Introduction to public health Menelik1.pptx

There is generally scarcity of teaching/ learning materials
in the higher education institutions of Ethiopia. The
available materials regarding the course on the
Introduction to Public Health are not appropriate to our
environmental and socio-economic set up.
This lecture note is prepared primarily for health officer
students, and is organized based on the course outline of
introduction to public health in the curriculum of health
officers. Nevertheless, the lecture note is deemed to be
useful for almost all degree and diploma health science
students in the University and elsewhere in the country.
Taking in to account the shortage of teaching /learning
materials for the course- introduction to public health, this
lecture note is recommended to be used as a reference
for students. Concepts, principles and terms are defined
and described to reduce confusion.
This material is presented in ten chapters. Chapters - 1
and 2 present the definitions and various perspectives of
health and public health and discusses the determinants
of health. Chapters - 3, 4 and 5 deal with culture,
traditional health care practice and family health. Chapter
ii
6 is about personal hygiene. Chapter 7 is about health
and development. In this chapter the difference between
development and economic growth, the role of health in
development and health and development in the
Ethiopian context are presented. Chapter 8 is about
health service in Ethiopia and the history, the structure
and the developments of the health service. Chapter 9 is
about Primary Health Care and the definition, historical
development, concepts and philosophies of Primary
Health Care. Chapters 10 discusses community based
health services and team approach in the health service.
All chapters begin with learning objectives, by indicating
what is expected from students on completion of the
chapter. Furthermore, at the end of each chapter there
are exercises related to the core issues of the respective
chapter. Globalization and Health
Globalization is the process of increasing political and
social interdependence and global integration that takes
place as capital, traded goods, persons, concepts,
images, ideas and Values diffuse across the stated
boundaries (Hurrel &woods 1995).
Globalization must ensure that people, particularly the
poor, enjoy better health that is the most important
factor in improving the economic wellbeing of the
population in general and in reducing poverty in
particular.
Introduction to Public Health
11
The effects of Globalization on health are diverse; these
can be positive, negative or mixed. Some of the effects
of Globalization are listed hereunder.
Effects of Globalization on health includes
¾ Externalities of some diseases due to
increased communication decreased human
mobility
¾ Accelerated economic growth and
technological advances have enhanced
health and life expectancy in many
population
¾ Increasing effects of international and
bilateral agencies (structural adjustment
pro

1. Principles and Concepts of Public Health   Menelik Legesse ( BSc, M PH , P h D )             2019 30-Oct-19 1

2. D efin e an d unde rs tand ü d i ff e r ent concep t s i n pub li c hea l t h ü t he h i s t o r i cal deve l op m ent of pub li c hea l t h. ü t he m a i n f unc t i ons of pub li c hea l t h ü t he concept of ev i dence based pub li c hea l t h ü t he d i ff e r ent app r oaches i n pub li c hea l t h ü G l obal C on t ext of P ub li c hea l t h ü A pp r ec i a t e i m po rt ant and con t e m po r a r y i ssues i n g l obal P H A pp r ec i a t e i m po rt ant and con t e m po r a r y of hea l t h needs U nde r s t and t he concept of ev i dence based m ed i c i ne and ev i dence based pub li c hea l t h ; Learning Objectives By the end of this course students will be able to: 30-Oct-19 2

3. Objectives cont’d… ü App r e c iat e th e adde d v alu e o f e v iden c e ba s e d P H o v e r the t r aditiona l p r a c ti c e o f publi c health;   ü Appl y th e p r in c iple s o f e v iden c e ba s e d publi c healt h to de v elopin g a c tio n pla n tha t add r e s s lo c a l p r oblems   ü App r e c iat e ethi c a l i ss ue s an d v alue s i n publi c health   ü App r e c iat e ethi c a l i ss ue s i n globa l publi c health   ü App r e c iat e c onfli c t s bet w ee n v alue s i n publi c healt h & politi cs ;   ü App r e c iat e c onfli c t s bet w ee n v alue s i n e c onomi c s & P H;   ü App r e c iat e c onfli c t s bet w ee n v alue s o f s o c ia l ju s ti c e & P H 30-Oct-19 3

4. Course content as units UNIT 1. Basic concepts in public health UNIT 2. Global Health Issues UNIT 3. Demography Unit 4. Public Health Ethics 30-Oct-19 4

5. Course content as units       Introduction to the Course Definition and Philosophy of Public Health History of Public Health Important Milestones in the Development of Public Health Modern Concepts of Public Health and Its Components Models of Disease Causation Health and Development Global Context of Public Health Challenges of Public Health Globalization and Social Determinants of Health Climate Change and Health Health and Human Rights Social Justice and Public Health Primary health care, from Alma Ata to the present day situation 30-Oct-19 5

6. Teaching methods ü Lec t u re   ü I ndividua l exe r cis e ü G r ou p w o rk ü S e m inar ü I ndependen t s t udies 30-Oct-19 6

7. Assessment Project assignment 30% Case analysis report 10% Portfolio 10% Written examination 50% 30-Oct-19 7

8. Definitions and Philosophy of Public Health Definitions and Philosophy of Public Health 30-Oct-19 8

9. Definitions and Philosophy of Public Health Definitions Public Health Communities Community Health Public Health 30-Oct-19 9

10. Definitions Public – people in general. Health WHO definition - ‘a state of Complete physical, mental, and social well being and not merely the absence of disease, or infirmity’ . Physical health is the overall condition of a living organism at a given time, soundness of the body, freedom from disease or abnormality, and the condition of optimal well-being. 30-Oct-19 10

11. Definitions cont … Mental health - WHO defines mental health as: – a state of well-being in which the individual realizes his or her own abilities , – can cope with the normal stresses of life, – can work productively and fruitfully , and – is able to make a contribution to his or her community 30-Oct-19 11

12. Definitions cont … Mental health reflects: – emotional well-being, – the capacity to live a full and creative life, and – the flexibility to deal with life's inevitable challenges. 30-Oct-19 12

13. Definitions cont … social health - can refer both to a characteristic of a society, and of individuals. A society is healthy when there is: – equal opportunity for all and – access by all to the goods and services essential to full functioning as a citizen. Indicators of the health of a society might include: -the existence of the rule of law– the existence of the rule of law, – equality in the distribution of wealth, – public accessibility of the decision-making process, 30-Oct-19 13

14. Definitions cont … The social health of individuals refers to that dimension of an individual's well-being that concerns: – how he gets along with other people, – how other people react to him, and – how he interacts with social institutions and societal mores“ those who are well integrated into their communities tend to live longer and recover faster from disease. Conversely, social isolation has been shown to be a risk factor for illness. 30-Oct-19 14

15. Definitions cont … Community: a group of people who share or have common intent, belief, resources, preferences, needs, risks and a number of other conditions . WHO defines community as “a group of people, often living in a defined geographical area who share a common: – culture – values, and norms, are arranged in a social structure– are arranged in a social structure according to relationships they have developed over a period of time”. 30-Oct-19 15

16. Definitions cont … Members of a given community gain their personal and social identity by sharing common beliefs, values and norms. (Muslim/Christian ) Communities may also be based on shared interests or characteristics, such as race/ ethnicity, sexual orientation, age, or occupation Black/white Homosexual/heterosexual Women/men Adolescents/children sex workers/ long distance truck drivers 30-Oct-19 16

17. Definitions cont … Community health A field within public health, that concerns itself with the study and betterment of the health of communities . Public Health: 1. In 1923 Winslow defined public health as the science and art of preventing disease, prolonging life and promoting physical health and mental health and efficiency through organized efforts and informed choices of society, organizations, public and private, communities and individuals”. 2. John Last defines public Health: “ Efforts organized by society to protect, promote and restore the peoples health”. 3. It is the combination of science, skills and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions . 30-Oct-19 17

18. Definitions cont … International Public Health Is the application of the principles of public health to health problems and challenges that affect low- and middle-income countries and to the complex array of global and local forces that influence them global and local forces that influence them 30-Oct-19 18

19. Definitions cont … The global forces include : Urbanization Migration Explosion in information technology Expanding global markets 30-Oct-19 19

20. Definitions cont … Most of the attention is focused on low and middle-income countries because they have: – the greatest morbidity & mortality – Inadequate health systems to meet the needs of their most vulnerable populations 30-Oct-19 20

21. Definitions cont … Important features of public Health 1. Social justice- is the central pillar of public health 2. Inherently Political nature 3. Expanding agenda 4. Link with government 5 Grounded in science5. Grounded in science 6. It focuses on prevention 7. Uncommon culture 30-Oct-19 21

22. Definitions cont … Social justice philosophy Justice - there is fairness in the distribution of benefits and burdens; injustices - when persons are denied some benefit or when some burden is imposed unduly. Factors that impede the fair distribution of benefits and burdens Social class racism disability etc. Public health works to overcome those impediments. 30-Oct-19 22

23. Definitions cont … Inherently political nature Public Health is both public and political in nature. The social justice component of public health stimulates political conflict Public health advocates at times appear as antigovernment Governmental public health agencies seeking to serve the interest of both government and public health are frequently caught in the middle 30-Oct-19 23

24. Definitions cont … Expanding Agenda Prior to 1900, the primary problems were infectious diseases and related environmental risks. After 1900 the focus expanded to include problems and- and needs of children and mothers Middle of the century: chronic disease prevention and medical care fell into public health Later - substance abuse, violence, injuries Recently: Bioterrorism, other disaster preparedness are also added to the public health agenda 30-Oct-19 24

25. Definitions cont … Bioterrorism - deliberate release of viruses, bacteria or other germs (agents) used to cause bacteria, used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be changed to: – increase their ability to cause disease, – make them resistant to current medicines, or – increase their ability to be spread into the environment 30-Oct-19 25

26. Definitions cont … Smallpox and anthrax are examples of biological agents that could be used for bioterrorism. A biological attack may not be recognized immediately and may take local health immediately and may take local healthcare workers time to discover that a disease is spreading in a particular area. 30-Oct-19 26

27. Definitions cont … Link with Government Public health is linked with government in Two ways: 1. Issuing policies that govern the health of the population 2. Directly provide programs and services that are designed to meet the health needs of the population 30-Oct-19 27

28. Definitions cont … Grounded in Science Often five basic science of public health are identified: identified: Epidemiology, Biostatics, Environmental science, Management sciences and Behavioral sciences. Other sciences of public health: Maternal and Child Health Nutrition Occupational Health Epidemiology and biostatics are essential tools of public health. 30-Oct-19 28

29. Definitions cont … Focus on prevention Prevention is the main purpose of public health It is aimed at preventing disease; However, public health also prevents – deaths, – hospital admissions, – days lost from school and work – consumption of human and fiscal resources; etc. 30-Oct-19 29

30. Definitions cont … Uncommon culture Public health is unique in that many different sciences, art and methods can contribute towards the same outcome. Vast majority of public health workers are not formally trained in public health. Public health professionals include professionals from different disciplines, like anthropologist, sociologist, psychologist, physicians, nurses , nutritionist, lawyers ,mangers etc.. 30-Oct-19 30

31. Definitions cont … 30-Oct-19 31

32. Definitions cont … 30-Oct-19 32

33. Definitions cont … Why invest in public health? Poor public health takes economic tolls in various ways reduced attraction for investors, tourists, continued expenditure in combating diseases and diseases and Reduced labor productivity 30-Oct-19 33

34. Assignment Describe the different concepts and perspectives of Health. How do you perceive health? List the various determinants of health a community. Out line the strengths and weaknesses, the preventive measures demanded by each model. What is the influence of globalization on community health? Do you think that globalization affects the overall health situation of your country? How? 30-Oct-19 34

35. PHC principles* Emphasized principles in PHC are: Inter-sectoral collaboration 35 30-Oct-19 35

36. PHC principles* Emphasized principles in PHC are: Inter-sectoral collaboration Community participation Appropriate technology Equity ( human right ) Focused on prevention and promotion of Health Decentralization 36 30-Oct-19 36

37. PHC Philosophy Health for all, is justified on the Alma-Ata Declaration as a “fundamental human right” on the basis of equity and /or economic and social development. PHC is not more medicine for the poor and it should not be considered to mean a second-class health service meant for rural population It is an essential health service valuable for all countries from the most to the least developed ones . In fact, it is particularly a burning necessity for developing countries. 37 30-Oct-19 37

38. PHC Philosophy cont … Therefore, PHC as a philosophy includes : Equity and Justice Individual and community self reliance Inter relationship of Health and Development 38 30-Oct-19 38

39. PHC strategy Changes in the Health care system Design, planning and management of Health System (decentralization) Individual and collective responsibility for Health Intersectoral Action for Health 39 30-Oct-19 39

40. Community health practice 40 30-Oct-19 40

41. Community health practice Primary (before infection) Secondary (early) Tertiary (Late) Primordial (It addresses broad health determinants rather than preventing personal exposure to risk factors ) 41 30-Oct-19 41

42. If you get the opportunity to be a prime minister or a health minister on which strategy will you invest more ? ( curative or Public ) Why? 42 42 30-Oct-19

43. History of Public Health Unit Objectives At the end of this session, you are expected to Identify the historical development of public health Identify public health concepts and practices in the past Explain the disease causation theories Identify the critics of the disease causation theories 43 43 30-Oct-19

44. Why history of public health? To learn from the past experiences To understand the present situation To forecast the future conditions To recognize the dynamic transition in social, economic and political factors and their implication on human health.Example: life expectancy; population growth, food production, physical growth (trans-generation) 44 44 30-Oct-19

