10 Health Management in Anthropology

Ajeet Jaiswal

Contents:

    1.      Introduction: Health

2.      Public Health

3.      Different Concepts of Health

3.1 Biomedical Concept

3.2 Ecological Concept

3.3 Biosocial and Biocultural Concept

3.4 Holistic Concept

4.      Physical Health

5.      Mental Health

6.      Social Health

7.      Positive Health

8.      Factors that Influence the Health

8.1 Genetic

8.2 Environment

8.3 Ways of living

8.4 Socio-economic Status

8.5 Health Services

9.      Role of Anthropology in Public Health

10.      Role of Anthropology in Health System Development

11.  Health and Management

12.  Why Health Management is Important

13.  Distinguishing features of public health management

14.  Roles of public health management

15.  Summary

    Learning objectives:

• The course will provide an introduction to the field of Health Management in Anthropology.
• It will include the Basic Concept of Concepts of Health and Factors that Influence the Health
• This module will enable the students at postgraduate level to understand the Role of Anthropology in Public Health, Health and Management, Roles of public health management

    1.  Introduction: Health

The Constitution of WHO (1946) states that good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. Health is a resource for everyday life, not the object of living, and is a positive concept emphasizing social and personal resources as well as physical capabilities. Health is a fundamental human right, recognized in the Universal Declaration of Human Rights (1948). It is also an essential component of development, vital to a nation’s economic growth and internal stability. Along with the traditional and unequivocal arguments on social justice and the importance of health, it is now accepted that better health outcomes play a crucial role in reducing poverty. There is also increased understanding of how health fits into a wider cross-sectoral, cross-border and globalized framework. Four key values guide efforts to address health issues:

• Recognition of the universal right to health
• Continued application of health ethics to policy, research and service provision
• Implementation of equity orientated policies and strategies that emphasize solidarity
• Incorporation of a gender perspective into health policies.

   Health ethics involves a process of systematic and continuous reflection on the norms and values which should guide decisions about health care at the personal, institutional, or societal level, and by which the outcomes of such decisions may be judged.

Moral reasoning involves pursuing rules, principles, and theories. Moral rules state that actions of a certain kind ought (or ought not) to be done because they are right (or wrong). These rules are justified by basic and independent principles such as justice (fairness), respect for persons, beneficence, and parsimony (efficient use of resources). These principles reflect comprehensive ethical theories, such as utilitarianism (in which the rightness of a choice depends on whether it maximizes the good) and deontology (in which actions are judged according to their adherence to fundamental duties). Compared to medical ethics, which focuses on individuals, health ethics also encompasses the full range of health determinants and their interconnections, viewed from a societal or systems perspective (Jaiswal, 2012).

A health determinant is a force or element that affects health, either positively or negatively. Health is determined by both intrinsic forces, such as genetics, behaviour, culture, habits and lifestyles, and extrinsic forces such as preventative, curative and promotional aspects of the health sector, as well as elements outside the health sector including:

• Economic factors, such as trade
• Social factors, such as poverty
• Environmental factors, such as climate change
• Technological factors, such as information technology.

    Global health refers to widespread health impacts that affect large numbers of people across boundaries of geography, time and culture. It includes the impacts on the global ecosystem and other health determinants, such as poverty and genetics. Global health implies a context that includes the whole world and produces its own institutional complexities.

Recently, a clear recognition has emerged that the solution to many health problems lies in addressing their root causes (health determinants), many of which are outside the direct control of the health sector. This means it is necessary to integrate effective health dimensions into other sectors such as agriculture, transport and housing, in what are called cross-sectoral policies. For example, poor housing, inadequate and unsafe water, and pollution all expose people to health risks. This requires new levels of cooperation between health and various other development sectors. However, cross-ministry and multi-donor coordination is particularly difficult in countries that are poor and when ministries lack resources to fulfill their mandate (WHO, 1948).

2. Public Health

Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease. The three main public health functions are:

• The assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities.
• The formulation of public policies designed to solve identified local and national health problems and priorities.
• To assure that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services.

   Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviours to ensure that populations stay healthy. One way to illustrate the breadth of public health is to look at some notable public health campaigns:

• Vaccination and control of infectious diseases
• Motor-vehicle safety
• Safer workplaces
• Safer and healthier foods
• Safe drinking water
• Healthier mothers and babies and access to family planning
• Decline in deaths from coronary heart disease and stroke
• Recognition of tobacco use as a health hazard.

    The term global public health recognizes that, as a result of globalization, forces that affect public health can and do come from outside state boundaries and that responding to public health issues now requires attention to cross-border health risks, including access to dangerous products and environmental change.

The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments. Many diseases are preventable through simple, non-medical methods. For example, research has shown that the simple act of hand washing with soap can prevent many contagious diseases. In other cases, treating a disease or controlling a pathogen can be vital to preventing its spread to others, such as during an outbreak of infectious disease, or contamination of food or water supplies. Public health communications programs, vaccination programs, and distribution of condoms are examples of common public health measures. Measures such as these have contributed greatly to the health of populations and increases in life expectancy(Jaiswal, 2013).

