Health Outcomes
This section examines the concept of health and the current approaches adopted in the delivery of health care services and the implications these have on the attainment of better health outcomes. The discussion begins with an examination of the definition of health outcomes, including terms such as health indicator and health status, which are often used interchangeably.
2.3.1 Health Outcomes and Related Terms
‘Health outcomes’ refer to:
a change in the health status of an individual, group or population which is attributed to a planned intervention or series of interventions, regardless of whether such an
intervention was intended to change health status. These interventions may include government policies and consequent programs, laws and regulations, or health services and programs. They may also include the intended or unintended health outcomes of government policies in sectors other than health. Health outcomes are normally assessed using health indicators (Nutbeam 1998:357).
This definition suggests a relationship between health outcomes and interventions and implies that one does not exist without the other. Outcomes are generally the result of actions taken to improve an identified problem in the health of individuals or a population, so a country’s health outcome cannot be confused with the health status and be generalised, without linking specific interventions taken by the government and other stakeholders.
In contrast, ‘health indicators’ are:
characteristics of an individual, population or environment which is subject to measurement, whether directly or indirectly, and can be used to describe one or more aspects of the health of an individual or population. Health indicators can be used to define public health problems at a time in a level of the health of a population or individual, to define differences in the health of population, and to assess the extent to which the objectives of a program are being reached (Nutbeam 1998:356).
Health indicators may also include measurements of illnesses or diseases that are commonly used to measure health outcomes, or positive aspects of health such as quality of life, life skills or life expectancy, including an individual’s behaviours and actions that are related to health. They may include indicators measuring social and economic conditions and the physical environment as it relates to health, health literacy and public policies on health (Nutbeam 1998:356).
‘Health status’ is a description or measurement of the health of an individual or population at a particular point in time against identifiable standards, usually in reference to health indicators (Nutbeam 1998:358).
These three concepts, including the definition of health from the SDOH approach given earlier in this chapter, are further explained in Figure 2.3, which has been adapted for this study from Jan Sansoni’s Health Outcomes Framework. There are several points to draw from the figure. First, health outcomes are a reflection of interventions undertaken to address determinants of health, as provided in the definition. This implies that a health
outcome depends on the type of interventions selected, the choice of the determinants of health to be addressed and the outputs committed, including processes and inputs within a health system. If interventions are selective and directed at certain target groups, the health outcomes will reflect only that group but not others. Second, health outcome is a result of a number of relationships between policies, practices, resources, and processes involved in implementing interventions that affect the various determinants of health of an individual or a population. Third, the dimensions of health that affect the health of a population are consistent with the SDOH concept that health is not only physical.
Source: Adapted from Sansoni (2016).
Figure 2.3: Health Outcomes Framework
Figure 2.3 shows that health outcomes can be either direct or intermediate and it is useful to differentiate between the interventions that have a direct effect on a health outcome and those that do not. Sansoni (2016:6–7) maintained that intermediate health outcomes are changes in behavioural risk factors from the interventions but they will take some time before they are noticed, such as a reduction in mortality or morbidity for a particular disease or condition. Health outcome measures include only clinical or biomedical indicators, health outcomes-related performance indicators, standard clinical assessments and outcomes-related outcome measures.
Dimensions of Health Physical Mental Social Emotional Determinants of Health Interventions Programmes Services Outputs Process Inputs Population Health Outcomes
2.3.2 The Definition of Health and Service Delivery Approaches in the Context of Health Outcomes
Two major perspectives of health were presented earlier in this chapter. To obtain a better understanding of the relationships and establish a background against which different country contexts can be analysed, the definitions of health from the biomedical and SDOH perspectives are compared here with the health service delivery approaches adopted in developing countries, where efforts to improve health outcomes have been discouraging.