45. History… The history of public health goes back to almost as long as history of civilization. Possible traditions during civilization maybe: Taboos against waste disposal within communal areas or near drinking water sources; Rites associated with burial of the dead; and communal assistance during birth. 45 45 30-Oct-19

46. History of public health It has chronological awareness Prehistory Ancient Egypt Ancient Greece The Roman Empire The Dark Ages (Middle ages) Modern times 46 46 30-Oct-19

47. Prehistoric Archeological findings from the Indus valley (north India) and the Middle kingdom of ancient Egypt (2700-2000BC) Evidence of bathrooms and drains in homes, sewers below street level and drainage systems 47 47 30-Oct-19

48. Prehistoric cont… There were written records concerning public health 1700 BC The Code of Hammurabi – Rules governing medical practice 48 48 30-Oct-19

49. Prehistoric cont... Book of Leviticus (1500 BC) there are guidelines for Personal cleanliness, Sanitation of camp sites, Disinfection of wells, Isolation of lepers, Disposal of refuses, Hygiene of maternity 49 49 30-Oct-19

50. Population and disease in the ancient world Human species has colonized most of the inhabitable area of the world They were food collectors rather than food producers The causes of illness and death were: preyed by animals Slaughter by other humans Food shortage, Change in climatic condition (e.g.-the ice age) 50 50 30-Oct-19

51. Agricultural revolution Shift from food collecting to food production (8000 BC) Transformed the societal organization of humans. Small wondering groups were replaced by much larger, settled communities in most parts of the world. Human beings start domestication of animals and cultivation of a wide range of plants Produce more food, which in turn allowed a substantial increase in population . Likely to have led to the rise of infectious diseases as the main cause of illness and death. 51 51 30-Oct-19

52. Agriculture cont... Why this change infection dynamics? Increase in both the total population size and the size of local groups living in close personal contacts . Many intruders such as rats and mice into human habitations, attracted by the stored food 52 30-Oct-19

53. Why this change… Switch from the often highly varied diet of the hunter-gatherers to the mono diets Much higher degree of social order, emergence of social hierarchies hence inequality, wealth & poverty etc. 53 53 30-Oct-19

54. Why this change infection dynamics? 1. Increase in both the total population size and the size of local groupsliving in close personal contacts. 2. Many intruders such as rats andmice into human habitations, attracted by the stored food 3. Switch from the often highly varied dietof the hunter-gatherers to the mono diets 4. much higher degree of social order, emergence of social hierarchies hence inequality, wealth & poverty ……etc 54 54 30-Oct-19

55. Ancient Egypt Irrigation introduced (4000BC) Sewerage disposal using earth closet (1000BC) 55 55 30-Oct-19

56. Ancient Greeks (500 –323 BC) The Greeks understood the importance of washing hands, taking a bath, exercising and eating good food. Ex: personal hygiene, physical fitness, etc Naturalistic concept –ill health caused by an imbalance between man and environment 56 56 30-Oct-19

57. Hippocrates (460-377 B.C. ) Father of Western medicine Believed that illness had a physical and rational explanation Described causal relationship b/n disease & factors such as climate, soil, water, lifestyle and nutrition Coined the term Epidemic: Epis= ‘on’; Demos = ‘people’ 57 57 30-Oct-19

58. Roman empire 500 BC to 1000 AD Introduction of public sanitation Aqueduct to transport water Sewer system Regulation on street cleaning 58 58 30-Oct-19

59. Dark age 500 – 1000 A.D Europe – destruction of Roman society and the “rise” of Christianity It was very unfortunate that the values for hygiene declined during the Dark age . Why?? 59 59 30-Oct-19

60. Middle age or Dark ages(500 –1500 AD) Colonial expansion & abandonment of the Greek & Roman values of hygiene & sanitation Decline of hygiene and sanitation Spreads infectious diseases around the world (Measles, influenza and small pox, syphilis, dysentery, malaria). 60 60 30-Oct-19

61. Dark age… Health problems were started to be considered as having spiritual causes and solutions; A. Supernatural powers for pagans Health problems were started to be considered as having spiritual causes and solutions; A. Supernatural powers for pagans B. Punishments for sins for Christians; 61 61 30-Oct-19

62. Dark age… Health problems were started to be considered as having spiritual causes and solutions; A. Supernatural powers for pagans B. Punishments for sins for Christians; C. Faith and prayer, appeasing the gods by offering , were the accepted treatment for illness 62 62 30-Oct-19

63. Dark age… As biological reasons were neglected epidemics become rampant Leprosy Plague –“Black death” during 14thCentury ( 2/3 of Europe) Syphilis Nevertheless, it was during this era that important public health tools introduced 63 63 30-Oct-19

64. Middle age or Dark ages… Important public health tools developed: Isolation of diseased individuals could help prevent the spread of disease; Quarantine of ships and travelers for 40 days; Persons denied entry to infected ships. 64 64 30-Oct-19

65. Renaissance and exploration (1500 -1700 AD) Exhibited as a ‘Re -birth of thinking’ about the nature of the world and humankind; Growing belief that diseases are caused by environment, not by spirits; Critical thinking about disease causation- “ Malaria” –Bad Air 65 65 30-Oct-19

66. Thomas Sydenham(1624-1689) 66 66 Founder of Clinical Medicine and Epidemiology Emphasized detailed observations of patients & accurate recordkeeping 30-Oct-19

67. James Lind(1700’s) Designed first experiments to use a concurrently treated control group. 67 67 30-Oct-19

68. The eighteenth century Marked by extensive health & social improvement and Mortality declines dramatically in Europe and USA, mainly due to Improved living and working conditions & improved nutrition. Improved Medical interventions Improvements in urban water supply Introduction of sewage system Municipal hospital Relevant laws enacted Data on deaths and births began to systematically be collected 68 68 30-Oct-19

69. The Industrial revolution 1750-1830 : Age of enlightenment Yet it Produced a new set of public health problems: Ex: slums & Poverty Unsafe Work places also considered as a factor Urban slums leading to unsanitary conditions 69 69 30-Oct-19

70. Edward Jenner (1749-1823) Pioneered clinical trials for vaccination to control spread of smallpox Jenner's work influenced many others, including Louis Pasteur who developed vaccines against rabies & other infectious diseases. 70 30-Oct-19

71. Ignas Semmelweis (1840’s) Pioneered hand-washing to help prevent the spread of septic infections in mothers following birth 71 30-Oct-19

72. Nineteenth Century Build on the concept of ‘Problems of industrialization’ Agricultural development led to improvements in nutrition Real progress towards understanding the causes of communicable diseases 72 72 30-Oct-19

73. John Snow (1813-1858) Father of Epidemiology Careful mapping of cholera cases in East London during cholera epidemic of 1854 Traced source to a single well on Broad Street that had been contaminated by sewage 30-Oct-19 73

74. John snow… 74 74 30-Oct-19

75. Nineteenth Century cont… Louis Pasteur 1862 germs caused many diseases 1888 first public health lab Robert Koch 1883 identified the vibrio that causes cholera, 30 years after Snow’s discovery Discovered the tuberculosis bacterium 75 75 30-Oct-19

76. L o uis Pasteur Disproved the spontaneous generation theory. Spontaneous generation states that living organisms can arise from inanimate, non living matter. This theory was used to explain why microbes, maggots, flies cover left out food. Pasteur used a special designed flask which allows pure air to enter and kept boiled broth. 76 76 30-Oct-19

77. Koch’s postulate 1. Micro organisms must be present in all cases of disease 2. Pathogen can be isolated and grow in pure culture 3. The cultured organism should cause disease when introduced to healthy experimental animal. 4. The same micro organism must be re-isolated from the new host 77 77 30-Oct-19

78. 20 th century Twentieth century has been the period of : Health resources development (1900-1960), social engineering (1960 - 1973), health promotion (Primary Health Care), and market period (1985 and beyond) 78 78 30-Oct-19

79. 21 st century cont… The challenges in the twenty first century are : a. Reducing the burden of excess morbidity and mortality among the poor; b. Unhealthy environment and lifestyle; c. Developing more effective health system 79 79 30-Oct-19

80. Historical markers in the history of PH 1348 – 1350 Black Death – origins in Asia, spread by armies of Genghis Khan, world pandemic kills 60 million people (1/3 to 1/2 of the population of Europe) 1300 Pandemics – bubonic plague, smallpox, leprosy, diphtheria, typhoid, measles, influenza, tuberculosis, anthrax, trachoma, scabies and others until eighteenth century . 80 80 30-Oct-19

81. Historical… 1673 Antony van Leeuwenhoek – microscope, observes sperm and bacteria. 1796 Edward Jenner – first vaccination against smallpox. 1830 Sanitary and social reform, growth of science. 1854 John Snow – waterborne cholera in London: the Broad Street Pump. 1854 Florence Nightingale, modern nursing and hospital reform 1862 Louis Pasteur publishes findings on microbial causes of disease. 1876 Robert Koch discovered Anthrax bacillus. 1879 Neisser discovered Gonococcus organism. 1882 Robert Koch discovered the tuberculosis organism, tubercle bacillus. 81 81 30-Oct-19

82. Historical… 1880 Typhoid bacillus discovered (Laveran); leprosy organism (Hansen); plasmodium (malaria) organism (Laveran ). 1883 Robert Koch discovered bacillus of cholera. 1883 Louis Pasteur vaccine against Rabies. 1884 Diphtheria, staphylococcus, streptococcus, tetanus organisms identified 1890 Anti-tetanus serum (ATS) 1892 Gas gangrene organism discovered byWelch and Nuttal 1894 Plague organism discovered( Yersin , Kitasato ); botulism organism (Van Ermengem ). 82 82 30-Oct-19

83. 1923 Health Organization of League of Nations 1926 Pertussis vaccine developed 1928 Alexander Fleming discovered penicillin 1946 World Health Organization founded. 1977 WHO adopted Health for all by the year 2000 1978 Alma-Ata Conference on Primary Health 2000 MDG ( what were the reasons not to accomplish the goals?) After 2015 SDG 83 83 30-Oct-19

84. 84 History of public health in Ethiopia 84 30-Oct-19

85. Evolution 85 Can be organized in: Pre-Italian war During Italian war Post-Italian war The Basic Health care period Public health during the Derg regime Public health in FDRE 85 30-Oct-19

86. 1.Public health Pre-Italian war 86 Most travelers, missionaries, diplomatic members participated in catering medical treatments mainly around the palaces of various monarchs. Atse Lebnadengel (1508-1540). In 1521 wrote to King Joao III of Portugal asking him to send various skilled people, including “ men who make medicines, and physicians and surgeons to cure illness’ (Pankhurst 1965). 86 30-Oct-19

87. Pre-Italian war Cont… 87 Joao Bermudes ; The first foreign practitioner -surgeon, a member of the Portuguese diplomatic mission of 1520-1526 Emperor Fassilades (1632-1667). In 1636, a German Lutheran Missionary , Peter Heiling was practicing medicine at the then new city of Gondar 87 30-Oct-19

88. Pre-Italian war Cont … 88 Emperor Iyassu I (1682-1706) In 1698 the Emperor requested the French consul in Cairo to procure medical aid & the consul sent Dr. Poncet , a French physician in 1699 (the emperor & his son were suffering from skin problem) There were also preventive activities measures to control cholera in the army of Emperor Theodros smallpox vaccination during the time of Emperor Yohannes I V 88 30-Oct-19

89. Pre-Italian war Cont… 89 A new chapter in Ethiopian medical history was in the 1830 and 40s. Among diplomatic missions there were physicians who treated not only royalty, but also certain section of the populations in the capital cities 89 30-Oct-19

90. Pre-Italian war Cont… 90 The Emperor Menelik era Russian Red Cross mission , which was a direct result of the Battle of Adwa was one of the biggest events in the medical history of Ethiopia. Used to treat a large number of people Produced the first modern Amharic Medical Text book. They established the first Ethiopian hospital in 1897 90 30-Oct-19

91. 91 91 30-Oct-19

92. Managing health services 92 There was no management system in early ages. Individual 'doctors' came on their own or invited by the nobilities and practiced unfettered. There was, apparently, no licensing . Most had no or little training in medicine ; foreigner, was taken as potentially hakim, doctor, with strong medicine. The first management structure was initiated when a health department (bureau) was established as a unit in the Ministry of Interior (MOI). 92 30-Oct-19

93. Health policy and legislation 93 The first Legislation decree were for vaccination against smallpox by Emperors Yohannes and Menilek Modern medical legislation could be traced back to the coronation Haile Selassie I in 1930 A law to regulate the work of the doctor, dentist, pharmacist and midwife and veterinarian specified that “ no one could exercise these professions or run a pharmacy without a relevant diploma ” 93 30-Oct-19

94. Human Resource Development (HRD) 94 Dr. Martin (Hakim Workeneh ): the first Ethiopian doctor As a child, he was taken to India by one of the officers of the British army after the battle of Mekedela . He went on to became a doctor, worked as a physician in India and came back to Ethiopia after Adwa and served as doctor, governor of a province and, in the years before and during the Italian Occupation as an ambassador to Britain . 94 30-Oct-19

95. Finance 95 Missionaries provided free services There was no government budgetary allocation for health. Budget allocation started in the early 1930s and the budget for public health services had reached Ethiopian dollars 550,000 by 1933 95 30-Oct-19

96. PH during the Italian war 96 In Addis Ababa & in the major provincial towns occupied by the Italians ( Harar , Dire Dawa , Gondar, Dessie and Jimma ) were supplied with hospitals and clinics, but reserved primarily for the use of the Italian population They upgraded hospitals to 300-400 bed capacity They built 22 hospitals & several clinics and dispensaries in the countryside. 96 30-Oct-19

