7 Responding to health risks
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Unit 14: Prevention
When you have completed this unit you should be able to:
- Describe the different levels of prevention.
- Identify a good screening programme.
- Identify a good screening test.
14-1 What is the meaning of prevention in healthcare?
Once risks to good health have been identified, it is necessary to think how these risks can be avoided. Avoiding or managing risks to health is called prevention. There are 3 broad approaches to avoiding or managing health risks:
- Primary prevention
- Secondary prevention
- Tertiary prevention
14-2 What is primary prevention?
With primary prevention risk factors are identified and removed before they have caused harm, or measures are taken to stop people from coming into contact with these risk factors. Therefore primary prevention is dealing with risk factors before a problem has started. Encouraging young people not to start smoking cigarettes is an example of primary prevention.
Primary prevention is identifying and removing a risk factor before it causes a problem.
14-3 What is secondary prevention?
If risk factors have already caused a harmful process to begin, measures may still be taken to reduce the amount of harm. This includes screening for problems that are at an early stage. The process of intervening early to return a person to a full state of health as soon as possible is called secondary prevention. Strictly speaking, all curative healthcare could be included in the term secondary prevention. Secondary prevention is needed if primary prevention fails. Screening a community for hypertension and then managing individuals with hypertension is an example of secondary prevention.
Secondary prevention is identifying a problem and intervening early to return the person to full health.
14-4 What is tertiary prevention?
If it is not possible to remove the risk factor, to intervene early to return a person to a full state of health or cure the condition, it is necessary to manage the consequences or complications so that there is as little impact on people’s lives as possible. This is called tertiary prevention. Tertiary prevention is only needed when both primary and secondary prevention have failed. Providing wheelchair access in a workplace enables a person who cannot walk to get to work and provide for their family. This is an example of tertiary prevention.
Tertiary prevention means making sure that a person with an established, incurable health problem can function as fully as possible.
14-5 Is primary prevention always an easy option?
No. Primary prevention is a good option, but it can be difficult to get people to accept it. This is because:
- Prevention must be applied to many people in order to stop illness from occurring in a few. Not everybody who smokes will get lung cancer and not everybody who has unprotected sex with a stranger will get HIV, but that does not make these practices safe. Several people must be persuaded to stop smoking and practice safe sex in order to prevent one case of illness. This means that primary prevention is mostly applied to people who are healthy and who may not individually benefit from prevention.
- Primary prevention is aimed at stopping future problems that may be difficult for people to imagine at the present, such as polio or diphtheria.
Primary prevention has to be applied to many to benefit a few.
14-6 What are the drawbacks to screening for early disease?
Screening for early disease in secondary prevention is a very appealing idea, but it has drawbacks. Like primary prevention it has to be applied to many to help a few. This means that screening for secondary prevention has:
- Cost implications (expensive for the person or the state).
- Emotional consequences for a person who thought they were healthy, but who has now become a “case” with a disease.
Targeting the screening programme to the population group most likely to have the disease can reduce these negative consequences. For example, in the UK all women between the ages of 50 and 70 are invited to have regular mammogram screening for breast cancer as this is the age group where breast cancer is most common.
Screening programmes have financial and emotional implications.
14-7 What are the criteria for a good screening programme?
Because of these drawbacks to screening, there are certain criteria that a screening programme should meet:
- The disease must be important (common or severe).
- There must be a suitable screening test.
- There must be effective treatment for the early stages that improves outcome.
- There should be sufficient resources to do the screening test, interpret the results of the test, then follow up and provide the appropriate early stage treatment.
Screening for syphilis in all pregnant women and screening for cervical cancer in sexually active women are good screening programmes as they meet all the criteria listed above.
14-8 What are the criteria for a suitable screening test?
A suitable screening test is:
- Sensitive – it picks up nearly all the people who have the disease
- Precise – it gives repeatable results when performed on the same individual, even with different observers
- Acceptable – with minimum discomfort
- The cost of the test should be justified by the benefits.
Using the on-site rapid test for syphilis is a good screening test as it meets all the above criteria.
- Sensitivity and specificity are 2 terms used to describe how good a test is. Sensitivity refers to how reliably it gives a positive result in somebody with a disease (few “false negatives”). Specificity refers to how reliably it gives a negative result in somebody who does not have the disease (few “false positives”). Unfortunately, most tests are either sensitive or specific but not both. A screening test must be sensitive because it needs to pick up nearly all people with the disease, but this is often at the cost of a number of false positives. Specificity is not so critical because people with a positive screening test usually go on to have a more specific test to confirm or exclude whether they really have the disease. Having a false positive test can be emotionally stressful.
