1004L- BACKGROUND TO MAIN PUBLIC HEALTH CONCERNS REQUIRING EPIDEMIOLOGICAL USE OF EPIDEMIOLOGICAL EVIDENCE FIR DECISION MAKING

Presented at a workshop on evidence-based decision making organized by the Ministry of Health Kingdom of Saudi Arabia Riyadh 24-26 April 2010 by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics Faculty of Medicine King Fahd Medical College

1.0 INTRODUCTION

This paper provides a background on the major areas of decision making in public health as a basis for discussion on how to use epidemiological evidence in making decisions.

2.0 HEALTH ECONOMICS

Health economics, an integration of medicine and economics, is application of micro-economic tools to health. Economic concepts used in health economics are scarcity, production, efficiency, effectiveness, efficacy, utility, need, want, demand & supply, elasticity, input-output, competition, marginal values (marginal costs and marginal benefits), diagnosis related group (DRG), service capacity, utilization, equity, value of money (present and future), and compounding & Discounting. Economic analysis uses models and hypothesis testing. The assumptions of a free/competitive market is not always true in health care because of supplier-induced demand and government regulation. Measurements of production costs, health outcomes, the value of human life, and the quality of life are still controversial. The purpose of economic analysis is to evaluate projects regarding cost minimization, cost benefit analysis, cost effectiveness analysis, and cost utility. It also plays a role in decision analysis.

3.0 HEALTH POLICY

Health policies are framed within a context of 4 contrasting alternatives that remain un resolved: prevention vs. cure, health promotion vs. disease prevention, primary care vs specialty practice, physician decision making vs. joint physician-patient decision making. Health policy is formulated to achieve specific objectives: ensuring adequate supply of services, ensuring accessibility of services, assuring equity, assuring technical and economic efficiency, assuring quality, and cost control. The main outstanding issues in health policy are: justice, needs (needs assessment, unmet needs, and prioritization of needs), rationing health care, centralization and decentralization, maximizing benefits, access and coverage, quality of care, and cost considerations. Health policy is regulated by laws and regulations. Public health laws have 5 functions: prohibition of injurious behaviour, authorization of services, allocation of resources, financing arrangements, and surveillance over the quality of care. Health policy varies by country and there are variations within the same country.

4.0 HEALTH PLANNING

Planning is a circular process that includes: situation analysis, prioritization, goal and objective definition, and choice of strategies, and evaluation. Objectives of health planning can be universal, national, or local. Rational planning is based on analysis of data, defining objectives, and formulating plans to achieve those objectives. In incremental planning plans evolve as problems arise and solutions are found for them. Mixed scanning is a judicious mixture of rational and incremental planning. The methodology of planning is defined by answering the questions about planning: how techniques), who (planning by specialists of the community or both), when (long term or short term), and where (place and whether centralized or decentralized). Planning can be for manpower, facilities, or services. Planning for a new program proceeds by identifying a problem, defining the problem, understanding the problem, planning an intervention, and evaluating the intervention. Needs assessment and prioritization are necessary preliminary steps in planning. Indicators of need are morbidity, mortality, and social deprivation. Needs assessment proceeds in 5 steps: determining present health status, assessing the environment, identifying and prioritizing existing programs, assessing service deficits in light of existing programs, dealing with the problems, and validating the needs. Prioritization considers: extent and seriousness of the problem, availability of effective cure or prevention, appropriateness and efficiency of the cure or prevention, and whether intervention will be at the level of the individual or the level of the community. The goals of public health intervention include: raising awareness of the health problem, increasing knowledge and health skills, changing of attitudes and behavior, increasing access to health care, reducing of risk, and finally improved health status. The following are the public health interventions: behavioral modification, environmental control, legislation, social engineering, biological measures, and screening for early detection and treatment of disease.