97. Post Italian war The Reconstruction Period (1941-1953) 97 The country was preoccupied with effort of reconstructing the state apparatus under severe financial constraints The focus was on rehabilitating the curative facilities left by the Italians and building new ones making the name 'Hospital and Clinic Based' appropriate for the period . Ministry of Health was established in 1948 & developed the Basic Health Service policy (Pankhurst 1990). The 1 st health personnel training school established at the Red Cross in 1949 . 97 30-Oct-19

98. The basic health services approach 98 Because the “ modern medical care model” couldn’t address the health needs of the majority. The Basic Health Services approach came & advocates the extension of peripheral health centers and health stations to solve the problems of availability, accessibility and appropriateness of health services In particular, improving access to health care was achieved to a greater extent by taking services to where the people live through:–home visits, outreach, prison, school, work place , 98 30-Oct-19

99. Five Years Development Plan 99 The 1 st 5-Year Development Plan (1957-1961) (1950-1954 EC). Was launched & in its community Development Programs, improving hygiene and health was mentioned . The 2 nd 5-Year 1963-1967 (1955-1959 EC) oriented towards modernizing the government’s administration, and social services, particularly education and health. Emphasis was given to preventive medicine Expansion of a network of health centers & health stations. One HC for 50,000 people & one HS for 5000 people 99 30-Oct-19

100. Ten Year Health Sector Plan1985-1994 100 The goal was to strengthen & expand MCH services, particularly: immunization of all pregnant women & children under 2 years, An increase per-capita visit to the health institutions, A decrease in infant mortality from 155/1000 to 95/1000, A decrease in child mortality from 247/1000 to 150/1000 An increase in life expectancy from 42 to 55 years. 100 30-Oct-19

101. Ten Year Health Sector Plan1985-1994 cont. 101 This is to be achieved : 1. Through community participation 2. Inter-sectoral collaboration 3. Integration of vertical programs and specialized health institution 4. Deliver service at affordable cost 5. Development of six-tier health system ( central, regional ref. hos.; rural hos, HC, HS, community health service) 101 30-Oct-19

102. Public health in the Post Derg - regime 102 The sector wide approach: The health policy in this period in Ethiopia emphasizes the equitable access of all people to decentralized , preventive and promote health-oriented services through integrated PHC . In 1993, the government approved the National Health Policy and strategy based on principles covering the following: Democratization and decentralization of the HSD system; 102 30-Oct-19

103. Public health in the Post Derg – regime cont … 103 b . Strengthening of preventive and promotive health programs; c. Ensuring equitable access to all segments of the population ; d. Improving the quality of health services ; e.increasing demand through changes in population behavior; f. Promotion of inter-sectoral activities; g. Development of institutional capacity; and h. Promotion of private sector and NGO participation ( Decentralization and privatization are unique for this period) 103 30-Oct-19

104. Public health in the Post Derg – regime cont … 104 Based on the National Health Policy and Strategy, the 20-year Health Sector Development Program (HSDP) was developed with a series of medium-term implementation plans and investment programs. The first phase , HSDP I, 1997/98–2001/02 the second phase, HSDP II (2002/03–2004/05), and the third phase, HSDP III (2005/06–2009/10). The fourth phase , HSDP IV (2010/11 – 2014/15) 104 30-Oct-19

105. Public health in the Post Derg – regime cont … 105 Currently Health Sector Transformation Plan (2015/16 - 2019/20 (2008-2012 EFY) Transformation agenda 1. Quality health service 2. CRC Professional 3. Health information 4. Woreda transformation 105 30-Oct-19

106. Important Milestones in the Development of Public Health 30-Oct-19 106

107. Vaccination Jenner (top) uses cowpox to vaccinate against smallpox, 1796. Vaccination used by British troops in 1800, and made compulsory in the UK by the Vaccination Act of 1853, spreading the practice to Europe and the Americas. Smallpox eradicated globally in 1980. Jonas Salk (bottom) develops first inactivated polio vaccine and performs largest field trial in history in 1954. Sabin’s live, attenuated polio vaccine follows in 1961. Most countries declared free of polio from 1990. Vaccination now widely available against measles, mumps, rubella, polio, diphtheria, tetanus, pertussis, H. influenzae , meningococcal meningitis, Pneumococcus spp., HPV, influenza and herpes zoster, hepatitis A, hepatitis B and yellow fever. From www.vaclib.org/news/smallpoxalert.htm From www.famous-scientists.net/jonas-salk.htm 30-Oct-19 107

108. Motor Vehicle Safety 1930s-1950s: Several US physicians install lap belts in their personal vehicles, begin lobbying auto manufacturers. Colorado State Medical Society (1953) publishes policy calling for universal seat belt installation. 1961 - Wisconsin becomes first US state to require seat belts in front outboard seats. CDC (2007) attributes decline in motor vehicle mortality to “seat belt usage, child safety measures, improved car design, improved policing and public attitudes reducing drunk driving, improved roads and lighting, and others.” From en.wikipedia.org/wiki/File:IIHS_crash_test_dummy_in_Hyundai_Tuscon.jpg 30-Oct-19 108

109. Safer Workplaces Occupational health one of the oldest sectors of public health: scurvy among sailors (James Lind (top), 1753, treats scurvy with citrus fruits) scrotal cancer among English chimney sweeps “black lung” in coal miners mercury poisoning in hat makers (thus the phrase “mad as a hatter” - e.g., Lewis Carroll’s Mad Hatter (bottom)) mesothelioma in asbestos workers hepatitis B in health care workers carpal tunnel syndrome in typists and computer workers Factory and Workshops Act (1833) in UK led to general improvement in working conditions. Thomas Legge became first medical doctor appointed Chief Factory Inspector in UK (1898); articulates Legge’s axioms, including: “All workmen should be told something of the danger of the material with which they come into contact and not be left to find out for themselves--sometimes at the cost of their lives.” (Cited in Tulchinsky & Veravikova , 2009.) From en.wikipedia.org/wiki/File:James_lind.jpg. From www.phrases.org.uk/meanings/mad-as-a-hatter.html A lime a day keeps bleeding gums away! 30-Oct-19 109

110. Control of Infectious Disease Dr. John Snow traces cholera deaths to the Broad Street pump and to two water companies (1854). Infection control multifactorial: germ theory (Pasteur, 1854 and Koch, 1883); antisepsis (Lister, 1867); chlorination; vector control; antibiotics (Fleming, 1928); vaccination (see above). From www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm

111. Decline in Deaths from Coronary Heart Disease and Stroke Development of “risk factor” concept: “biologic, lifestyle, and social conditions were associated with increased risk for disease” (Turnock, 2009). Multiple parallel interventions: Cigarette smoking reduction (42% of adults in 1965 to 25% of adults in 1995). More aggressive hypertension treatment. Availability of effective cholesterol-lowering medications (e.g., “statins”). Changes in US diet including decrease in saturated fat, cholesterol and trans-fats. Improved medical response and in-hospital care (e.g., cardiac catheterization, stenting, thrombolytics and coronary artery bypass). From health.howstuffworks.com From www.brockport.edu. From www.dietindetails.com 30-Oct-19 111

112. Safer and Healthier Foods 1887: Federal nutrition laboratory established, forerunner of NIH. 1927: US Food and Drug Administration established. 1939: Federal food stamp program launched. 1972: USDA established WIC program. US nutritional status followed by periodic NHANES surveys (1971-4, 1976-80, 1988-91, 2005-6). Food safety depends on overlapping responsibilities of farmers and ranchers, private companies, transportation, local and federal government. 1958 - US Food, Drug, and Cosmetics Act required food manufacturers to comply with federal law regarding additives: Banned cyclamates, cobalt salts, polyvinyl chloride, some food coloring, some pesticides and herbicides. Still, 5-10% of population in industrialized countries suffer with food poisoning annually ( Tulchinsky & Varavikova , 2009). From www.fda.gov From ecoliblog.com From pediatrics.about.com. 30-Oct-19 112

113. Healthier Mothers and Babies 19 th century France: gouttes de lait (“milk stations”- preventive health for women and children); incentive payments to women whose infants survived one year. Koplik , 1889 and Strauss, 1893 - promoted safe milk supply to children in NYC slums. Lillian Wald (bottom) coins “public health nurse,” leading to VNAs, public perinatal health services and school health services. 1990s - immunizations provided as part of WIC, expanding coverage to vulnerable populations. Improvements in obstetrical safety, perinatal care and technology have resulted in age of viability decreasing to ~ 22 wks gestation. However, no intervention yet proven to prevent preterm labor and delivery. From www.breastfeeding-problems.com From http://en.wikipedia.org/wiki/File:Lillian_Wald_at_National_Portrait_Gallery_IMG_4579.JPG From www.wicprogram.org. 30-Oct-19 113

114. Family Planning 1952-4: Margaret Sanger supports hormonal contraceptive research of Pincus and Rock. 1956: Clinical trials of first combined hormonal contraceptive, Enovid . Modern contraception: barrier/physical methods (e.g., condoms, IUD), chemical (e.g., pills, implants, spermicides) and traditional (e.g., rhythm method, withdrawal), surgical (vasectomy, tubal ligation). Teenage pregnancy continues to be a widespread and serious public health problem, more common in lower socioeconomic populations and associated with poorer health outcomes. But, some progress made: rates of teen pregnancy declined and teen abstinence increased from 1990-2004. From www.vanityfair.com “[Mother Teresa] spent her life opposing the only known cure for poverty, which is the empowerment of women and the emancipation of them from a livestock version of compulsory reproduction.” - Christopher Hitchens, The Missionary Position: Mother Teresa in Theory and Practice, 1995. 30-Oct-19 114

115. Fluoridation of Drinking Water Dentist Frederick McKay spends thirty years investigating “Colorado brown teeth” - mottled but cavity-free dentition seen in high-fluoride areas. 1930s-1940s: NIH publishes research showing that fluoridation significantly reduces decay and cavities; advocates for universal fluoridation. “Fluoridation of community water supplies reduces the number of caries and extractions in both children and adults by some 60%...This is one of the most effective public health interventions available.” (Tulchinsky, Varavikova, 2009). From www.doh.state.fl.us. From www.holistickid.com 30-Oct-19 115

116. Recognition of Tobacco Use as a Health Hazard Cigarette smoking becomes endemic with WWII - and lung cancer rates increase almost 10x compared to 1930s rates. 1950s-1960s: first research supporting link between smoking and lung cancer; first Surgeon General’s report. Late 20 th century - reduction seen in adult smoking rates, but plateauing at 25%. Taxation and price increases seem most successful at decreasing population smoking rates. However, rates remain highest among American Indians/Alaska Natives, black and southeast Asian men (Turnock, 2009). Little change seen in use of smokeless tobacco. From www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a2.htm#fig1 From blog.modernmechanix.com 30-Oct-19 116

117. Environmental health Cancer treatment Addiction Public health infrastructure Are also be among the milestones 30-Oct-19 117

118. References Peterson J. (1997). Solving the mystery of the Colorado Brown Stain. J Hist Dent, 45(2):57-61. Snow J. (1854). On the mode of transmission of cholera. In Snow on cholera: A reprint of two papers. (1936). New York: The Commonwealth Fund. Tulchinsky T. H. & Varavikova E. A. (2009). The new public health (2 nd ed.). Burlington, MA: Elsevier Academic Press. Turnock B. J. (2009). Public health: What it is and how it works (4 th ed.). Sudbury, MA: Jones and Bartlett Publishers. All image references accompany the image. 30-Oct-19 118

119. Modern Concepts of Public Health and Its Components 30-Oct-19 119

120. understand the core functions of public health understand the 10 Essential Services of Public Health 30-Oct-19 120

121. Core Functions Assessment Policy Development Assurance 30-Oct-19 121

122. The Ten Essential Services of Public Health 1. Monitor health status to identify community health problems 2. Diagnose and investigate health problems and health hazards in the community 3. Evaluate effectiveness, accessibility, and quality of personal and population-based health services 4 Research for new insights and innovative solutions to 4. Research for new insights and innovative solutions to health problems 5. Inform, educate, and empower people about health issues 30-Oct-19 122

123. 6. Mobilize community partnerships to identify and solve health problems health problems 7 . Develop policies and plans that support individual and community health efforts 8.Assure a competent public health and personal healthcare workforce 9. Enforce laws and regulations that protect health and ensure safety ensure safety 10. Link people to needed personal health services and assure the provision of health care when otherwise unavailable 30-Oct-19 123

124. Assessment Every public health agency regularly and systematically collect, assemble, analyze, and make available information on the health and make available information on the health of the community, including: - statistics on health status, - community health needs, and - epidemiological and other studies of health problems. 30-Oct-19 124

125. 30-Oct-19 125

126. Policy Development Every public health agency exercise its responsibility to serve the public interest in the responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy. 30-Oct-19 126

127. 30-Oct-19 127

128. Assurance Assure that services necessary to achieve agreed upon goals are provided: either by encouraging actions by other entities (private or public sector), by requiring such action through regulation, or by providing services directly. 30-Oct-19 128

129. 30-Oct-19 129

130. 10. Research for new insights and innovative solutions to health problems – Research serves all functions of public health 30-Oct-19 130

131. Models of Disease Causation 30-Oct-19 131

132. Models of Disease cont … A model is a representation of a system that specifies its components and the relationships among the variables. E.g. includes graphs, charts, and decision trees I – Nineteen-century models Each effort to prevent disease in the 19 th century was based on one or the other three theories of disease causality. These are: 1. Contagion theory 2. Supernatural theory 3. Personal behavior theory 4. Miasma theory 30-Oct-19 132

