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How can we make Health Care a more effective
determinant of health?
Michael M. Rachlis MD
York University
November 29, 2002
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Outline:
• Health care historically has not been a major determinant of population health
• Health care could be a more important determinant of health but only if we re-design our health services.
• What Mr. Romanow said yesterday and where are we headed tomorrow.
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Health care historically has not been a major determinant of population health
• The major improvements in health status have not been due to health care
• The key factors were nutrition, clean water and sewage disposal, smaller families, education, women's rights, etc.
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Relative risk of CHD death in the British civil service and the explanatory power of risk factors. From Marmot M. J Epi Comm H. 1978;32:244-249.
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Determinants of Health1. Income and social status
2. Social support networks
3. Education
4. Employment and working conditions
5. Social Environments
6. Physical Environments
7. Personal health practices
8. Healthy child development
9. Biology and genetic endowment
10. Health services
11. Gender
12. Culture
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But Health care could be a more important determinant of health if services were re-designed.
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Tertiary prevention: Preventing deterioration in function
• Rehabilitation– coronary heart disease, stroke, etc.
• Treating frailty with exercise• Treating malnutrition with food• Putting it all together in a Program for All-
Inclusive Care of the Elderly (PACE)• Chronic Disease Management
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Secondary prevention: Screening and early detection
• Cancer– Cervical, breast, colon, prostate?
• Heart disease• Alcoholism, Depression• Prostate cancer? • Whole body CT scanning?
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Criteria for Screening Tests• Does screening lead improve outcomes?
• Can the health care system cope with increased demand?
• Will patients comply with treatment?
• Does the burden warrant screening?
• What are the costs, accuracy, and acceptability of the screening test
– DL Sackett et al 1991
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Primary prevention: Preventing disease in the first place
• Diabetes• Coronary Heart Disease• Lung Cancer• AIDS/HIV• Accidents and injuries
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“Medicine (Health) is a social science and
politics is nothing but medicine writ large!”
Dr. Rudolf Virchow 1848
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If politics is health writ large...
• Fundamental change in a society’s pattern of health requires structural change in society’s values and institutions
• Some powerful interests will be threatened and will use their power to oppose change
• Those favouring the status quo will emphasize the treatment of sick individuals and downplay opportunities to promote population health
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The prevention policy paradox
The higher the level of preventive action, the more effective it is at promoting health but the more political barriers it faces.
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Dr.Trevor Hancock notes that it is easier to start action locally:
• The smaller more human scale allows for closer ties amongst participants.
• Policy makers live where they work. They are both more accountable for decisions but also more likely to be affected by them.
• Municipal government is more accessible than senior levels of government.
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Population Health works best when:
• The overall policy environment is favourable
• The key individuals and organizations share common values and/or interests
• The decision-making process is favourable
• There is a consensus on relevant information
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Successful Intersectoral Action
• Saskatchewan's Assistant Deputy Ministers’ Forum on Human Services
• Downtown Eastside Vancouver HIV and intravenous drug user strategy
• Canada’s anti-smoking coalition
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How to get it going
• Get the right people together
• Clarify roles and rules
• Start small but get things done
• Make sure you have enough resources for the task
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How to make it grow
• Keep the team together
• Strike long-term relationships with key decision-makers and journalists
• Stay flexible
• Start small…but think BIG
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What to watch out for
• Avoid conflicts on philosophy
• Don’t attempt the impossible• Avoid long meetings and
complicated committee structures
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How to light a bonfire: The virtuous circle for health
• Light the kindling– local action sparks the flame
• Carefully lay on larger and larger logs– advance advocacy to higher levels but keep
strengthening your roots.
• Guarantee a constant supply of wood– build the infrastructure -- the importance of
primary health care
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What Mr. Romanow said yesterday and where are we headed tomorrow.
• Reaffirmation of the Canada Health Act
• More federal money to buy change
• Extension of Medicare to some home care and pharmacare
• Lot’s of nice rhetoric
• Gone missing: public health, health promotion, long-term care
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Therefore I’m suggesting that when you’re fighting this battle, as I hope you will to maintain Medicare, you’ll not forget that the ultimate goal of Medicare must be the task of keeping people well rather than just patching them up when they’re sick.
Tommy Douglas
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Summary:• Health Services have historically not been an
important determinant of health• If we work smarter, health care could be more
effective as a determinant of health• However, we will never achieve our goals for health
through health services. It’s politics that counts• Primary health care is the key part of health services• There’s a battle for Canada’s health care system:
Enlist now!
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Courage my friends, ‘tis Courage my friends, ‘tis not too late to make a not too late to make a better world!better world!
Tommy Douglas
