2. 1 Dr. Babar T Shaikh The Aga Khan University, Karachi Society, Culture & Health Care system

3. 2 “ New doctors advise that colostrum should be given. It is essential. Our elders say that colostrum should be disposed off, therefore, we practice what our elders advise us to do”. Mothers’ focus groupRural Sindh, Pakistan.

4. 3 Health System a set of cultural beliefs and practices; the institutional arrangements; and the socio-economic, political & physical context Health system includes environmental conditions, nutrition, water supply, education, housing, status of women, social structures, economic and political system

5. 4 Factors influencing health service utilization Age/sex of child Family size/ parity Education Occupation Socio-demographic factors

6. 5 Possession of household items Possession of cattle Possession of agriculture land Type of residential house Economic factors

7. 6 Availability of the transport Physical distance for Health Facility/Health Care Provider Time taken to reach Health Facility/Health Care Provider Physical accessibility factor

8. 7 Fare spent for one round trip to Health Facility/Health Care Provider Total amount spent for treatment of last illness (excluding fare) Financial accessibility factors

9. 8 Attitudes of health provider Satisfaction with the treatment Received medicines from Health Facility/Health Care Provider Received prescription for medicines to be purchased from bazaar Health service factors

10. 9 Freedom to visit HF alone Permission to spend money on health Decision power in emergency situation Mother’s autonomy

11. 10 Conceptual framework of Kroeger Socio-demographic factors Age/sex of child Family size/ parity Education Occupation Economic factors Possession of household items Possession of cattle Possession of agriculture land Type of residential house Physical accessibility factor Availability of the transport Physical distance for HF/HCP Time taken to reach HF/HCP Financial accessibility factors Fare spent for one round trip to HF/HCP Total amount spent for treatment of last illness (excluding fare) Health service factors Attitudes of health provider Satisfaction with the treatment Received medicines from HF/HCP Received prescription for medicines to be purchased from bazaar Govt./ Private HF/HCP Mother’s autonomy Freedom to visit HF alone Permission to spend money on health Decision power in emergency situation

12. 11 Challenges Knowledge of illness/wellness and of services available Perceptions of services/service providers Risk/symptoms assessment Cultural “prescriptions” Social barriers/social pathways to care Etc…

13. 12 Health Sector Change Agents Changing disease patters Advances in biomedical/ clinical sciences Health Sector Reform Global perspectives on health and health care New specializations/ professions Ethical issues: New dimensions Information/ Communication revolution Globalization

14. 13 PROVISION OF HEALTH CARE PRODUCING HEALTH Focus on Life-styles Focus on the Environment Shift focus from individuals to populations Cost-effective health care Evidence-based decision/ policy Resources to sector that contribute to health

15. 14 HEALTH CARE SYSTEM: TYPES AND COMPONENTS T R A D I T I O N A L M O D E R N P R I V A T E P U B L I C PRIMARY Physicians’ office Dispensaries NGO/Community Groups BHU/RHC SECONDARY Clinics/Maternity homes Tehsil Hospitals NGO-run clinics/hospitals TERTIARY Distric Hospitals Large Urban Hospitals

16. 15 GOVT. (PUBLIC) HEALTH DELIVERY SYSTEM (4 TIERS) Outreach/Community- based activities [Immunization, malaria control, MCH, FP] PHC Facilities (OPD) TEHSIL & DISTRICT HQ. Hospitals Tertiary Care Hospitals

17. 16 PUBLIC HEALTH DELIVERY SYSTEM DISTRICT HQ HOSPITAL (80 - 100 Beds) TEHSIL HQ HOSPITAL (40 - 50 Beds) RURAL HEALTH CLINICS (Extensive OPD; 10-20 Beds) BASIC HEALTH UNITS (Preventive & Curative; mostly OPD) 10-20,000 Pop 25-50,000 Pop 50,000-1 ml. Pop 1 - 2 Million Pop

18. 17 PREVENTIVE HEALTH SERVICES IMMUNIZATION PROGRAM MCH SERVICES FP SERVICES LHW PROGRAM [45,000 LHW /2000; Target 1:1,000 Pop]

19. 18 GOVT. HEALTH SERVICES: WEAKNESSES Insufficient focus on Prevention/Promotion Gender Imbalances Excessive centralization of management Political Interference Lack of openness Weak human resource development Lack of integration Lack of Healthy Public Policy

20. 19 PROBLEM AREAS POVERTY ILLITERACY LOW STATUS OF WOMEN INADEQUATE SANITATION & WATER SUPPLIES POOR QUALITY OF HEALTH SERVICES Problem areas

21. 20 Income influences health People in the top income bracket are healthier than middle income earners Middle income earners are, in turn, healthier than people with low income This means that the poorer people are, the less healthy they are likely to be.

22. 21 Social status affects health It affects health by determining the degree of control people have over life circumstances It affects their capacity to act and make choices for themselves Higher social position and income somehow act as a shield against disease.

23. 22 Gender influences health Gender is linked more to the roles, power and influence society gives to men and women, than it is to their biological differences.

24. 23 Culture influences health Culture and ethnicity influence how people link with health system, their access to health information and their lifestyle choices. ‘Dominant’ cultural values largely determine the social and economic environment of communities. Result: Marginalization Loss/devaluation of culture and language Lack of access to culturally appropriate health services

25. 24 Health Care system 25% Biological endowment 15% Physical environment 10% Socio-economic environment 50% Estimated Health Impact of Determinants of Health on Population health Status: CIAR 1997

26. 25 Focuses on the entire range of individual and collective factors (income and social status, education, employment and working conditions, social environment, physical environment, gender, culture, personal health and coping skills, healthy child development, health services) The interaction among these factors Population Health Approach

27. 26 Population Health Approach Health is determined by the complex interactions between individual characteristics, social and economic Strategies to improve population health must address the entire range of factors that determine health Important health gains can be achieved by focusing interventions on the health of the entire population/significant sub-populations rather than individuals

28. 27 Population Health Approach Improving health is shared responsibility that requires the development of healthy public policies in areas outside the traditional health system The health of a population is closely linked to the distribution of wealth across the population

29. 28 Creating a Healthy Community Community Economy Environment Based on a model from: Hancock, Trevor. 1993, “heath, human development and community ecosystem: three ecological models”

30. 29 Health Services move towards ‘broader resources’ to support well-being the design: services to maintain and promote health, to prevent disease, and to restore health system functioning to contribute towards population health.

31. 30