133. Models of Disease cont … 1. Contagion theory This theory was common at the beginning of the 19th century Most official disease prevention activities were based on the hypothesis that illness is contagious. It required: 30-Oct-19 133

134. Models of Disease cont … Keeping sick people away from well people. The institution of quarantine of ships (the traditional period was forty days la quarantine) during which time ships, their crews and cargos waited off shores or at some isolated islands. Setting up military cordons around infected towns Isolation of households if they were infected, and Fumigating or washing the bedding and clothing of the sick. 30-Oct-19 134

135. Models of Disease cont … 2. Supernatural theory Proponents of this theory argue that supernatural forces cause disease. Disease prevention measures based on this theory were important to the religious people. The view among them was that disease is a punishment for transgression of God’s laws. 30-Oct-19 135

136. Models of Disease cont … Because epidemic took a great toll on the poor than the rich, the healthier rich can employ the super natural theory as a justification for berating for the poor for sinful behavior i.e. presumed idleness, intemperance and uncleanness. This theory expressed a political philosophy. People could not advocate the belief that sin causes disease without, at the same time, implicitly supporting the idea that government need to redress poverty. 30-Oct-19 136

137. Models of Disease cont … 3. Personal behavior theory This theory held that disease results from wrong personal behavior. It was democratic and raise authoritarian in intent since it gave responsibility to individuals to control their own lives. 30-Oct-19 137

138. Models of Disease cont … In this formulation the source of the disease was not tied up with the mysterious ways of God, instead people caused their own disease by living fully unhealthy. Hence, improper diet, lack of exercise, poor hygiene and emotional tension become the focus of preventive actions. This theory does not blame the poor for the illness and in many aspects; it was homage to middle-class life. 30-Oct-19 138

139. Models of Disease cont … 4. Miasma theory This theory argues that disease is caused by the odor of decaying of organic materials. It dates back to the Hippocratic idea that disease is related to climate. It contrasted sharply from the other three theories since it conceptually separated the source of the disease from the victim of the disease . 30-Oct-19 139

140. Models of Disease cont … II – Twenty-century models Although economic and ideological considerations influenced the 19 th century disease prevention policy, sound research determines policy today. The 20 th century theory focuses on: 1. The Germ Theory 2. The Life Style Theory 3. The Environmental Theory 4. The Multi Causal Theory 30-Oct-19 140

141. Models of Disease cont … 1. The Germ Theory This theory rapidly over took other explanations of disease causations. It held the notion that microorganisms cause diseases and it is possible to control diseases using antibiotics and vaccines. There was criticism on this theory by Thomas Mckeown that stated as the incidence of all major infectious diseases begun to fall several decades before the introduction of vaccines and antibiotics. Thus rising of living standards was responsible for the reduction of disease not the discovery of antibiotics and vaccines. 30-Oct-19 141

142. Models of Disease cont … 2. The Life Style Theory This holds that unhealthy lifestyles are causes for diseases. This hypothesis blames stress, lack of exercise, the use of alcohol and tobacco improper nutrition for most chronic diseases. This theory rejects the notion central to the classic germ theory, that a single disease has a single etiology. Instead they emphasize the interrelatedness of many variables in disease causality, principally those under the control of the individual. 30-Oct-19 142

143. Models of Disease cont … 3. The Environmental Theory Environmental theory explains that significant number of chronic disease are caused by toxins in the environment and it implies that disease prevention, instead of requiring medical treatments or personal hygiene, demands change in the industrial production . 30-Oct-19 143

144. Models of Disease cont … The first aspect of the environmental hypothesis is occupational hazards, the second concentrates on toxic substances in the air water and soil (advocates of this theory places particular emphasis on radioactivity), and the third aspect focus on synthetic additives to foods “organic foods”. Two scientific disputes surround the hypothesis viz the suitability of extrapolating from animals to humans and the concept of threshold levels. 30-Oct-19 144

145. Models of Disease cont … 4. The Multi Causal Theory It is also called the web of disease causation. The theory express that there are multiple factors for a cause of a single disease entity. But it is incapable of directing a truly effective disease prevention policy as the theories it replaces. Its shortcomings are it gives few clues about how to prevent disease, the actual prevention policies it implies are inefficient in many ways and there is a gap between what it promises and what epidemiologist’s deliver. 30-Oct-19 145

146. Health and Development 30-Oct-19 146 146

147. Health and Development 1 . Learning objectives : Define development and economic growth Differentiate between development and economic growth. Describe the relationship between the health sector and development Identify and define relationships existing between individual and community health and various socio-economic conditions 30-Oct-19 147

148. 1. Introduction Individuals in good health are better able to study, learn and be more productive in their work. Improvements in standard of living have long been known to contribute to improved public health However, the course has not always been recognized. 30-Oct-19 148 148

149. Introduction cont… Investment in health care was not considered a high priority in many countries. Many investments are directed to the “productive” sectors such as manufacturing and large scale infrastructure projects, such as hydroelectric dams. 30-Oct-19 149 149

150. Introduction cont… Socially oriented approach sees investment in health as necessary for the protection and development of “human capital” just as investment in education is needed for the long-term benefit of the economy of a country. 30-Oct-19 150 150

151. Introduction cont… According to the World Development Report by World Bank in 1993: Investing in health, is articulated as a new approach to economic growth in which health , along with education and social development are considered essential contributors for economic development 30-Oct-19 151 151

152. Introduction cont… Development on the other hand should be the concern of all in the developing countries. The health planner, manager, and others are equally charged with that concern and must be knowledgeable of what development implies and the role health should play in the development of ones country. 30-Oct-19 152 152

153. Introduction cont… Hence, it is important to know what development means, How it differs from economic growth? What role health plays in development and vice versa ? 30-Oct-19 153 153

154. 2. Development Development has been variously defined. The modern view of development perceives it as both a physical reality and a state of mind in which society has, through some combination of social, economic and institutional processes, secured the means for obtaining a better life. Development in all societies must consist of at least the following: 30-Oct-19 154 154

155. Development cont… To increase the availability, distribution and accessibility of life sustaining goods such as food, shelter, health, security and protection to all members of society. To raise standards of living including higher incomes , the provision of more jobs , better education and better health and more 30-Oct-19 155 155

156. Development cont… Attention to cultural and humanistic values so as to enhance not only material well-being, but also to generate greater individual, community and national esteem To expand the range of economic and social opportunities and services to individuals and communities by freeing them from servitude , and dependence on other people and communities and from ignorance and human misery. 30-Oct-19 156 156

157. Development cont… Development is linked not just to the improvement of social indicators or the attainment of basic needs , but with wider aspirations such as high health status , and with social well-being and change . The development process embraces not only the so-called “productive” sectors of the economy, but also the social sectors 30-Oct-19 157 157

158. Development… The scope of development definition shall fit to the local scenarios. It has to be understood in terms of household Livelihood security 30-Oct-19 158 158

159. Development… Household Livelihood Security(HLS) is defined as: ‘Adequate and Sustainable Access to Income and Resources to Meet Basic Needs’, including: Food, Proper Nutrition, Clean Water, Health Facilities and services; Economic Opportunities; Education; Housing/Habitat Security; Physical Safety; and time for Community Participation. 30-Oct-19 159 159

160. Development… Health as a basic commodity of livelihood; is an important means as well as prerequisite for achieving livelihood security. Livelihood security can be affected by productivity, income, savings and expenditures 30-Oct-19 160 160

161. 3. Difference b etween economic growt h & Development. For a long time, the terms “development” and “economic growth” were used interchangeably . Although the two are closely related, they are, however, different . 30-Oct-19 161 161

162. Difference cont… Development Encompasses the total well-being of individual , a community or a nation. Must be measured by the rate of economic growth Concerned with the total person, his economic, social, political, physiological, and psychic and environmental requirements. 30-Oct-19 162 162

163. Difference cont… Economic growth can be defined as an increase in country’s productive capacity, identifiable by a sustained rise in real national income over a period of years. Concerned with the area in per capital earning of the people making up the nation. Is one characteristic of development It is possible for a country to experience economic growth without development 30-Oct-19 163 163

164. 4. The role of Health in Development Health plays a major role in promoting economic development and reducing poverty. The health sector is the key social sector for development. Good health , both at the individual, Community and national levels, is a prerequisite for full-scale productivity and creativity In the first place, the health sector should not be looked isolated from the rest of the economy , as a sort of charitable handout to ensure that people do not die, for example, of preventive diseases. Development of the health sector is seen to be a necessary requiremen t for future development 30-Oct-19 164 164

165. Role of health cont … The fact that development in the health sector may lead to further general development has given rise to a new area of economic theory called “ Investment in Human Capital ”. The importance of this theory is that, it not only helps to explain the development process in an economic way, but it also forms the basis of measuring benefit in cost benefit-analysis in the health sector . This is not to suggest that all the benefit of health or education projects is necessarily economic. The health sector, besides producing benefits, which in their own right , are necessary for improving the wellbeing of the people. Development of the health sector helps to lay the foundation for development in the wider sense. Good health affects several aspects of life and personal well-being. A healthy population will not only have high work productivity, but may also require less health care , which implies lower health expenditures for both the individual and the public sector. 30-Oct-19 165 165

166. Role of health cont … Poor health on the other hand , make people unable to work full-time and thus their income level is reduced which will affect their livelihood and they will not be able to get their basic needs including health services . Hence, the relationship of health status and i ncome is like the ‘ chicken and egg dilemma ’ and is bi-directional . This effect is reflected at individual level, household and community level. 30-Oct-19 166 166

167. Health and the MDG In September 2000, leaders of 191 countries around the world met at the UN to adopt the Millennium Declaration. The Declaration outlined the central concerns of the global community and articulated a set of interconnected and mutually reinforcing goals for sustainable development that are designated as the Millennium Development Goals (MDGs ). The MDGs, as set of global development agenda reflect the renewed commitment of the international community towards the overall well-being of people in the developing world The MDGs within the health sector can be considered as paralleling the philanthropic drives of the 1970s that led to the emergence of the “Health For All by 2000” movement. 30-Oct-19 167 167

168. The eight major goals of the MDGs 1. Eradication of extreme poverty and hunger 2. Achievement of universal primary education 3. Promotion of gender equality and empowerment of women 4. Reduction of child mortality 5. Improvement in maternal health 6. Combating HIV/AIDS, malaria and other diseases 7. Ensuring environmental sustainability 8. Developing a global partnership for development 30-Oct-19 168 168

169. MDG cont… Goal 4: Reduce Child Mortality Target 5: Reduce the under five mortality rate by two-thirds, between 1990 and 2015 Goal 5: Improve Maternal Health Target 6: Reduce the maternal Mortality ratio by three quarters, between 1990 and 2015 ( IMR=55.77/1000 . CMR= 59/1000, MMR=350/100000 live births) 30-Oct-19 169 169

170. MDG cont… Goal 6: Combat HIV/AIDS, Malaria and other Diseases Target 7: have halted by 2015 and begun to reverse the spread of HIV/AIDS Target 8: have halted by 2015 and begun to reverse the incidence of Malaria and other major diseases 30-Oct-19 170 170

171. Sustainable Development Goals SDGs Known as Transforming our world : the 2030 agenda for sustainable development. 2015-2030 1. End poverty in all its forms everywhere People are living on less than $ 1.25 1 day By 2030, reduce at least by half according to national definition 2. Zero Hunger End hunger, achieve food security and improved nutrition and promote sustainable agriculture 3. Good Health and well-being Ensure healthy lives and promote well-being for all at all ages MMR < 70/100,000 live births ; Neonatal MR <12/1000 live births ; U5M < <25/1000live births 30-Oct-19 171 171

172. 4. Quality Education Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Ensure all complete free, equitable and quality primary and secondary education 5. Gender Equality Empower all women and girls End all forms of discrimination against females 6. Clean water and sanitation Ensure availability and sustainable management of water and sanitation for all By 2030, achieve universal and equitable access to safe and affordable drinking water for all End open defecation 7. Affordable and clean energy Ensure access to affordable, reliable, sustainable and modern energy for all 30-Oct-19 172 172

173. SDG cont... 8. Decent work and economic growth Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all At least 7% GDP growth per annum in the least developed countries 9. Industry, innovation and infrastructure Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation ( Include regional and trans border infrastructure ) 10. Reduce inequalities within and among countries Achieve and sustain income growth of the bottom 40 % of the population at a rate higher than the national average 11. Sustainable cities and communities Make cities and human settlements inclusive, safe, resilient and sustainable Ensure access for all to adequate, safe and affordable housing and basic services and upgrade slums 30-Oct-19 173 173

174. 12. Responsible consumption and production patterns Implement the 10-year framework of programmes on sustainable consumption and production, all countries taking action, with developed countries taking the lead, taking into account the development and capabilities of developing countries Achieve the sustainable management and efficient use of natural resources 13. Climate action Take urgent action to combat climate change and its impacts Integrate climate change measures into national policies, strategies and planning Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries 14. Life below water Conserve and sustainably use the oceans, seas and marine resources for sustainable development. By 2025, prevent and significantly reduce marine pollution of all kinds, in particular from land-based activities, including marine debris and nutrient pollution 30-Oct-19 174 174

175. 15. Life on Land Protect, restore and promote sustainable use of terrestrial ecosystem, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss By 2020, promote the implementation of sustainable management of all types of forests, halt deforestation, restore degraded forests and substantially increase afforestation and reforestation globally 16. Peace, Justice and strong institutions Significantly reduce all forms of violence and related death rates everywhere End abuse, exploitation, trafficking and all forms of violence against and torture of children Promote the rule of law at the national and international levels and ensure equal access to justice for all 30-Oct-19 175 175

