizens ... The first step forward is to admit that inequalities exist.” Gunnarsdóttir HK. Ójöfnuður í heilsufari áÍslandi. Tímarit hjúkrunarfræðinga 2005;81:18-25

  38. Upstream factor: determinant for health Other +2,3 Family and demographic changes -0,6 Labour market changes -0,6 Government transfers -4,3 2,0 2000 Child Poverty in NorwayPolicy implications 5,2 1991 Child Poverty in Rich Countries 2005. UNICEF: Innocenti Research Centre.

  39. Upstream factor Public health policyFrom ‘evidence’ to ‘action’ Bowen S, Zwi AB (2005). Pathways to “evidence informed“ policy and practice. A framework for action. PLoS 2(7):e166

  40. Mortality in diarrhoea and access to piped waterChildren <2 yrs, Stockholm, 1878-1925 Burström B et al. Equitable child health interventions. The impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925. Am J Publ Health 2005;95:208-16

  41. Child Public HealthEconomic benefits Belli PC et al. Investing in children´s health: what are the economic benefits? Bull World Health Org 2005; 83(10):777-84.

  42. We as policians and health administrators must overlook the fact that our health care organisation is in principle like a tree full of monkeys. When the monkeys look down they only see a mass of anynomous faces, but when the monkeys down there look up the only thing they see is a mass of assholes!

  43. 1/2 Shared Full None ConclusionResponsibility for health informed voluntary uncoerced spontaneous deliberated

  44. 2/2 Conclusion • Downstream factors • health outcome influenced by gross inequalities • Midstream factors • lifestyles and psychosocial environment can be changed • health services need to be accessible, appropriate, available and affordable • Upstream factors • prime role of the state and global community in protecting and promoting the public´s health • adopt and adapt the evidence and act locally, nationally and globally

  45. Thanks

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