14-9 How is tertiary prevention provided?
Tertiary prevention is about intervening in an established condition, which has already presented clinically to maximise independence and prevent a health problem becoming a disability.
Tertiary prevention means efforts to get individuals, and sometimes communities, to their optimal level of physiological, psychological and social function despite problems we cannot “cure”. When health problems pose a risk of disability, efforts to restore normal functioning are called “rehabilitation”. The term includes the management of problems present from birth, such as cerebral palsy, as well as new health problems such as a stroke. The allied health professionals, such as physiotherapists and occupational therapists, are the experts in rehabilitation.
14-10 How helpful is it to classify prevention as primary, secondary and tertiary?
Classifying prevention in this way is a useful framework to discuss the different approaches to dealing with health risks by reducing exposure to risks, effective early treatment and the prevention of disability. However, in the real world these should not be considered as separate approaches.
Treatment can also be prevention. For example, treating HIV lowers viral load and reduces the risk of transmission to others, and the early detection and treatment of tuberculosis also reduces the risk of spread to others. People are also more likely to come for screening if they know that effective and acceptable treatment is available. Good rehabilitation prevents falls and reduces the need for medical treatment of problems such as bedsores and urinary tract infection.
Primary, secondary and tertiary prevention are all connected. All 3 are necessary in an effective health system.
14-11 What is the meaning of risk reduction and risk mitigation when used for the management of health risks?
The terms risk reduction and risk mitigation are often used in the non-clinical setting when considering factors in the physical environment, rather than the disease process in a human.
Risk reduction means identifying the risk and removing it at source. This is the same as primary prevention. For example, reducing the risk of climate change by reducing carbon emissions.
Risk mitigation means trying to reduce the consequences (impact) of the risk. This is equivalent to tertiary prevention. For example, designing cooler cities and developing drought resistant crops to reduce the damage caused by climate change.
14-12 What is the role of government in the reduction of health risks?
Governments play a crucial role in the reduction of health risks by:
- Legislation: Passing laws
- Regulation: Establishing rules and regulations
- Taxation: Charging or reducing taxes
These 3 actions can affect exposure to health risks and consumption of healthy or unhealthy products. Together, these approaches can improve the quality of health and healthcare.
14-13 How can these 3 approaches improve health and healthcare?
Legislation, regulation and taxation can improve health and healthcare in the following way:
- For primary prevention, national governments can control the exposure of the population to risk factors. Examples of interventions include:
- Increasing taxes to raise the price of cigarettes, which is known to reduce smoking and help prevent lung cancer.
- Regulating the salt content of processed foods to control the population’s risk from hypertension.
- Reducing the risk of socially determined poor health by providing high quality education to those born in disadvantage. Healthy eating and habits should be taught at school.
- Local governments also play a role in primary prevention by monitoring water quality, sanitation, commercial food sources and pest control.
- For secondary and tertiary prevention, national, provincial and local government departments of health.
- Make decisions about which health programmes and services will be made available to the whole population.
- Deliver these healthcare programmes.
- Set standards and oversee quality in the health sector.
14-14 What is the “one health” approach to reducing health risks?
It has been recognised that the health of humans, animals and the environment are all closely linked and dependent on each other. For example, good farming practices reduce water contamination and control animal diseases, both of which will protect human health. Animal health can also give “early warning” signals of environmental problems that can also affect human health. A classic example is the canaries taken down mines many years ago; if the canary died it warned the miners of dangerous methane gas. “One Health” is an international collaboration of human health scientists, veterinarians and environmental scientists working to reduce health risks to both humans and animals.
The health of humans, animals and the environment are closely linked. Reducing risks to animal health and environmental damage is important for preventing human disease.
Case study 1
It is Breast Cancer Awareness week. The Breast Bus, a mobile mammography unit run by a non-governmental organisation, has announced on the radio that it will be visiting a town and offering screening for breast cancer free of charge to anybody who wants a mammogram. The hospital manager has been asked if the van may park in the hospital grounds.
1. What are the criteria for a good screening programme?
The criteria for a good screening programme are:
- The disease being screened for must be important (common or severe)
- There must be a suitable test (that is acceptable, affordable and reliable)
- There must be effective treatment for the early stages that improves outcome.
- There should be sufficient resources to do the test, interpret the test, follow up and provide the appropriate early stage treatment.