176. SDG cont... 17. Partnerships for the goals Strengthen the means of implementation and revitalize the global partnership for sustainable development Strengthen domestic resource mobilization, including through international support to developing countries, to improve domestic capacity for tax and other revenue collection 30-Oct-19 176 176

177. Thank you !!! 30-Oct-19 177 177

178. Health and Human Rights 30-Oct-19 178

179. Introduction Modern human rights movement a response to Nazi atrocities of WWII Universal Declaration of Human Rights passed by United Nations on December 10, 1948 Defines the fundamental human rights of persons and violations of those rights Universalist Aspirational Lacking enforcement mechanisms 30-Oct-19 179

180. Human Rights Instruments and Public Health 1948 The Universal Declaration of Human Rights 1976 International Covenant on Civil and Political Rights 1976 International Covenant on Economic, Social and Cultural Rights General Comment 14: Health rights Prevention, treatment, control of epidemic diseases Focus on realizing rights of women to health throughout the life span 1981 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) Health services to be consistent with the human rights of women: Autonomy, Privacy, Confidentiality, Informed consent, and Choice 30-Oct-19 180

181. State Responsibilities Signatory States must not violate these rights Commit to measurable progress to: Respect Protect Fulfill 30-Oct-19 181

182. What is meant by “ The Right to Health ” “ The right to health does not mean the right to be healthy, nor does it mean poor governments must put in place expensive health services for they have no resources. But it does require authorities put in place policies and action plans which lead to available and accessible health care for all in the shortest possible time . To ensure that this happens is the challenge facing both the human rights community and public health professionals. ” UN High Commissioner for Human Rights, Mary Robinson 30-Oct-19 182

183. “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being..." -Preamble to the WHO Constitution 30-Oct-19 183

184. What is Health? “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” WHO Definition of Health WHO as a UN related international body links health and human rights Declaration of Alma Ata, 1978 “Health…is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.” Commitment by WHO for “Health for All by the Year 2000” 30-Oct-19 184

185. Public Health lacks: Conceptual framework based on history How many lay people know what public health is or does? Vocabulary that is understandable Clarity of direction that is insightful System of ethics Biomedical ethics  Public health ethics 30-Oct-19 185

186. Human Rights has: Distinct values agreed upon around the world Codified in internationally recognized treaties Adopted by most countries, unlike few other rules of international engagement 30-Oct-19 186

187. An Alternative Definition Health is the condition in which human rights are fulfilled 30-Oct-19 187

188. Combining Health and Human Rights provides: Common language and framework to reference A junction on which to collaborate Opportunity for cross-disciplinary education A system of public health ethics 30-Oct-19 188

189. Right to Health What does it mean? health  medical care  health care “Right to Health” = right to health protection = medical care + healthy conditions Where does it come from? 30-Oct-19 189

190. Right to Health Components Declaration of the right to health Prescription of standards aimed at meeting the health needs of specific groups Prescription of ways and means for implementing the right to health 30-Oct-19 190

191. Universal Declaration of Human Rights, Article 25.1 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control. 30-Oct-19 191 Non-binding declaration

192. International Covenant on Economic, Social, and Cultural Rights, (ICESCR) Article 12.1* The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 30-Oct-19 192

193. Right to Health in other International Documents Constitution of the World Health Organization (WHO) Convention on the Rights of the Child African Charter on Human and People’s Rights Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) Convention on the Elimination of All Forms of Racial Discrimination (CERD) 30-Oct-19 193

194. Right to Health in National Law 20 Constitutions in Western Hemisphere include language invoking a right to health “Right to Health” in 5 Constitutions “Right to Health Protection” in 8 others US Constitution/Bill of Rights does NOT include any mention of a right to health Argentina, Colombia, and Costa Rica do not What Ethiopia does? 30-Oct-19 194

195. ICESCR, Article 12.2 International Covenant on Economic, Social and Cultural Rights The steps to be taken by the states parties to the present Covenant to achieve the full realization of this right shall include those necessary for: The provision for the reduction of the still-birth rate and of infant mortality and for the healthy development of the child; The improvement of all aspects of environmental and industrial hygiene; The prevention, treatment, and control of epidemic, endemic, occupational and other diseases; The creation of conditions which would assure to all medical service and medical attention in the event of sickness. 30-Oct-19 195

196. Essential aspects of primary health care approach (Alma Ata): Emphasis on preventive health (immunization/family planning) more than curative medicine Promotion of food supply and proper nutrition Basic sanitation and safe water supply Emphasis on maternal and child health Prevention and control of local endemic diseases Treatment of common diseases and injuries Provision of essential drugs Importance of health education High priority given to vulnerable groups Equal access to all at an affordable cost Importance of participation in planning and implementation 30-Oct-19 196

197. Contemporary expansion of Human Rights Initial focus on civil and political rights has expanded to include advocacy for the realization of economic and social rights, as well as concerns about the environment and consequences of global economic development on health. Wider societal involvement and participation in human rights struggles and discourse is broadening the language and uses of human rights concepts, based always on core fundamentals. 30-Oct-19 197

198. Contemporary expansion of Human Rights Increasing realization that non-state actors, such as societal institutions and transnational corporations, may strongly affect health status and influence the capacity for realization of rights, yet elude state control. Melding of approach-using human rights protection and promotion concurrently. 30-Oct-19 198

199. Old Conceptual Model 30-Oct-19 199 Human Rights Well- Being Health

200. New Conceptual Model Framework for Understanding 30-Oct-19 200 Human Rights Health Human Rights Human Rights Health Health

201. Framework of Understanding RELATIONSHIP #1 Understand the impact, positive or negative, of health policies, programs, and practices on human rights. Maxim/challenge: All public health interventions and programs are potentially burdensome to human rights. 30-Oct-19 201

202. Health  Human Rights Three core functions of public health each can have human rights components: Assess health needs and problems, using both investigation, surveillance, and research Develop policies designed to address priority health issues Implement programs to achieve specific health goals, and monitor one’s progress 30-Oct-19 202

203. Restriction of rights Article 29, UDHR In the exercise of (his) rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society. 30-Oct-19 203

204. Derogation of Rights The public good* can take precedence to: “secure due recognition and respect for the rights and freedoms of others; meet the just requirements of morality, public order and the general welfare, and in times of emergency when there are threats to the vital interests of the nation.” -ICCPR, Article 4 30-Oct-19 204 *Public health qualifies as one such public good.

205. The Siracusa Principles Provided for and carried out in accordance with the law; In the interest of a legitimate objective of general interest; Strictly necessary in a democratic society to achieve the objective; There are no less intrusive and restrictive means available to reach the same goal; and The restriction is not imposed arbitrarily 30-Oct-19 205 UNECOSOC,1985

206. Framework of Understanding RELATIONSHIP #2 Understand the impact of human rights violations on human health. Maxim: Violations of all human rights, not just those explicitly describing health, have indirect and direct health impacts. 30-Oct-19 206

207. Human Rights  Health Obvious and inherent health impact of severe human rights violations Torture Imprisonment under inhumane conditions Summary execution without trial Disappearances (“dirty wars” of Central and South America in 1980s) Other – Unethical research practices Nazi medicine & US Tuskegee study (CDC) 30-Oct-19 207

208. Human Rights  Health Direct and indirect health consequences of many other human rights violations UDHR Article 23-Violation of the right to work under just and favorable work conditions, and right to join trade unions. UDHR Article 26-Violation of right to education. UDHR Article 1-Violation of right to collective dignity. UDHR Article 25.2-Violation of women’s rights. 30-Oct-19 208

209. Human Rights  Health Discrimination Health policies Compromise of medical independence Lack of access to medical care Violent conflict affecting civilian populations Indiscriminate harm from weapons Unethical research practices Dangerous environmental exposures 30-Oct-19 209

210. Framework of Understanding RELATIONSHIP #3 Understand that the promotion and protection of human rights and the promotion and protection of health are fundamentally linked. Maxim: This inextricable connection is at the core of human health. It has strategic implications and practical consequences. 30-Oct-19 210

211. Health  Human Rights What are the underlying conditions needed for health? Complementary approach and interdependence of all rights in advancing human well-being Dignity and health Individual and population vulnerability to disease, disability, and the ultimate outcome once ill (death) is inextricably linked, and in fact dependent upon, respect for human rights and dignity. Rights (provided by States) are often accompanied by duties (of individuals) 30-Oct-19 211

212. So, now that you know what your rights are… You have a duty to participate as a civil actor to guarantee that your (and others) rights are respected, protected and fulfilled. 30-Oct-19 212

213. “Human rights are our common heritage and their realization depends on the contributions that each and every one of us is willing to make, individually and collectively, now and in the future." -Louise Arbour , United Nations High Commissioner for Human Rights 30-Oct-19 213

214. Social Justice and Public Health What Is Social Inequity ? Social inequity excludes people from full and equal participation in society . A  social justice  approach to population  health  challenges us to deal with these underlying concerns, to recognize that racism, socioeconomic inequality, gender discrimination, and hate, to name a few, have negative consequences for  health , and that we simply cannot improve the  health  of populations without tackling  30-Oct-19 214

215. What is the social justice perspective?   social justice  is based on the concepts of human rights and equality, and can be defined as "the way in which human rights are manifested in the everyday lives of people at every level of society". A number of movements are working to achieve  social justice  in society. 30-Oct-19 215

216. What is social justice in health? Health  and  social justice . ... But good  health  does more than that. It is important in allowing individuals to exercise a range of human rights – both civil and political (e.g. physical integrity, personal security, political participation),  social  and economic (e.g. employment, education and family life). 30-Oct-19 216

217. Social Inequities Root Causes of Health Inequities Health Inequities Segregation Income & Employment Education Housing Transportation Air Quality Food Access & Liquor Stores Physical Activity & Neighborhood Conditions Criminal Justice Access to Healthcare Social Relationships & Community Capacity Social Inequities 30-Oct-19 217

218. Approach to Achieving Health Equity Community Capacity Building Institutional Change Policy Change HEALTH EQUITY Data and Research Programs Services 30-Oct-19 218

219. Segregation “It is often easier to become outraged by injustice half a world away than by oppression and discrimination half a block from home.” – Carl T. Rowan Author and journalist 30-Oct-19 219

220. Racially Restrictive C ovenant 30-Oct-19 220

221. Effects of Social Inequities Social Inequities Body Mind Spirit 30-Oct-19 221

222. Effects of Social Inequities “When the symbols, rituals, rites of one’s culture lose their legitimacy and power to compel thought and action, then disruption occurs within cultural orientation and reflects itself as pathology in the psychology of the people belonging to that culture.” (Nobles, et al., 1987) 30-Oct-19 222

223. Not Quite Home: The Psychological Effects of Oppression Ken Hardy’s article “ Home isn’t just a place to sleep and hang your clothes; it is also a state of being, a sense of intrinsically fitting in to the community around you and being welcomed, invited, accepted and free to be complete…Home is the spirit we hope to find in others; an end to being pushed out in the cold because of some difference that is deemed unacceptable .” 30-Oct-19 223

224. Impact of Social Inequities on Well-Being Psychological homelessness: result of oppression and injustices by racism Historical legacy of colonization Guilt, anger, self-hate & powerlessness Fear and depression Isolation, break up of families, loss of identity and destruction of culture 30-Oct-19 224

225. When the External Becomes Internal How Health Inequities Get Inside the Body Transportation Housing Segregation Increased commute times Lack of access to stores, jobs, services Crime Stress Stress Stress Stress Stress Stress Poor air quality Stress Stress Poor quality Education Physical and Mental Health Impacts 30-Oct-19 225

226. Health Disparities “A difference in rates of illness, disease, or conditions among different populations.” – UW, Robert Wood Johnson & NACCHO 30-Oct-19 226

227. Health Inequities Health inequities are “differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust.” – Margaret Whitehead Department of Public Health University of Liverpool 30-Oct-19 227

228. Determinants of Health 30-Oct-19 228

229. The Impact of Public Health Increased Life Expectancy More than Doubled between 1850 and 1950 Biggest Impact on Children Reduced Acute and Chronic Morbidity Cholera, Yellow Fever TB, Malaria, Syphilis 30-Oct-19 229

230. Changing Public Perceptions Communicable Disease Once Paralyzed Government and Community Life No More Visible Public Health Crises Quarantine for TB and Other Diseases Closing of Public Facilities and Limiting Travel for Polio Magic Bullet Mentality Vaccines Antibiotics 30-Oct-19 230

231. Lowered Public Support No Crisis – No Political Support Reduced Funding Politization of Agencies Resistance to Interventions Loss of Academic Support Research Money Shifts to Social Science and Biotech Public Health Training Loses Focus “No There, There” Problem 30-Oct-19 231

232. Public Health as Oppression (Assignment) Tuskegee Syphilis Experiment Typhoid Mary TB as a Housing Problem STD Control as Sexual Discrimination Fluoridation Foes Anti-Vaccination Movement Environmental Justice 30-Oct-19 232

233. Public Health as Suspect Activity Shift from Societal Protection to Personal Protection Shift from Police Power to Parens Patria Increased Due Process Increased Agency Cost Shift from Expert Decisionmakers Civil Rights Mentality 30-Oct-19 233

234. Lawyers and Law Professors Prefer Civil Rights Helping the Downtrodden Empowering the Individual Distrust of the State Lots of Money in Suing for Individuals Not Much Money in Representing the State No Money or Private Practice in Public Health Law 30-Oct-19 234