5.0 HEALTH CARE FINANCING

Expenditure on health is rising in all countries due to higher demand for care, higher wages of health care workers, more sophisticated and expensive medical technology. The traditional cost containment strategies included insurance deductibles, co-payments, and exclusion of certain services from coverage. The new cost containment procedures are prospective payments based on DRGs and managed care (pre admission review and certification, emergency room review, concurrent reviews to reduce hospital stay, discharge planning, second opinions, and gatekeepers to check referrals to specialists. HMOs have built-in incentives to control costs by curtailing hospitalization. Reimbursements based on DRGs control what care providers can charge for given services. The zeal to control costs can lead to inadequate or inappropriate care and decreased of access and equity. Health care finance can be from general taxation, social insurance, direct payments, and private insurance. Outstanding issues in health care financing are distributive justice (access, affordability, and quality) and allocation priorities (rural vs urban, curative vs preventive medicine, administrative costs vs actual care).

6.0 HEALTH CARE DELIVERY

The health care system can be described as resources, organization, and management. It is described according to availability, adequacy, accessibility, acceptability, appropriateness, assessibility, accountability, completeness, comprehensiveness, and continuity. It consists of institutions, human resources, information systems, finance, management, and organization, environmental support, and service delivery. Its nature is determined by demographic, cultural, political, social, and economic factors. Health care services include: preventive care, primary care, secondary care, tertiary care, restorative care, and continuing health care (for the elderly). Health care delivery systems can be classified by ownership (profit or not for profit and government or private), method of funding (public taxation, direct payment, or insurance), type of care (western, alternative, or traditional), and level of care (primary, secondary, or tertiary). Modes of health care delivery can be the physician office, a Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), or ambulatory Care Centers. Health care personnel are classified as independent providers (physicians), limited care providers (eg dentists), nurses, allied health professionals, and public health professionals. Health care facilities are physician offices, hospitals, nursing homes, out-patient services (ambulatory services), emergency room services, Health care maintenance organizations (HMO), rehabilitation centers, and continuing care facilities.

Primary health care (PHC) was defined by the World Health Organization in 1978 as essential health services universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and the country can afford. It is the frontline or point of entry of an individual into the health care system. It is centered on the individual and not the organ system or disease. It is provided at physician offices, clinics, and other patient facilities. It is a comprehensive care for common diseases including prevention, screening, diagnosis, and treatment. It  rests on 8 elements: health education, food supply and proper nutrition, safe water and basic sanitation, maternal and child health services including family planning, immunization against major infectious diseases, prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential drugs.

Health promotion refers to activities that improve personal and public health such as health education, health protection, risk factor detection, health enhancement, and health maintenance. Health protection includes accident prevention, occupational safety and health, environmental health, food and drug safety, and oral health.

Overall health status is assessed using mortality statistics, life expectancy, years of potential life lost (YPLL), Disability Adjusted Life years (DALY), and results of Nutritional and Health Surveys.

Program evaluation is study of effectiveness, outcomes, efficiency, goals, and impact. Process evaluation: is evaluation of the processes involved in health care without reference to the output. Outcome evaluation focuses on results. The following are used as outcome measures: mortality, morbidity, patient satisfaction, quality of life, degree of disability or dependency, and any other specific end-points.

Quality assurance (QA) is formal and systematic identification, monitoring, and overcoming problems in health care delivery. Quality indicators are mortality, morbidity, patient satisfaction, and various rates. Consensus guidelines, Good Clinical Practice guidelines, clinical protocols, and nursing guidelines are a bench-mark against which clinical performance can be evaluated. QA review may be concurrent or retrospective. The QA reviewers may be independent clinical auditors from outside or may be part of the health care team. QA in hospitals centers around review of the patient charts. The aim of QA review is to ascertain compliance with the given guidelines. If a deviation is found, it is documented as well as its surrounding circumstances. It is discussed at the departmental QA committee. The committee will suggest actions to be taken to alleviate the deficiency and map out an implementation plan. The QA review process is cyclical.