Faculty of Medicine Health Economics and Policies (31505391) By Hatim Jaber MD MPH JBCM PhD 29-01-2018

Presentation outline Introduction to course 31505391 08:00 to 08:20 Time Introduction to course 31505391 08:00 to 08:20 Health as social and economic issue. 08:20 to 08:30 Determinants of health: Genetic factors , Socioeconomic factors , Environmental factors 08:30 to 08:40 Determinants of (inequalities in) health: Exogenous determinants of health 08:40 to 08:50

معلومات وقواعد عامة الالتزام والوقت ساعات العمل في المكتب :الأحد- الاثنين –الأربعاء 10-12 الحضور والغياب الامتحانات المراجع والكتب Björn Ekman, 2015, Introduction to Health Economics: Theory, Practice, and Policy- Course Note for the Health Economics Course organized by WHO-EMRO and the MENA Health Policy Forum (MHPF)

Introduction to course 31505391 Course Title : Health Economics and Policies Credit Hours : 2 Credit Hours Calendar Description : 15 weeks/ Second Semester - 3d year (2017/2018) Teaching Approaches : 2 Lectures (50min) per week (mon + wed—8:00 -8:50 am) for 15 weeks

Introduction to course 31505391 (cont…) General Objective: Introduce the key concepts of healthcare management and administration , health policy, health economics and economic evaluation, including how it can serve as a useful tool in prioritizing interventions or strategies for implementation in the health system.

Introduction to course 31505391 (cont…) Course Goals: Discuss health value, health determinants, and health behaviors. Describe the health policy making process and the factors influencing it Define and understand health insurance markets within health care management. Understand governmental health insurance programs and health reform policies. Discuss the role of profit and not-­for-­profit provider firms in the health care industry. To understand the specific nature of the health care service in implementing economic principles and techniques Understand and Interpret and appropriately apply the key concepts of economics within the context of the health system Describe major types of economic evaluation and to understand their use in the decision-making process. To describe direct, indirect, intangible and opportunity costs. To understand the effect of some economic factors on health status of society. Gain historical and current information on health related markets in Jordan and in the rest of the world and its application to health care markets. Discuss demand and supply model of the health care industries. Discuss the roles of both public and private sector financing of health care and the division between public and private health care goods and services. Understand the role of professional education, training and licensing in physician and allied health professions, and their effects on quality and cost of health care. Understand economics of bad habits including smoking and alcohol consumption. Discuss evaluation of medical technology, regulations of health care delivery physicians. Discuss components of health care delivery including hospitals and the pharmaceutical industry.

Introduction to course 31505391 (cont…) Method of Instruction : Lectures 2 Lectures (50min) per week (mon + wed—8:00 -9:00 am) for 15 weeks Evaluation and Grading : two exams (MCQ) Midterm - assessment = 50% Final Examination = 50%

Introduction to course 31505391(cont..) Course Content Week 1 Introduction to Course introduction to Health: health value, health determinants. Week 2 Introduction to: Health care management Health Policy and Healthcare Delivery. Week 3 The scope of health economics :Economics And Health Economics . Week 4 Demand and Supply Demand for Medical Care. Supply of public health .  Week 5 The Market for Health Insurance Week 6 Financing health care Economic in Health Policy Cost and price Week 7 Health systems performance analysis. Measurement and evaluation in health care Week 8 Midterm assessment (Exams.) 21-3-2018 Week 9 Public Goods, Market Failures, and Cost-Benefit Analysis. Week 10 Economic evaluation . Economics and efficiency cost analysis and cost effectiveness, Week 11 Economic effects of Bad habits including smoking and alcohol consumption Week 12 Quality Improvements in healthcare delivery Methods to improve health care delivery Week 13 Human resources in Healthcare delivery. Week 14 Health Markets and Regulation and Economic regulation of health markets Week 15 Final assessment (Exams.)