235. Was Public Health Oppression? Was Public Health More or Less Discriminatory than Society As a Whole? Generally Much More Progressive The Burden of Disease Always Falls Hardest on the Poor and Marginalized Greatest Benefits to the Worst Off Separate Out Medical Care Public Health Was the Most Unrestricted Service 30-Oct-19 235

236. Public Health Elitism AIDS Think Driven by White Affluent Gay Men Privacy and Autonomy is More Important than Disease Control Ignores Casual Contact Diseases Self-Empowerment Model Driven by Political Power in Urban Centers Aggressive Involvement in Medical Care Even Private Importation of Drugs 30-Oct-19 236

237. Impact of Public Health Elitism AIDS and Poor and Minority Women Denied Access to Medical Care Left Out of Clinical Trials No Protection from Sexual Contacts Environmental Justice East Fix Really About the Environment Just Results in Improvement 30-Oct-19 237

238. Public Health Justice Reject Elitism Empowerment only Benefits the Affluent and Powerful Is Privacy More Important than Life and Health? Real Oppression Underfunded Public Health Services Incompetent Public Health Professionals Ignoring the Most Significant Risks to Health and Community 30-Oct-19 238

239. Public Health Challenges Global health problems are complex and systemic. The gross inequalities in health that we see within and between countries present a challenge to the world. The conditions in which people are born, grow, live, work and age are at the root of much of these inequalities in health, and these social determinants are relevant to infectious and non-communicable diseases alike. Their resolution requires partnerships transcending the boundaries between disciplines. 30-Oct-19 239

240. Millennium Development Goals Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Global partnership for development 30-Oct-19 240

241. 30-Oct-19 241

242. Globalization of Health Challenges During the last two decades there has been a fundamental shift in global patterns of disease. New epidemics of chronic illness are following in the wake of rapid urbanization and economic change. The epidemiological profile of many LMICs is becoming similar to that in developed nations. 30-Oct-19 242

243. Main cause of premature death – worldwide. 1990-2010. 1990 1 Lower Respiratory infections 2 Diarrhea 3 Preterm Birth complications 4 Ischemic Heart Disease 5 Stroke 6 Malaria 7 COPD 8 Protein-energy Malnutrition 9 Tuberculosis 10 Neonatal encephalopathy 2010 1 Ischemic Heart Disease 2 Lower Respiratory infections 3 Stroke 4 Diarrhea 5 Malaria 6 HIV/AIDS 7 Preterm Birth complications 8 Road Injury 9 COPD 10 Neonatal encephalopathy 30-Oct-19 243 Source: The Lancet 2012; 380:2095-2128

244. Global Challenges Challenges are interdependent: an improvement in one makes it easier to address others; deterioration in one makes it harder to address others. Challenges are transnational in nature and transinstitutional in solution. Cannot be addressed by any government or institution acting alone. Need collaborative action among governments, international organizations, corporations, universities, NGOs, and creative individuals. 30-Oct-19 244

245. Global Influences on Health 30-Oct-19 245 Health Adapted from McMichael AJ. N Engl J Med 2013;368:1335-1343

246. Demographic and Social changes that influence health Demographic Changes Population Growth Aging Urbanization Increased Mobility Family Structure Social Changes Governance Institutions International codes, treaties and relationships Cultural change and diffusion 30-Oct-19 246

247. Global economic influences on health Trade and Capital Mobility Labor conditions Wealth creation Wealth distribution International financial stability International Aid 30-Oct-19 247

248. Environmental influences on Health Land and water resources Use, degradation and depletion Energy security and use Ecosystem disturbances Climate change Extreme weather conditions Warming 30-Oct-19 248

249. Global Influences on Health 30-Oct-19 249 Health Adapted from McMichael AJ. N Engl J Med 2013;368:1335-1343

250. Initial Reports of HIV AIDS 30-Oct-19 250 June 5, 1981: 5 cases of PCP in gay men from UCLA (MMWR) Gottlieb MS NEJM 2001;344:1788-91

251. Emergence of HIV-AIDS 30-Oct-19 251 AIDS

252. Spatial dynamics of HIV-1 group M spread 30-Oct-19 252 Faria et al, Science 346: 56. 2014

253. T otal: 35.0 million [33.2 million – 37.2 million] Middl e East & N orth Africa 230 000 [160 000 – 330 000] Sub-Sahara n Africa 24. 7 million [23. 5 millio n – 26. 1 million] Easter n Europ e & Central Asia 1.1 million [98 000 – 1. 3 million] Asi a an d th e Pacific 4. 8 million [4. 1 millio n – 5. 5 million] Nort h Americ a an d W est ern and Central Europe 2.3 million [2. millio n – 3. million] Latin America 1. 6 million [1. 4 millio n – 2. 1 million] Caribbean 250 000 [230 000 – 280 000] Adult s an d childre n estimate d to be living with HI V  2013 30-Oct-19 253

254. 30-Oct-19 254

255. 30-Oct-19 255

256. Current State of HIV control 30-Oct-19 256 HIV control 34 million infected people (only 24% on Rx) - 2.5 million newly infected each year Marginalization of many populations – women and children, MSM, Drug-users, Mentally ill Financial cost – donor fatigue Lack of Adherence and behavioral disinhibition obstacles to sustained effectiveness of proven interventions NEED Vaccine and Cure

257. “ As the HIV disease pandemic surely should have taught us, in the context of infectious diseases, there is nowhere in the world from which we are remote and no one from whom we are disconnected. ”   IOM, 1992 30-Oct-19 257

258. Factors involved in the emergence of new infections – especially viral Microbial adaptation and change . Mutations or recombination events in pre-existing viruses. Inter-species transmission ( zoonoses ) Changing ecosystems . Climate and weather . Human demographics and behaviour . War and famine . International travel and commerce . Breakdown of public health measures . Adoption of exotic animals . 30-Oct-19 258

259. Interdependence: The Shrinking World 1 billion people cross international borders each year or 25/second unprecedented vulnerability Threats spread faster, further, and non-linear Increased threats of global pandemics Significant risk in resource-poor countries with under funded public and animal health systems “ If the forest is dry enough and dense enough …” 30-Oct-19 259

260. 30-Oct-19 260

261. Emergence of Ebola in West Africa -2014 30-Oct-19 261 Ebola Virus Disease

262. Transmission of Ebola Individuals are only infectious if they have symptoms of Ebola. No risk of transmission from people who have been exposed to the virus but are not yet symptomatic. Ebola is spreads through direct contact with bodily fluids. In the current outbreak, most new cases are occurring among people who have been taking care of sick relatives or who have prepared an infected body for burial. Health care workers are at high risk Need personal protective equipment (PPE) and training to use and decontaminate it. The virus can survive on heavily contaminated surfaces, objects contaminated with bodily fluids, e.g., latex glove or a hypodermic needle, may spread the disease. 30-Oct-19 262

263. Best-case scenario 11,000-27,000 cases through Jan. 20 Worst-case scenario 537,000-1.4 million cases through Jan. 20 CDC Modelling of Epidemic 30-Oct-19 263 Sept Oct Nov Dec Jan Sept Oct Nov Dec Jan 1,000,000

264. Ebola – a Global Crisis needing a global large-scale, coordinated humanitarian, social, public health, and medical response Public Health Classic public health measures (case identification, contact tracing and isolation). Safe and effective interventions including behavioral changes, developed in collaboration with the affected communities. Appreciation of the culture of the societies in the affected countries, and redevelopment of local trust in governance. Coordination and real-time, open sharing of information across diverse disciplines and with all the players involved. Medical Science Development of diagnostic tools, therapies, and vaccines. Performance of clinical research in the midst of care. Development of an accepted, ethical mechanism for accelerating development and testing such interventions in epidemic situations. 30-Oct-19 264 Adapted from Farrar and Piot , NEJM 2014

265. HIV, SARS, H5N1, MERS, Ebola, ………What next? Global vulnerability remains Microbial evolution Opportunities for exposure Human behaviors Most countries lack adequate public health infrastructure to cope Transdisciplinary science explains but can it anticipate? Better models of prediction Better tools for surveillance Better modes of response Critical role for education Future leaders Current public 30-Oct-19 265

266. Global Challenges – how to respond The critical aspects of global health interaction with policymakers and professionals in countries at varying stages of development, policy development by national and international organizations, questions of funding and prioritization, the social determinants of health, education, governance and capacity-building, all take place within a complex political, moral and philosophical environment. 30-Oct-19 266

267. What can Research Universities do? “………..complex political, moral and philosophical environment ”. Foster collaboration between academics at their own institutions, among them biomedical scientists, social scientists, engineers, epidemiologists, anthropologists, economists, psychologists, political scientists and historians. Innovative research Transformative education Develop cross-national collaborations addressing the major global challenges Manage creatively the tension created by individual/institutional recognition Develop sustainable public/private partnerships focused on applying innovative technologies 30-Oct-19 267

268. What Can Research Universities do? Develop ethically strong collaborations with centers in LMICs Develop capacity to allow them to identify leadership, and research/educational capability Promote opportunities for short-term and long-term training Provide equity in relationships Understand and develop innovative approaches to brain drain Provide leadership in their own communities Tackle the local dimensions of global problems Public health, social determinants of disease, food security and food quality; waste, water and air quality. Educate Students, faculty, public 30-Oct-19 268

269. Delivering effective Health interventions over a life course 30-Oct-19 269 Based on Frieden TR. Am J Public Health 2010; 100:590

270. Globalization and Social Determinants of Health 30-Oct-19 270

271. The  social determinants of health  are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual risk factors (such as behavioral risk factors or genetics) that influence the risk for a disease, or vulnerability to disease or injury. 30-Oct-19 271

272. The distributions of social determinants are often shaped by public policies that reflect prevailing political ideologies of the area. The  World Health Organization  says, "This unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer], and bad politics. 30-Oct-19 272

273. 30-Oct-19 273

274. In 2003, the  World Health Organization  (WHO) Europe suggested that the social determinants of health included: The social gradient Stress Early life Social exclusion Work Unemployment Social support Addiction Food Transportation 30-Oct-19 274

275. 30-Oct-19 275

276. Globalization is a term with multiple, contested meanings. Generically, it describes the ways in which nations, businesses and people are becoming more connected and interdependent across national borders through increased economic integration, communication, cultural diffusion and travel . 30-Oct-19 276

277. Lee considers globalization as a product of the interaction of technology, culture and economics leading to a compression of time (everything is faster), space (geographic boundaries begin to blur) and cognition (awareness of the world as a whole). This is an important and useful theoretical contribution. Further, it can be argued that in terms of the overall trajectory of humankind’s future, one of the most important influences is the unprecedented ‘globalization’ of human impacts on the natural environment – a phenomenon with important implications for human health. 30-Oct-19 277

278. This focus on processes of economic integration and on the global marketplace does not mean a focus solely on economic phenomena as conventionally defined. Notably, we do not wish to exclude various social and cultural dimensions of globalization, such as the increased speed with which information about new treatments, technologies and strategies for health promotion can be diffused and the opportunities for enhanced political participation and social inclusion that are offered by new, potentially widely accessible forms of electronic communication. 30-Oct-19 278

279. Globalization and the Social Determinants of Health (SDH) A UNICEF study of “Adjustment with a Human Face” represented an early and important attempt to identify causal pathways linking what we would now call globalization with the SDH. 30-Oct-19 279

280. The study involved 10 countries 12 that had adopted policies of domestic economic “adjustment” in response to economic crises that led them to rely on loans from the IMF. It found that in many cases, although not all, the policies adopted had resulted in deterioration in key indicators of child health (e.g. infant mortality, child survival, malnutrition, educational status) and in access to determinants of health (e.g. availability and use of food and social services), with reductions in government expenditure on basic services emerging as a key intervening variable. 30-Oct-19 280

281. The study situated these national cases within an analytical framework that linked changes in government policies (e.g. expenditures on education, food subsidies, health, water, sewage, housing and child care services ) with selected economic determinants of health at the household level (e.g. food prices, household income, mothers’ time) and selected indicators of child welfare . Based on that analysis, it identified a generic package of policies that would minimize the negative effects of economic adjustment on what would today be called health equity . The package emphasized protecting the basic incomes, living standards, health and nutrition of the poor or otherwise vulnerable – priorities that have been stressed in subsequent policy analyses. 30-Oct-19 281

282. Woodward and WHO colleagues devised a model that focused on “five key linkages from globalization to health,” three direct and two indirect. Direct effects included impacts on health systems, health policies, and exposure to certain kinds of hazards such as infectious disease and tobacco marketing; indirect effects were those “operating through the national economy on the health sector (e.g. effects of trade liberalization and financial flows on the availability of resources for public expenditure on health, and on the cost of inputs); and on population risks (particularly the effects on nutrition and living conditions resulting from impacts on household income).” 30-Oct-19 282

283. The global marketplace and health systems Health care interventions that would be taken for granted in the industrialized world are just as routinely unavailable, or available only to the wealthy, outside it. Globalization may have worsened this situation, and almost certainly has inhibited progress, by promoting and reinforcing a market-oriented concept of health sector reform (HSR) that strongly favours private provision and financing . Multilateral institutions like the World Bank have been especially important in this respect. In keeping with the World Bank’s preference for markets and private insurance in health care, reductions in public sector health spending, introduction of user fees, and other cost recovery measures aimed at making health systems “sustainable” were often mandated as part of structural adjustment conditionalities . 30-Oct-19 283

284. On equity grounds, the best that can be said for official user charges is that they may replace informal, and even more inequitable patterns of side payments demanded by care providers or suppliers of medicines … and abundant evidence exists that their effectiveness in generating revenue is limited, even while access to health care for the poor and otherwise vulnerable often deteriorates 34 because very large numbers of people in the developing world simply cannot afford necessary health care. 30-Oct-19 284