Case study 1 continued
The hospital manager finds out the following:
- Breast cancer is an important disease because it is the most common cause of cancer death in women
- Mammograms are acceptable to most women, and because the mammogram is being offered for free, she is not worried about the cost. Also, screening mammography can pick up many (but not all) types of breast cancer early, but mammograms can be difficult to read and need somebody experienced to interpret them.
- There is effective treatment for early stage breast cancer that is picked up on mammography. However, if an abnormal area is seen on mammography the woman must be referred to a breast clinic where further investigations such as a needle or open biopsy must be done. These facilities are not usually available in smaller hospitals in South Africa.
1. What questions should the manager ask the Breast Bus before deciding to support their project?
It would be a good idea to ask who will be reading the mammograms, what plans will be made for giving people their results, and what the arrangements are for referring and managing patients with abnormal mammograms if the local hospital does not have the facilities for the required further investigations.
Case study 2
In planning a health programme, a hospital manager says that it is important to distinguish between primary prevention, treatment and rehabilitation because government sometimes has to decide which is the better approach.
1. Is it reasonable for government to choose only one approach?
No. Primary prevention, early treatment (secondary prevention) and rehabilitation (tertiary prevention) are related. Therefore, in planning a health programme, all should be considered.
2. What might an effective HIV prevention programme look like in a low income urban area? Think about primary, secondary and tertiary prevention?
An effective programme might include:
- Primary prevention: Health education, condom distribution, needle exchange programmes to prevent HIV infection.
- Secondary prevention: Screening for early diagnosis and treatment. This is more likely to be successful if people know good quality care is available. It also requires de-stigmatisation of high risk groups, sex workers and gender non-conforming people. Early diagnosis and treatment will reduce viral load and lower the risk of transmission.
- Tertiary prevention: This involves reducing the impact of the disease on people’s lives. Tertiary prevention strategies might include support groups, de-stigmatisation by providing information, good treatment with antiretroviral drugs (ARVs), help with employment and food supplements.
Case study 3
In 2010, people living in Northern Nigeria noticed that the ducks were dying. Some months later, children started becoming ill and hundreds of them died in what became the largest outbreak of lead poisoning in history. The lead was in the water and in the soil as a result of informal gold mining in the area. It was also in milk and meat products from poisoned animals that ate contaminated grass.
1. How would a One Health approach have picked up this problem sooner?
One Health recognises that the health of humans, animals and the environment are closely related. The death of the ducks should have been an early warning that the environment was not healthy.
Unit 15: Healthcare systems
When you have completed this unit you should be able to:
- Define a healthcare system.
- Explain the role of government and the private sector in a healthcare system.
- Describe the governance of a healthcare system.
- Explain approaches to health systems strengthening and why it is difficult.
15-1 What is a healthcare system?
A healthcare system is made up of everything needed to provide health care to a population and consists of:
- The people, facilities and supplies that offer services for the prevention and treatment of illness to a population.
- A system of financing for healthcare.
- A system for providing information about health needs and also about the effectiveness of healthcare.
- A system for setting standards and providing oversight of activities and results.
Both government and the private sector play important roles in a healthcare system.
15-2 What is the World Health Organisation (WHO) framework for understanding a healthcare system?
The World Health Organisation (WHO) framework shows 6 necessary “building blocks” of a healthcare system, together with 4 desirable outcomes.
Although the WHO framework can be useful to help politicians understand the various components of a healthcare system that might need funding, together with the desired outcomes, it is of limited use in trying to understand how a healthcare system might work better. This is because it does not show how the components of a system interact with each other and how changes in one part of the system might affect other parts. An alternative way of understanding a healthcare system is as a “complex system”.
15-3 What is a complex system?
Complex systems are found throughout nature. They have the following characteristics:
- They consist of many parts
- The parts interact with each other
- The behaviour of the whole system cannot be understood by looking at the behaviour of only one part of it
- Complex systems often behave almost if they have a “mind of their own” and tend to learn and bounce back after an external pressure is applied.
An example of a complex system is an ecosystem such as a pond or a forest, but the thinking behind complex systems is being increasingly used to explain the difficult problems in health and healthcare. A healthcare system can be shown as a complex system (see Figure 15-1).
A complex system is an appropriate way of understanding a healthcare system.
Figure 15-1: Healthcare can be shown as a complex system with financing, governance and information interacting with facilities, supplies and staff.
15-4 How does “systems thinking” help in healthcare?