Week 1 Overview of course syllabus and time table. Health as social and economic issue. Determinants of health: Genetic factors , Socioeconomic factors , Environmental factors Determinants of (inequalities in) health: Exogenous determinants of health The social and economic environment and health The value of health: Health related quality of life Health vs. Welfare/Utility Value in Health and Health Care Measuring Value in Health Care Definition of health behaviors

What is health? Nutritious foods help us stay healthy. Regular exercise helps keep us strong and healthy. Nutritious foods help us stay healthy. Doctors, hospitals & medicines help us get healthy if we’re sick. 11

Definition: ‘Health …’ ‘…is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’(WHO, 1948) ‘Health is only possible where resources are available to meet human needs and where the living and working environment is protected from life-threatening and health threatening pollutants, pathogens and physical hazards’(WHO, 1992) 12

Concepts of Health Biomedical : “ health is the absence of disease”- (Germ theory of disease). Ecological Concept: Health is an Dynamic Equilibrium between Man and his Environment. Imbalance results in Disease. Psychosocial concept: Psychological, Social, Cultural , Economic, Political factors are included in defining and measuring health. Holistic concept: Include all the factors of the other concepts in addition to all human activities such education, communication, agriculture, industry, housing , recreation etc.

Physical , Mental & Social Health Physical health deals with the body’s ability to function. Mental heath deals with how we think, feel and cope with daily life. Social Health deals with the way react with people within our environment.

New philosophy of Health Health is a Fundamental right Health is the essence of Productive life Health is Intersectorial Health is Integral part of Development Health is central to Quality of Life Health Involves Individuals, Families, Communities Local, National and International responsibilities Health and its maintenance is a Social Investment Health is Worldwide Social Goal.

DIMENSIONS OF HEALTH Health is multidimensional and are interrelated, each has its own nature Physical Dimension “Perfect functioning” of the body. It conceptualizes health biologically as a state in which every cell and every organ are functioning at optimum capacity and in perfect harmony with the rest of the body. Mental Dimension Ability to respond to many varied experiences of life with flexibility and a sense of purpose. Mental health has been defined as “a state of balance between the individual and the surrounding world, a state of harmony between oneself and others

Social Dimension Harmony and integration with the individual, between each individual and other members of society, and between individuals and the world in which they live. “quantity and quality of an individual’s interpersonal ties and the extent of involvement with the community.” Spiritual Dimension Spiritual health refers to “something” that transcends physiology and psychology.

Vocational Dimension Emotional Dimension Relates to “feeling.” it reflects emotional aspects of humanness. Vocational Dimension Work often plays a role in promoting both physical and mental health. Physical work is usually associated with an improvement in physical capacity, while goal achievement and self-realization in work are a source of contentment and enhanced self-esteem. Others A few other dimensions have also been suggested such as philosophical dimension, cultural dimension, socioeconomic dimension, environmental dimension, educational dimension, nutritional dimension, and so on.

DETERMINANTS OF HEALTH Biological Behavioral & sociocultural condition Other factor Health Environment Gender Socioeconomic Aging Health services

Determinants of health

Socioeconomic Conditions ● Economic status: Economic situation in a country is an important factor in morbidity, increasing life expectancy and improving quality of life, family size and pattern of disease ● Education: Illiteracy correlates with poverty, malnutrition, ill health, high infant and child mortality rates. ● Occupation: Productive work provides satisfaction, promotes health and improves quality of life. ● Political system: timely decisions concerning, resource allocation, choice of technology etc

Health Services To be effective, the health services must reach the masses, equitably distributed, accessible at a cost the country and community can afford and social acceptable. Aging of the Population A major concern of rapidly aging population is increased prevalence of chronic diseases and disabilities that deserve special attention. Gender Women’s health is gaining importance in areas such as nutrition, health consequences of violence, aging, lifestyle related conditions and the occupational environment. There is an increased awareness among policy makers of women’s health issues, and encourages their inclusion in all development as a priority.