285. For example, national survey data in Mexico indicate that 51.8 percent of people who did not seek medical care for severe illness gave cost, or their own lack of money, as a reason. A smaller scale study of patterns of health service utilization in Lusaka, Zambia found that costs were the most commonly given reason for choosing self-medication as a first resort in case of illness, and also the most common reason for noncompliance with treatment regimes following a visit to the centralized university teaching hospital. 30-Oct-19 285

286. The marketization of health systems under the influence of external agencies may also have the effect of emphasizing commodified interventions and ‘vertical,’ disease-specific programs at the expense of integrated approaches that incorporate SDH. For example, although its initiatives are crucially important (and underfunded), “t he Global Fund targets 49% of its expenditure on drugs and commodities such as antiretrovirals and new antimalarials but only 20% on human resources and training,”, even though human resources are recognized with increasing frequency as the single most formidable challenge to improving the quality and comprehensiveness of health care in Africa. 30-Oct-19 286

287. Four further equity-related dimensions of globalization’s effects on health systems must be considered. First, despite a WTO interpretation of TRIPS that limits patent protection for essential medicines, concern remains about the effectiveness of this interpretation as reflected both in national legislation (in countries with substantial pharmaceutical industries) and trade policy practice (in countries without). Second, commitments made under the General Agreement on Trade in Services (GATS) and other agreement such as NAFTA have the potential to ‘lock in’ privatization initiatives against future governments’ efforts to expand public provision or insurance, although disagreement exists about the seriousness of this prospect. 30-Oct-19 287

288. Third, the ‘brain drain’ of health professionals from developing countries, in particular those in sub-Saharan Africa, to industrialized countries where they can earn far more is now recognized as one of the most serious problems confronting health systems. Solutions, however, remain elusive because the situation reflects a bidding contest for the services of health professionals that is analogous in many respects to the bidding contests for urban space and locationally valuable resources without decisive policy intervention, in the case of ‘brain drain’ almost certainly requiring multilateral agreements, the rich will always win those contests. 30-Oct-19 288

289. Fourth, leaving health research priorities to the global marketplace is highly problematic on equity grounds. The private pharmaceutical industry now accounts for 41.5 percent of all health research spending, and public funding agencies in many industrialized countries are linking priorities to the anticipation of commercial returns. The result is the so-called ‘10/90 gap’: roughly 10 percent of health research spending addresses conditions that account for 90 percent of the global burden of disease, overwhelmingly outside the industrialized world. 30-Oct-19 289

290. Global public goods for health (GPGH) In common use, the phrase “public good” is often associated with the common welfare, or with such value-based goals as social equity, social justice and environmental sustainability. Its definition in economic theory is more precise: a private good 42 is one whose individual consumption is both excludable (my use of the good is not dependent on others’ use) and rivalrous (my use of the good could preclude use by another). Conversely, a public good is one that is non-excludable (the classic illustrations are the order created by traffic lights and, from the days before GPS, the safety benefits of lighthouses) and, in pure form, is non-rivalrous (my use of the traffic light or lighthouse in no way impairs your use of it). 30-Oct-19 290

291. Although health itself is not generally regarded as a public good, there are numerous public goods for health, with control of communicable diseases and the production of knowledge in the health sciences being the paradigmatic examples. Both would be drastically undersupplied if provision were left entirely to private markets. Few pure public goods exist, and public policy choices, which may vary over time, often determine the balance between private and public characteristics of a good. 30-Oct-19 291

292. The Knowledge Network work plan the following list of research syntheses would comprise the major input into the work of the KN. A. Globalization and socially determined health conditions and risks 1. Interrogating the evidence base for recent globalization links with income, wealth, health convergence/divergence 45 2. Globalization and innovations in global governance for the social determinants of health 30-Oct-19 292

293. B. Key processes of globalization that affect social determinants of health 3. National and international labour markets and social determinants of health 4. Trade liberalization 5. Financial liberalization, financial crises, global financing, and governance 30-Oct-19 293

294. C. Key health determining services/resources 6. Impacts of globalization on policy space, political structures and processes 7. Globalization and health systems change (health reform) 8. Health human resources and global migration 9. Globalization and food/nutrition transitions 10. Water and sanitation 30-Oct-19 294

295. Climate Change and Health 30-Oct-19 295

296. What is Climate change? Temperatures are rising rapidly, following increases in CO 2 emissions and concentrations. 30-Oct-19 296

297. “Climate change is the biggest global challenge in the 21 st century.” WHO Temperature increases cannot be explained by natural processes, given that records show that climate is changing, the next question is the degree to which human activities are responsible. Precipitation will also change, and become more extreme 30-Oct-19 297

298. Many aspects of weather have changed, and will continue to do so What is climate change?

299. How does climate change affect health? Climate change undermines the environmental determinants of health Without effective responses, climate change will compromise: Water quality and quantity : Contributing to a doubling of people living in water-stressed basins by 2050. Food security : In some African countries, yields from rain-fed agriculture may halve by 2020. Control of infectious disease : Increasing population at risk of malaria in Africa by 170 million by 2030, and at risk of dengue by 2 billion by 2080s. Protection from disasters : Increasing exposure to coastal flooding by a factor of 10, and land area in extreme drought by a factor of 10-30. 30-Oct-19 299

300. Health effects Temperature-related illness and death Extreme weather- related health effects Air pollution-related health effects Water and food-borne diseases Vector-borne and rodent- borne diseases Effects of food and water shortages Effects of population displacement Contamination pathways Transmission dynamics Agroecosystems, hydrology Socioeconomics, demographics CLIMATE CHANGE Human exposures Regional weather changes Heat waves Extreme weather Temperature Precipitation Based on Patz et al, 2000 Modulating influences Climate change connects to many health outcomes Some expected impacts will be beneficial but most will be adverse. Expectations are mainly for changes in frequency or severity of familiar health risks How does climate change affect health?

301. Some of the largest disease burdens are climate-sensitive Each year: - Undernutrition kills 3.5 million. - Diarrhoea kills 2.2 million. - Malaria kills 900,000. - Extreme weather events kill 60,000. WHO estimates that the climate change that has occurred since the 1970s already kills over 140,00 per year. 30-Oct-19 301

302. Weather-related disasters kill thousands in rich and poor countries Weather-related disasters kill thousands in Paris 2003, in India 2012 Hurricane Katrina, 2005 Increases in diseases of poverty may be even more important Diarrhoea is related to temperature and precipitation. In Lima, Peru, diarrhoea increased 8% for every 1 C temperature increase. Health impacts are unfairly distributed 30-Oct-19 302

303. Health impacts are unfairly distributed Cumulative emissions of greenhouse gases, to 2002 WHO estimates of per capita mortality from climate change, 2000 Map projections from Patz et al, 2007; WHO, 2009. How does climate change affect health?

304. Wat as been done? International community has given clear direction UNFCCC, Article 1, paragraph (1) states need to minimize adverse effects on " natural and managed ecosystems or on the operation of socio-economic systems or on human health and welfare ” . World Health Assembly Resolution WHA/61.R19, and Executive Board Resolution EB124.R5, request WHO to develop capacity to assess the risks from climate change for human health and to implement effective response measures , and support countries through Awareness raising, Partnerships, Evidence, and health system strengthening . 30-Oct-19 304

305. Assignment 2 What has been the contribution of Ethiopia towards climate change since 2010? 30-Oct-19 305

306. Awareness raising: High public concern over climate risks to health Globescan poll in 30 countries (UNDP 2007): “Now I would like to ask you some questions about climate change, which is sometimes referred to as global warming or the greenhouse effect. Which ONE of the following possible impacts most concerns you personally, if any?” What has been done? Awareness raising

307. Awareness Rising: Governments request international support 193 countries endorse WHO resolution calling for action to protect health from climate change. 95% (39/41) of National Adaptation Programmes of Action ( NAPAs ) from least developed countries identify health as a priority sector affected by climate change. 73% (30/41) of the NAPAs have included health interventions within adaptation needs . 30-Oct-19 307

308. Awareness raising: WHO achievements Among health leaders : WHA resolution, backed by regional Ministerial declarations and frameworks for action. Among health and metorological professionals : Workshop series , covering over 50 countries across all WHO regions . Among climate leaders : Representation of health in the UNFCCC, formation of "Friends of Public Health " network of negotiators and NGOs . Among the general public : World Health Day 2008 on " Protecting health from climate change, supported by advocacy products and key messages 30-Oct-19 308

309. UNFCCC provides international framework for climate action, with health as a key justification. UNFCCC operational mechanisms include health ; Nairobi Work Programme on Adaptation, Social Dimensions of Climate Change. "One-UN" country teams implementing health adaptation projects . Establishment of networks of health NGOs campaigning on climate change. Partnerships: UN system working together, and with others What has been done? Partnerships

310. Awareness raising partnerships : Establishment of "Friends of Public Health " network, coordination with major health NGOs . Policy partnerships : Representation of health in UNFCCC negotiations and support mechanisms ; co-convenor of UN task team on Social Dimensions of Climate Change. Scientific and technical partnerships : Representing health on IPCC, technical guidance with WMO and UNEP. Operational partnerships for health adaptation : Projects implemented through UN country teams; with UNDP and GEF; with bilateral aid agencies . Partnerships: WHO achievements What has been done? Partnerships

311. Over 1000 papers on health and climate change in peer-reviewed journals . Research covering risks , costs , cobenefits of mitigation, resource requiremennts . Evaluations of health risks in three IPCC assessment reports. Evidence: Definition of health risks and responses What has been done? Scientific evidence

312. Sustainable urban transport – could cut heart disease and stroke by up to 20%. Improved stoves could save 2 million lives over 10 years in India alone, and reduce warming from black carbon. Health benefits from actions to reduce greenhouse gas emissions could substantially offset mitigation costs. Evidence: Benefits of healthy mitigation measures documented " while the climatic effects of mitigation measures are long-term and dispersed throughout the world, the health benefits are immediate and local " – WHO director-General Margaret Chan, 2009 What has been done? Scientific evidence

313. Over 50 books, reports and papers on climate change - health links. Guidance and systematic review of research output vs. requests of countries. Quantitative assessment of global health impacts of climate change. Technical guidance on vulnerability and adaptation assessment, and specific risks. Comprehensive review of health implications of mitigation policies across major sectors. Evidence: WHO achievements What has been done? Scientific evidence

314. Health system strengthening: Identification of principles for health adaptation We have proven, cost-effective interventions against every climate-sensitive health impact. Clean water and sanitation, vector control, disaster risk reduction, early warnings, humanitarian aid… All of these are "win-wins": saving lives now, and reducing vulnerability to climate change. Adaptation to climate change is part of a preventive approach to public health – not a distraction. 30-Oct-19 314

315. Health system strengthening: Documentation of country need Less than 30% of least developed countries have adequate health vulnerability assessments and health adaptation plans. Only 11% of proposed adaptation projects , and only 3% of requested funds , are for health protection. Health adaptation projects comprise just 1% of international climate finance, and less than 0.5% of estimated health damages from climate change. 30-Oct-19 315

316. Estimated global annual cost of climate change adaptation (US$ billion): All estimates derived by applying unit costs to WHO estimates of health impacts of climate change UNFCCC (2 00 7 prices) World Bank (2005 prices) Sector 2030 2010-2050 Period or time point 3.8 - 4.4 2.0 Health sector 9.0 - 11.0 13.7 Water supply 14.0 7.6 Agriculture, forestry and fisheries - 6.7 Extreme weather 26.8 - 29.4 30.0 Total health-related 56.8 - 193.4 89.6 Total (all) 13.8 - 47.1% 33.4% % health-related Health system strengthening: Estimation of required resources for health adaptation What has been done? Health system strengthening

317. Health system strengthening: Definition of an essential public health package Most health risks in next 20-30 years could be averted through comprehensive assessments of climate risks to health and health systems; integrated environment and health surveillance; delivery of preventive and curative interventions for identified climate-sensitive public health concerns; preparedness and response to the public health consequences of extreme weather events; applied research; and strengthening of human and institutional capacities and inter-sectoral coordination. 30-Oct-19 317

318. What still needs to be done? Goal: Policy makers and general public recognize health as a practical and positive argument for climate policy Requires : More effective engagement of health actors and messages in climate policy debate. WHO contribution : Production of targeted awareness-raising products for specific audiences. Mobilization of health networks on evidence-based advocacy messages. Sustained engagement with health and climate policy-makers. 30-Oct-19 318

319. Goal : Coherent, evidence-based health and climate policy, matching demands of Governments and the public Requires : Sustained partnerships to design and implement climate and health policy, and health access to financial support. WHO contribution : Articulating health opportunities and resource requirements within the UN system response. Convening operational partnerships of health and climate actors at national, regional and global levels. Establishing and maintaining networks to guide, implement and monitor applied research, in response to country needs. 30-Oct-19 319

320. Goal : Policy-relevant evidence on health adaptation, and healthy mitigation policy, accessible to decision-makers Requires : Greater emphasis on applied research, and on knowledge management for practical application. WHO contribution : Systematic review and guidance of research output to match the needs of decision-makers. Specific evidence products, on the benefits and costs of health adaptation interventions, and on health promoting mitigation. Translation of research into practical guidance for health protection from climate change, and health-enhancing mitigation policy. 30-Oct-19 320