The biomedical view of health focuses on the absence of disease and adopts biomedicine to maintain the physical structure and biological functions of the human body. In contrast, the SDOH approach sees health as being more comprehensive and not just the physical state and absence of disease. As such, it focuses on addressing the mental, social, environmental and cultural determinants of health. The biomedical definition of health appears to be dominant in influencing the current disease focus and selective approaches for delivering health services that are adopted by developing countries. Targeted interventions, such as the control of many infectious diseases and family planning, have contributed to improvements in health status and increased overall life expectancies of many developing countries. However, diarrhoea and malnutrition remain the leading barriers to the health of children (United States Fund for UNICEF 2004 cited in Magnussen et al. 2004:171), despite immunisation of children against the five major childhood diseases decreasing infant mortality rates (Berman 1999:2).
Several implications can be drawn from this conceptual framework to be considered when developing policies and strategies for attaining better health outcomes. First, disease- focused interventions are concerned with curing illness using biomedical processes and biomedicine and concentrate on only one disease at a time; thus, they do not address the causes of disease or prevent it from recurring. The illness could be related to multiple causes that may not be easily traced, as these could be determined by the social, economic, cultural and environmental factors in which the people live. This focus confines health to one dimension and ignores the mental, emotional and social health of individuals. Consequently, when health as a state of well-being is not addressed, the broader understandings of health and illness are overlooked, as well as the broader context of development. For example, health care services in the health facilities of many developing countries, including PNG, do not cater for the mental health of the individual. They
provide medication to treat illness but do not offer counselling support services. Further, when health care is concerned only with curing the disease, it overlooks social equity and social justice, which are valued in both PHC and SDOH approaches. The objective of combating one disease at a time promotes specific aspects of health but does not contribute to improving the general health status of the population (Magnussen et al. 2004:170). While this is happening, other individuals may suffer from other illnesses and die, thus contributing to a poor health status through reduced life expectancies and other health indicators.
Second, targeting specific segments of the population, such as women of childbearing age and children below five years, excludes the rest of the population, including women who are yet to have children, young people and men. When health policies and practices neglect the general population, this results in a high burden of infectious diseases and mortality among people of various age groups. For example, the burden in many developing countries of HIV and AIDS among people of 20 to 39 years is a clear indicator of the neglect of this group in health interventions (Magnussen et al. 2004:170).
Third, health outcomes are normally a result of formal modern biomedical interventions addressing prioritised and targeted illnesses that contribute to high rates of morbidity and mortality in a country. As reflected in Figure 2.3, the health outcome framework captures the formal interventions for treating diseases but not the informal interventions that promote the social and mental well-being of individuals and prevent afflictions. The sociocultural factors affecting the physical and mental well-being of the human life are ignored in the framework. Although the framework acknowledges intermediate health outcomes as a result of indirect interventions, it does not include TM and AM, which exist outside the formal health systems in many developing countries, including herbs and diet, as well as religious beliefs and practices that promote health and well-being. For example, some Christian churches, such as the SDA Church, prohibit members from smoking, drinking alcohol, using illegal substances and eating certain foods. When health outcomes are attributable to only government interventions (i.e., biomedical policies, regulations and practices), they overlook other sources that contribute to changing people’s behavioural risk factors for health and illness, and their health status. Of significant concern is that health outcomes are not necessarily a reflection of government interventions in the health field but can be a result of religious and cultural beliefs and practices intersecting with each other, including education and the programmes of other sectors and agencies. It becomes difficult to capture in the framework other sources that
contribute to people’s health and health status that are outside government interventions. In addition, it would be a negative depiction of a country’s health status if there were no interventions to address other illnesses and to describe its status based on health outcomes of selected interventions in only one sector.
Finally, given the economic constraints of developing countries with limited resources, inputs and outputs in systems, health is often donor-driven and priorities for interventions are determined by technocrats, as shown in Figure 2.3. As such, the selected interventions are provider driven and centred in urban hospitals and health facilities. There is no opportunity or space for users to participate in interventions to promote health within communities and achieve better health outcomes (Magnussen et al. 2004:170).