Economic Determinants Intersection between social (e.g. job) and economic (income) determinants is fuzzy. Concept of “social class” is less accepted here. Social status is more than income, though income is an important determinant. “Status Syndrome” (Marmot)

Effects of Disparities Complex relationship between determinants and outcomes. Some “determinants” are likely outcomes of others. Parental income associated with educational attainment and health of child. Low education associated with high tobacco use. Tobacco use associated with…..

Social effects of Disparities Discrimination? Stress? Low self-esteem? High-risk behaviors ??

Behavioral Determinants Tobacco Nutrition and Physical Activity Alcohol Violence What is the origin or cause of behavior?

The dependent variables: health and social problems In other words, these are the variables which may be affected by income inequality. Based on this social gradient principle, Wilkinson and Pickett (2009a: 18) produced a list of variables for which reliable data could be found. These were: level of trust; • mental illness (including drug and alcohol addiction); • life expectancy and infant mortality; • obesity; • children’s educational performance; • teenage births; • homicides; • imprisonment rates; and • social mobility (not available for US states

Health inequalities

Social inequalities and health Inequalities in social position Inequalities in access to determinants Inequalities in health Social structure

“health inequalities”? Difference or unfairness? Perception What comes to mind when I say “health inequalities”? Difference or unfairness? Differences, e.g. between numbers of men and women who smoke Unfairness, e.g. higher cost of fresh fruit in poorer areas

E.g. Height Being short as an adult could be due to genetics, ante-natal difficulties such as blood vessel malformation, physical illness or condition as a child, such as polio or cystic fibrosis Or, poor maternal nutrition, lack of access to food as an infant, poor nurturing relationship etc, i.e. as a result of poverty and disadvantage Being short could disadvantage social progress, or not For any factor where there are differences or a social hierarchy, there could also be unfairness

Theories for health inequality Relative poverty Absolute poverty Culture and behavior Biological responses to stress Life course effects starting from early years Social stratification and discrimination

Health policies say that health inequalities are related to: Environment Poverty Geography Individual differences Combined social circumstances Deprived areas Social inclusion Lifestyles Ethnicity Gender Disability Opportunities Discrimination Personal choices Age

From what you’ve heard (and what you know), A question From what you’ve heard (and what you know), what do you think should be the two main priorities to address in order to reduce the inequalities gap in children’s health and well-being?

Two priorities Reduce poverty Improve educational attainment

Inequalities in Health It is now generally recognised that there are many reasons for health inequalities. People can suffer health inequalities for many reasons, due in the main to: The geographical area they live in. The racial group they belong to. Their gender And, perhaps most importantly, their social class. The common denominator of all these factors is that they all link to POVERTY

Approaches to Solving Health Inequalities (1) There are two major approaches to tackling inequalities in health: THE COLLECTIVIST APPROACH THE INDIVIDUALIST APPROACH

Approaches to Solving Health Inequalities (2) >THE COLLECTIVIST APPROACH< This approach to solving inequalities is based on the view that differences in health are beyond the ability of the individual to change Subscribers to this view feel that improvements will only come by concerted government action centering on anti-poverty strategies The view is that differences in health are due to major economic and social problems in society - eg. poor housing stock, unemployment, inflation Idea first found favour in the Black Report (1980) and Acheson Report (1998) These problems impact on different people in different ways - but poorer social classes suffer most.

Approaches to Solving Health Inequalities (3) >THE INDIVIDUALIST APPROACH< This approach is based on the belief that health inequalities are the result of how INDIVIDUALS choose to lead their lives Government action should centre on high-profile health advertising campaigns etc. Approach favoured by Tory Government in early mid 1990s. There seems to be differences in health habits between different social classes Idea is that people should be largely responsible for monitoring own health People of lower social class seem to; smoke and drink alcohol more often, exercise less and have less healthy diets

Thank You