321. Goal : Populations protected from climate change by essential package of public health interventions Requires: Technical guidance, institutional collaboration mechanisms, and approximately US$1 billion/year financial support. WHO contribution : Country, regional, and global presence to convene and support intersectoral health and climate policy. Technical guidance, policy and capacity building support, building on established capacity in managing climate-sensitive disease risks. Project design and management, building on existing portfolio of climate change and health projects. 30-Oct-19 321

322. Governments, the health community and the general public, agree on the importance of health within the response to climate change. A package of health protection from climate change is feasible, comparatively cheap, and likely to be effective. Well-designed mitigation measures could bring major health gains, giving local and immediate repayment on investments. Countries need additional policy, technical, capacity building, and (in many cases) financial support to protect and promote health. Ethiopia has a unique contribution to make to achieve these goals. 30-Oct-19 322

323. Primary health care, from Alma Ata to the present day situation 30-Oct-19 323

324. Primary health care Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. 30-Oct-19 324

325. Primary health care It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process — Alma Ata Declaration, 1978. 30-Oct-19 325

326. Primary health care PHC Principles and Approaches The following principles underline the concept of PHC Intersect oral collaboration Community participation Appropriate technology Equity Focus on prevention and health promotion Decentralization 30-Oct-19 326

327. Primary health care Inter-sectoral collaboration is one of the key principles of PHC. It means a joint concern and responsibility of sectors responsible for development in identifying problems, programs and undertaking tasks that have an important bearing on human well being. Health has several dimensions that can be affected by other sectors. The cause of ill health are not limited to factors related to the health sector. 30-Oct-19 327

328. Primary health care Why is intersectoral collaboration important? To save resources (effective use of resources) To identify community needs together 30-Oct-19 328

329. Primary health care Community involvement Is the process by which individuals and families assume responsibility for the community and develop the capacity to contribute to their health and the community's development. Is a means by which communities can play a more influential role in health development, in which the emphasis is on strengthening the capacity of communities to determine their own needs and take appropriate action. Communities should not be passive recipients of services. Every body should be involved according to his/her ability. 30-Oct-19 329

330. Primary health care The community should be actively involved: - In the assessment of the situation - Problem identification - Priority setting and making decisions - Sharing responsibility in the planning, implementing, monitoring and evaluation. 30-Oct-19 330

331. Primary health care Appropriate Technology Take account of both the health care needs and the socioeconomic context of a country. This must include consideration of:- Costs (both capital and recurrent). Appropriate technology does not necessarily mean low cost. Efficiency and effectiveness in dealing with health problems. Acceptability of the health approach to both target community and health service providers. Broader social and economic effects. The sustainability including the capacity to maintain equipment of the approach. Based on these points, all levels of health system have to review their methods, equipment and techniques. 30-Oct-19 331

332. Primary health care Criteria for Appropriateness To be appropriate, a technology must be:- Effective - it must work and fulfill its purpose in the circumstances in which it needs to be used. Culturally acceptable and valuable. Affordable. i.e cost effective. Locally Sustainable. We should not be over dependent on imported skills and supplies for its continuing function, maintenance and repair. Possessive of an evolutionary capacity. A technology is highly appropriate if its introduction and acceptance can lead to further benefits. 30-Oct-19 332

333. Primary health care Environmentally accountable :-The technology should be environmentally harmless or at least minimally harmful Measurable:- The impact and performance of any technology needs proper and continuing evaluation, if it is to be widely recommended. Politically responsible 30-Oct-19 333

334. Primary health care Examples of Appropriate Technology: • ORS instead of expensive intravenous replacement of fluids in mild and moderate dehydration • Growth charts: these can be maintained by health workers • Vaccine Vial Monitor (VVM) instead of lab testing of potency of vaccine due to possible exposure to heat • Biogas system in a small community rather than Piped natural gas or LPG cylinders for clean fuel • A first-aid kit needs to be devised using appropriate materials easily available locally- Some examples would be o bamboo or wooden sticks with strings for temporary splinting, o a simple kit for first aid in snake bite consisting of string, sterile blade and simple suction device ordinarily used by local healers 30-Oct-19 334

335. Primary health care For provision of safe drinking water: o Pot chlorination o Chlorination with tablets in individual houses in water containers. These are very cheap and available from chemists o Chlorinating the wells on alternative days with the help of village health guides. It is necessary to chlorinate the wells at such frequency for two reasons:  there is a continuous process of pollution going on which has to be combated  The people get used to the smell and taste of chlorine on a continuing basis. o Educating the mothers to boil water- ·at least, the water that is to be used for the babies and children under 5 years of age. 30-Oct-19 335

336. Primary health care Equity In view of the magnitude of health problems, the inadequate, inequitable distribution of health resources between and within countries, and believing that health is a fundamental human right and world-wide social goal, the conference called for a new approach to health and health care. This is to close the gap between the have's and "have not's" which will help to achieve more equitable distribution of health resources, and attain a level of health for all the citizens of the world that will permit them to lead a socially and economically productive life. 30-Oct-19 336

337. Primary health care Possible definition of equity include:- Equal health Equal access to health care Equal utilization of health care Equal access to health care according to need Equal utilization of health care according to need Planning for equity in PHC requires the identification of groups which are currently disadvantaged in terms of health status access to or utilization of services. 30-Oct-19 337

338. Primary health care Focus on Prevention and Promotive Health Services Health promotion relates to the importance of adopting, where possible a promotive or preventive approach to health problems. Such an approach sees health as a positive attribute, rather than simply" the absence of disease". One of the important tasks of the planner is to redress the imbalance in allocation of resources to preventive and curative care, enhancing the role of resources available to prevention and promotion. 30-Oct-19 338

339. Primary health care Decentralization After the Alma-Ata conference, a sixth theme has emerged, that of decentralization, reflecting the two key principles of community participation and multi- sectoralism . Decentralization away from the national or central level brings decision making closer to the communities served and to field level providers of services, making it more appropriate. There is also a greater potential for multi- sectoral collaboration at the lower service-delivery level. Decentralization may enhance the ability to tap new sources for financing health care. 30-Oct-19 339

340. Primary health care By breaking down the large, monolithic decision making structures, typical of many national ministries, decentralization may lead to greater efficiency in service provision. However decentralization may lead to geographical inequalities in resource availability and technical quality. If handled inappropriately decentralization may actually result in a shift away from the principles of PHC. Planners should, therefore, consider whether specific strategies and decisions will enhance or hinder the achievement of PHC. 30-Oct-19 340

341. Primary health care PHC – The level of Care The term PHC- historically mean most peripheral level of organized health care- the point of contact between community & the health services. The ALMA-ATA declaration states that this level is an:- " Integral part of the national health care system of which it is the central function and main focus." 30-Oct-19 341

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343. Primary health care Major elements (components) of PHC: Health education Provision of food supply and nutrition Water supply and basic sanitation EPI MCH including family planning Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs 30-Oct-19 343

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345. Primary health care Alma-Ata declaration promoted three key ideas Appropriate technology Health technology was out of “social control” (Mahler) Opposition to medical elitism Over-specialization, top-down, urban focus Health as a tool for socioeconomic development Multi-sectoral effort Health not just an ‘ output’ of economic development, but also an important ‘input’ to development The refrain: “Health for All by the Year 2000!” 30-Oct-19 345

346. Primary health care Few countries tried to implement comprehensive PHC, and very few attempts were successful But for most countries….Strong, sustained political will was generally lacking Changing political context reinforced conservative attitudes of health professionals that PHC Promotes non-scientific solutions Demands too many sacrifices 30-Oct-19 346

347. WHO Strategies of PHC 1 . Reducing excess mortality of poor marginalized populations: PHC must ensure access to health services for the most disadvantaged populations, and focus on interventions which will directly impact on the major causes of mortality, morbidity and disability for those populations. 2. Reducing the leading risk factors to human health: PHC, through its preventative and health promotion roles, must address those known risk factors, which are the major determinants of health outcomes for local populations . 30-Oct-19 347

348. Primary health care 3 . Developing Sustainable Health Systems: PHC as a component of health systems must develop in ways, which are financially sustainable, supported by political leaders, and supported by the populations served. 4, Developing an enabling policy and institutional environment: PHC policy must be integrated with other policy domains, and play its part in the pursuit of wider social, economic, environmental and development policy. 30-Oct-19 348

349. The Basic Requirements for Sound PHC (the 8 A’s and the 3 C’s) Appropriateness Availability Adequacy Accessibility Acceptability Affordability Assessability Accountability Completeness Comprehensiveness Continuity 30-Oct-19 349

350. Appropriateness Whether the service is needed at all in relation to essential human needs, priorities and policies. The service has to be properly selected and carried out by trained personnel in the proper way. Adequacy The service proportionate to requirement. Sufficient volume of care to meet the need and demand of a community 30-Oct-19 350

351. Affordability The cost should be within the means and resources of the individual and the country. Accessibility Reachable, convenient services Geographic, economic, cultural accessibility 30-Oct-19 351

352. Acceptability Acceptability of care depends on a variety of factors, including satisfactory communication between health care providers and the patients, whether the patients trust this care, and whether the patients believe in the confidentiality and privacy of information shared with the providers . Availability Availability of medical care means that care can be obtained whenever people need it. Assessability Assessebility means that medical care can be readily evaluated 30-Oct-19 352

353. Accountability Accountability implies the feasibility of regular review of financial records by certified public accountants . Completeness Completeness of care requires adequate attention to all aspects of a medical problem, including prevention, early detection, diagnosis, treatment, follow up measures , and rehabilitation . Comprehensiveness Comprehensiveness of care means that care is provided for all types of health problems. Continuity Continuity of care requires that the management of a patient’s care over time be coordinated among providers 30-Oct-19 353

354. Primary health care National governments throughout the world adopted PHC as their official blueprint for total population coverage with essential PHC services. Goals and targets were set for Achieving Health For All by the Year 2000.Some of these goals were that: 30-Oct-19 354

355. Primary health care at least 5% of gross national product should be spent on health; at least 90% of children should have a weight for age that corresponds to the reference values; safe water should be available in the home or within 15 minutes' walking distance, and adequate sanitary facilities should be available in the home or immediate vicinity; people should have access to trained personnel for attending pregnancy and childbirth; and child care should be available up to at least one year of age. 30-Oct-19 355

356. Primary health care Almost as soon as the Alma-Ata Conference was over, PHC was under attack. Politicians and aid experts from developed countries could not accept the core PHC principle that communities in developing countries would have responsibility for planning and implementing their own healthcare services. 30-Oct-19 356

357. Primary health care A new concept of "Selective Primary Health Care" (SPHC) advocated providing only PHC interventions that contributed most to reducing child (< 5 years) mortality in developing countries. The advocates of SPHC argued that comprehensive PHC was too idealistic, expensive and unachievable in its goals of achieving total population coverage. By focusing on growth monitoring, oral rehydration solutions, breastfeeding and immunisation , greater gains in reducing infant mortality rates could be achieved at reduced cost. 30-Oct-19 357

358. Primary health care In effect, SPHC took the decision-making power and control central to PHC away from the communities and delivered it to foreign consultants with technical expertise in these specific areas. These technical experts, often employed by the funding agencies, were subject to the policies of their agencies, not the communities. SPHC reintroduced vertical programs at the cost of comprehensive PHC. 30-Oct-19 358

359. Primary health care The PHC versus SPHC debate continued throughout the 1980s. There were other reasons why PHC did not achieve Health For All by the Year 2000 Many ordinary people felt PHC was a cheap form of healthcare and, if they were able to, they bypassed this level to attend secondary and tertiary centres because of a lack of staff and essential medicines at the PHC level. Civil war, natural disasters and, more recently, HIV affected the ability of PHC to maintain comprehensive services, especially in many sub-Saharan countries. 30-Oct-19 359

360. Primary health care Political commitment was not sustained after the initial euphoria of Alma-Ata. In many cases PHC became a jargon term used as a slogan, and little else. The rhetoric was not backed with the necessary reforms. 14  Agencies were content if countries adopted PHC as a policy, and did not assess actual practice. Politicians saw PHC as a way to reduce expenditure in health and lacked the political will to ensure that services were equitably shared and distributed. Most healthcare resources continue to be directed to the large urban-based hospitals. 30-Oct-19 360

361. Primary health care Issues of governance and corruption in the use of resources resulted in donors becoming very wary of funding comprehensive, broad-based programs. Vertical, definable, time-limited programs that could be changed every few years suited both donor agencies and governments. 30-Oct-19 361

362. Primary health care The future: health beyond 2000 Given the enormous economic and political sway of the World Bank, the Health Sector Reform methodology will continue in the immediate future as the vehicle for healthcare service delivery, especially in countries having structural adjustment programs imposed on them. 30-Oct-19 362

363. Primary health care However, this is not unquestioned. Health Sector Reform is criticised as being driven by economic and political ideology. There is little provision for ensuring equity in access to services, especially for people living in absolute poverty or the indigent. 30-Oct-19 363

364. Primary health care As Whitehead et al point out, "The actual outcomes of previous and current market-oriented reforms have often been contrary to stated objectives, as economic access for poor people has declined and total costs have increased" 30-Oct-19 364

365. Primary health care Advocates of PHC are drawn largely from non-government organisations , academics and community groups within developing countries who argue that PHC was not given a chance to establish itself as a viable system or methodology. Once the economic and political implications of the Alma-Ata Declaration were recognised , it was not given a chance to survive politically or economically. 30-Oct-19 365

366. To Summarize Primary care is an approach that: Focuses on the person not the disease, considers all determinants of health Integrates care when there is more than one problem Uses resources to narrow differences Forms the basis for other levels of health systems Addresses most important problems in the community by providing preventive, curative, and rehabilitative services Organizes deployment of resources aiming at promoting and maintaining health. 30-Oct-19 366