Identifying something as a complex system explains why changes may have unexpected results or unintended consequences. An important feature of complex systems in health and healthcare is that the people at the centre of them are best placed to understand:
- The connections between the parts
- The effect of changing one part on the behaviour of the whole system
This is why it is so important to involve community members when planning a community-level prevention programme. It also explains why leadership by clinicians is important when changes need to be made, and why changes are more likely to be effective if clinicians are empowered to adapt solutions to fit the local situation.
Systems thinking helps people understand that changing one part of the system affects the behaviour of the whole system.
15-5 How does government play a role in the healthcare system?
National, provincial and local government play an important role in the health system by:
- Making decisions about health policies and allocating health funding.
- Setting rules and regulations that affect exposure to disease-causing agents.
- Enforcing compliance with rules and regulations.
15-6 How do private organisations play a role in the healthcare system?
Private organisations are important role players:
- Non-governmental organisations provide some health services.
- They can also play a role in advocating for health system changes.
- Private practitioners provide health services.
15-7 What does a well-functioning health system look like?
In a well-functioning health system:
- Facilities are situated in the areas where they are needed and are clean and well-maintained.
- People with appropriate skills and knowledge are employed, and they use their skills and knowledge in an effective way. This requires good human resource management, and access to information for staff, including access to clinical guidelines and protocols.
- Appropriate goods and medicines are obtained and distributed in a way that makes them available when needed, with the least amount of waste. This requires good supply chain management.
- Services are accessible to patients and of good quality.
- People can receive healthcare that they can afford.
- There is an information system that monitors health needs and allows decision-makers to respond appropriately to changing healthcare needs.
- The activities of different role players including other government departments, private providers and non-governmental organisations are coordinated.
- There is good governance.
15-8 What is the “governance” of a health system?
Health system governance is the process that sets standards and expected outcomes for services, together with a system of oversight and accountability.
Governance of a health system sets standards, expected outcomes, oversight and accountability.
15-9 What does accountability mean?
- People have responsibilities that are clearly defined and understood
- There are transparent ways of monitoring whether they meet their responsibilities.
- There are sanctions (penalties) if they fail to meet their responsibilities.
15-10 What happens when there is poor governance?
When governance is poor there is a risk of:
- Standards and outcomes not being realised and achieved
All the above result in poor health services.
Poor governance is an important cause of a failing health service.
15-11 Who is responsible for governance?
Governance happens at many levels:
- The World Health Organisation (WHO) is responsible for some aspects of global health governance, particularly around infectious disease.
- The ultimate responsibility for national health governance lies with the national Minister for Health. The national minister is responsible for setting standards and achieving outcomes. However the responsibility for providing services and adhering to these standards is delegated to levels of the provincial health system. All of these management levels are expected to report their activities and results the national department of health.
- Senior clinicians are responsible for governance in their own units. This process is called clinical governance. Quality improvement processes are part of clinical governance.
15-12 Why is the governance of health systems difficult?
Governance of some parts of the health system, such as finance and buildings are relatively easy. The difficult part is the oversight of clinical activities and outcomes by non-clinical managers who may be based some distance from the facility. It is difficult because:
- Clinicians feel that their time should be spent with patients rather than collecting data for their managers.
- Managers may not understand the clinical context. For example, they may expect the same outcome in sites where the caseload is different.
- Setting targets and providing incentives may result in unexpected outcomes. For example, doctors turning away high-risk patients so they can be sure of good results and meet their targets.
The challenge for those in charge of governance is maintaining standards and outcomes without overwhelming clinical providers with administration, but also empowering and trusting them to adapt policies and procedures to fit their local context.
15-13 What is a vertical health programme?
Sometimes departments of health or international organisations and funders wish to make an impact on a particular condition or disease, but are concerned that it cannot be effectively delivered through the existing health service.
Rather than waiting for improvements in the existing general health service, it may be decided to tackle priority problems by providing a specific programme with its own budget and management structure. Examples of these “vertical programmes” include the international campaign to eradicate smallpox in the 1960s and 1970s, and the HIV and TB programmes in South Africa.
Vertical programmes can be an efficient way to achieve the desired results, but may divert resources and attention from the rest of the health system. They can also cause confusion by duplicating services already provided by the health system. Therefore vertical health systems need to be carefully considered before they are introduced.
In the past, most health programmes funded by international organisations were vertical programmes. It is now recognised that efforts rather need to be made to strengthen the overall health system in low- and middle-income countries.
