An Introduction To Health

Policy, Planning and Financing

Brian Abel-Smith

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138172999
• eBook ISBN: 9781317891826
• Topic: Medicine
• Subtopic: Health Care Delivery

This book concerns itself with the key question: how to improve health in a cost effective and politically acceptable way. What makes people healthy? Why are the poor less healthy than the rich? Why do some countries have a better health record than others? An Introduction to Health is divided into four parts comprising the determinants of health, health service planning, health service financing, and controlling costs and securing user-friendly services.

Part One
The determinants of health

Chapter 1
Introduction

Over the past 150 years, the expectation of life for human beings in nearly all parts of the world has been transformed. This has been particularly marked in the industrialised countries towards the North of the world where about 30 years or more has been added to an average expectation of life of about 40 years for men and 45 for women. Some developing countries have made similar or very substantial progress since the Second World War, for example China, Costa Rica, Singapore, South Korea, Sri Lanka and Taiwan. While some exceptional groups of population in remote parts of Latin America or North India may have had a long expectation of life much earlier, this represents a transformation in whole countries compared to their whole past history in so far as it is known.

Why has this occurred? What determines the health of populations? This simple but critical question is by no means easy to answer. This is surprising in view of the vast expenditure on health research over the twentieth century and particularly in the later part of it. This is because the investment in health research has been largely biomedical - how to improve the treatment of particular diseases in individuals rather than how to improve the health of whole populations. As a result, a vast amount is known about disease but far too little about health. Two to four hundred years ago, a much higher proportion of writing about health in the English language concentrated on health in general than does writing in the past 50 years. However, in the past 20 years the issue of the health of whole populations has at last begun to be given somewhat greater prominence.

The essential question which needs to be answered is why the populations of some countries appear to be healthier than others. Or to narrow the question why do people live longer in some countries than others? Is it because they have more health services or better health services than others or is it from other causes? The same questions need to be asked within countries. Why do some groups in society not only live longer than others in the same country but appear to have less illness and less disability? The groups may be based on geographical parts of the country, on sex, on occupation, on income group, on racial origin, or on other criteria. But before these questions can be approached, we need to be clear about what we mean by health. One cannot say that one population or group is healthier than another unless there is some reliable way of measuring it.

The meaning of health

In its constitution of 1948, the World Health Organisation defined health as ‘A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’

This expresses high rhetorical ideals but it gives no indication of how health can be measured. What is physical well-being and who is to determine it - the patient or the doctor? How can mental well-being be measured let alone social well-being? The Health for All strategy of 1981 seemed a bit more precise when it talked of the aim of maximising economic and social life. But how does one measure ability to work as distinct from the fact of working? Are the tasks of child care or housework part of ‘economic’ life, even though there is no payment for them?

Such health statistics as there are, which can be compared between countries, measure ill-health rather than health. The only really reliable statistics are of death in those countries where deaths are accurately recorded and the age of the deceased person is known. Death is a fact though there has been some debate about how it should be determined. The concept of morbidity is much more difficult. At first sight it may seem possible to use the number of cases presented to doctors or hospitals where the doctor can find clinical evidence of ill-health. But there are three snags. First, there are many conditions which are very real to the patient but for which clinical evidence is lacking, such as back pain or almost any form of mental illness. Second, in all societies, by no means all health problems lead to a visit to a doctor. Most cases of ill-health are treated by self-care and family care, with or without a visit to a pharmacist. Some cases go to alternative healers under a variety of labels in developed countries and what is often just called ‘traditional medicine’ in developing countries can also have great variety. Third, feeling unwell is not the only reason for going to the doctor. If time off work on full pay or half pay depends on a certificate of incapacity to work issued by a doctor, then inevitably there will be some who simply want to sleep in after a late night or take a paid holiday to attend a wedding or a football match. As the British Medical Association once put it frankly, ‘in most cases the doctor does no more than countersign the patient’s declaration of his fitness or not to work’¹.

Does one then assess ill-health by questioning the patient? One approach is to ask about restricted activity. Did the person go to work or school or do the housework as usual? Was the person at home all day because of illness? Was the person in bed because of illness? A second approach is to ask more positively about what the patient is able to do - climb stairs, walk a mile, run for a bus, peel potatoes, and so on. A third approach is to ask about short term and long-standing illnesses. A fourth is to ask about perceived health: ‘Would you say that your health was very good, good, moderate, poor, or very poor?’. The trouble is that such questions are likely to be answered in terms of people’s reference groups, such as other members of the family, neighbours, work mates. Thus people living in a mining village, where most men have some lung condition, are likely to judge on different criteria from those living in leafy, unpolluted suburbs. A particular danger is that the reference group is likely to be taken from one’s own social class. Expectations of health are likely to differ not only between countries but within countries.

One must conclude that the concept of health is elusive. This is particularly the case as it has different dimensions. Mildred Blaxter lists five: disease, disability, frequency of illness, malaise (tiredness, depression, trouble with nerves, sleeplessness and worry) and fitness (Blaxter 1985: pp. 131-71)². It is hard to see how these five dimensions could ever be added together in any meaningful way. And their relative importance would differ between developed and developing countries because of the different pattern of disease.

There can hardly be only one measuring rod. Different measures may be useful for different purposes. The easiest measure is mortality and this is correlated with morbidity over a wide area. But there are conditions, such as asthma, which people should never die of. And mortality has little connection with mental illness. It is extremely difficult to say whether people have more mental illness today than a century ago. Of course more cases are presented to doctors and hospitals, but is this a useful measure? It is easy to romanticise the life of an agricultural village whether in Europe a century ago or in Africa or Asia today. One can depict it as a low-pace life full of neighbourliness and lacking in stress. Alternatively one can depict it as a life of constant uncertainty about subsistence, ruled by the weather and regulated by very strong social controls. What social and economic environment really is conducive to mental well-being? And how far is it affected by religious beliefs and practices?

Approaches to examining the fundamental determinants of health

There are two different approaches to trying to ascertain the fundamental determinants of health and their relative importance. The first is historical. What changes took place in particular societies which had a large improvement in mortality rates and which might have caused the improvement? The second approach is comparative. What are the differences between countries or regions with good and bad mortality rates which might explain the difference?

The historical approach

Britain is the country with the oldest reliable set of statistics. This is because registration of deaths by cause was introduced as early as 1837 (Flinn 1966: p. 14)³. When the process of extending expectation of life is examined, two important conclusions emerge. First, the major reductions in mortality have been at the earlier ages. In 1851, mortality rates were about 20 times higher at ages 1 to 14 than in 1981, about ten times higher at ages 15 to 44 and only twice as high at ages 55 to 64. The extension of life beyond age 65 has been relatively small. Second, Mckeown showed that the decline in mortality between 1851 and 1900 was entirely due to the reduction in death from infectious disease (Mckeown 1965: p. 42)⁴. Five groups of diseases accounted for the decline from 1838 onwards - tuberculosis for a little less than half; typhus, typhoid and fever for about a fifth; cholera and dysentery for nearly a tenth; and sma...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• Preface
• PART ONE The determinants of health
• PART TWO Planning health services
• PART THREE Health services financing
• PART FOUR Controlling costs and securing user-friendly services
• Index