It is better to strengthen the overall health system than to introduce vertical programmes to address specific problems.
15-14 What approaches are used for health systems strengthening?
Health systems strengthening can involve attention to any (or all) of the components of the system. However, two components are particularly important because they have an effect on many other parts of the health system. These are:
- Increasing human capacity
- Improving information flows
Increasing human capacity means making sure that the right people with the right skills and attitudes are where they are needed. Issuing protocols and guidelines is not enough. Increasing the human capacity in the health system means making sure that local clinicians and managers have the confidence and information to adapt, improvise and make their own improvements.
Having good information about the activities and outcomes in a health service helps clinicians to provide a better service, but also helps managers better to support them. An important example of this is the management of the supply chain. If managers have good information about the quantity of drugs and consumables that are being used, they should be able to replace them in time and avoid a stock out. There is a great interest in using electronic “apps” to improve information in the health system but these need to be well-designed and maintained so that they do not cause frustration.
15-14 How easy is it to change a health system?
It is difficult to change health systems. This is partly because they are complex systems that tend to bounce back to their original state after changes are made, but also because they are very dependent on people to implement any changes. Important factors making health systems difficult to change include the following:
- In large organisations, peoples’ behaviour is affected by those around them. For example, if a new employee joins an organisation where everybody arrives at work early, they will not wish to arrive after everybody else and will also arrive early. If everybody is taking very long lunch and tea breaks, an employee will not wish to be the only one working, and will also take time off during the day. What is considered normal behaviour in an organisation or workplace can be very difficult to shift and newcomers can be “trapped” by a good or a bad work ethic.
- It may be in some people’s interests to resist change because they benefit from a system that is not working very well. These people are known as “spoilers”. Spoilers can be particularly damaging when they are in important management roles. Change may mean more work and responsibility.
- Because so many parts of the system are connected to each other, attempts to improve one part of the system may have adverse effects on another part. For example, providing incentives for good outcomes after surgery might lead to doctors turning away high risk patients. Closing a pharmacy storage depot may decrease storage costs, but increase transport costs and stock outs.
Most successful reforms, particularly in primary healthcare have followed some great upheaval. For example:
- The UK’s National Health Service that was introduced after the Second World War.
- Cuba’s health service grew out of a revolution.
- Rwanda’s health service reforms followed the 1994 genocide.
Due to its complexity and its dependence on people, it is often difficult to change a health system.
Case study 1
In 1995, just after the genocide, Rwanda had the lowest life expectancy in the world, and some of the worst health outcomes. Very few people had access to clean water and there were several infectious disease epidemics. The Rwandan government started a programme of social and economic development that included health system reform.
Between 1995 and 2013, the life expectancy improved from 31 to 63 years. Numbers of children dying before their 5th birthday dropped from 268 per 1000 in 1993 to 42 per 1000. Numbers of mothers dying in childbirth dropped from 1260 to 290 per 100 000 births. These are very dramatic improvements.
1. What types of health reforms might have produced these improvements?
In broad terms, there needed to be the creation of healthcare providers, facilities and equipment, together with a system for financing, governance and the use of information to learn and improve.
In Rwanda, the health system reforms that are credited with many of these health improvements include:
- A national, community-based insurance scheme was rolled out and subsidised for the poorest.
- Community healthcare workers, elected by their communities, were trained to provide basic medical care.
- Specialist medical capacity grown by collaborating with American universities.
- Aid funding for vertical disease programmes was used to rebuild the country’s general health services at the same time. The minister of health said that she made vertical programmes into “diagonal” programmes.
- Rwanda has an effective online health management system, and uses mobile health technologies and an open source online medical record that can be customised to local use.
- There has been effective collaboration between different government departments, together with private organisations, to provide an extensive vaccination programme.
- The Department of Health has a strong focus on financial management, transparency and accountability.
- The national minister has used what she describes as an “equity approach”. She argues that if services are designed in a way that meets the needs of the poorest, then richer citizens will also be able to benefit from them.
Case study 2
The Rwandan minister of health, Dr Agnes Binagwaho, uses social media to engage the Rwandan public in health issues. She has a blog and a Twitter account. On alternate Mondays, she hosts a #Ministermonday Twitter chat. She says on her blog: “It is so important for Rwandans to be able to communicate with their government. In the Ministry of Health and throughout the central government, we strive for transparency, accountability, and accessibility”.
1. Transparency, accountability and the accessibility of a health ministry are part of which important health system function?