Public health plays an important role in disease prevention efforts in both the developing world and in developed countries, through local health systems and non-governmental organizations. The World Health Organization (WHO) is the international agency that coordinates and acts on global public health issues. Most countries have their own government public health agencies, sometimes known as ministries of health, to respond to domestic health issues. For example in the United States, the front line of public health initiatives are state and local health departments. The United States Public Health Service (PHS), led by the Surgeon General of the United States, and the Centers for Disease Control and Prevention, headquartered in Atlanta, are involved with several international health activities, in addition to their national duties. In Canada, the Public Health Agency of Canada is the national agency responsible for public health, emergency preparedness and response, and infectious and chronic disease control and prevention. The Public health system in India is managed by the Ministry of Health & Family Welfare of the government of India with state owned health care facilities.

There is a great disparity in access to health care and public health initiatives between developed nations and developing nations. In the developing world, public health infrastructures are still forming. There may not be enough trained health workers or monetary resources to provide even a basic level of medical care and disease prevention. As a result, a large majority of disease and mortality in the developing world results from and contributes to extreme poverty. For example, many African governments spend less than US$10 per person per year on health care, while, in the United States, the federal government spent approximately US$4,500 per capital in 2000. However, expenditures on health care should not be confused with spending on public health. Public health measures may not generally be considered “health care” in the strictest sense. For example, mandating the use of seat belts in cars can save countless lives and contribute to the health of a population, but typically money spent enforcing this rule would not count as money spent on health care.

3. Different Concepts of Health

Health is often taken for granted and its value is not fully understood until it is lost. During the past few decades, there has been a re-awakening that health of workers is a fundamental human right and therefore, the attainment of the highest level of health is a most important social goal. Health has been viewed by different people from different angles giving rise to different concepts(Jaiswal, 2012; 2013). These are:

• Biomedical Concept
• Ecological Concept
• Biosocial and Biocultural Concept
• Holistic Concept

    3.1 Biomedical Concept

Health of workers has been traditionally defined as ‘absence of disease’ and disease as deviation from the biochemical norm. However, this model was found inadequate to solve some of the major health problems of mankind such as, the population problems, problems of malnutrition, mental illness, chronic diseases, drug abuse and accidents.

3.2 Ecological Concept

The ecologists viewed health of workers as a harmonious equilibrium between man and his environment and disease as a maladjustment of the human organism to environment.

3.3 Biosocial and Biocultural Concept

Development in social sciences revealed that disease is both a biological and social phenomenon. These are not only biological factors, but also social, cultural and psychological factors, which must be given equal weightage in defining health and illness.

3.4 Holistic Concept

It is a synthesis of all the above concepts. According to this concept, health of worker is a ‘multidimensional’ process involving the well being of the whole person in the context of his environment. This concept corresponds to the ancient view that health implies a sound mind in a sound body, in a sound family, in sound environment.

According to W.H.O. (1948), health is a state of complete physical, mental and social well being and not merely an absence of disease or infirmity. The W.H.O. definition considers three specific dimensions of health — physical, mental and social. These three aspects of health are interdependent and influence each other determining the status of health of an individual at a particular moment

4. Physical Health

Physical health is a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body. This can be achieved by proper nutrition, balanced diet and regular exercise.

5. Mental Health

Mental health is a state in which the individual feels a sense of perfect well being and of mastery over his environment. A mentally healthy person is free from internal conflicts, well adjusted with others and has good self-control. He faces problems and tries to solve them intelligently.

6. Social Health

Social health is a state in which the individual’s capacities for participation in the social system are optimal. It focuses on well being of the ‘whole person’ in the context of his social network.

7. Positive Health

A person who enjoys health at the three planes viz., physical, mental and social well-being is said to be in a state of ‘positive health.

8. Factors that Influence the Health

Health is influenced by a complex group of factors and conditions related to each other (Jaiswal, 2012).

These may be classified as:

• Genetic
• Environmental
• Ways of living
• Socio-economic status
• Health services.

    8.1 Genetic

The physical and mental traits of every human being are to some extent determined by the nature of the genes at the moment of conception. The genetic makeup is unique and cannot be altered after conception. A number of diseases are now known to be genetic in origin such as, hemophilia, mental retardation and diabetes. The state of health, therefore, depends partly on the genetic constitution of man.

8.2 Environment

Environment has a direct effect on the physical, mental and social well-being of those living in it. Most of the diseases (typhoid, cholera, worm infestation etc.) are due to environmental deficiencies. There is also increasing evidence that chronic diseases, accidental injuries, mental illness are major outcome of man’s maladjustment to his exposure to environmental hazards.

8.3 Ways of living

Health is related closely to life style, which includes ways of living, personal hygiene, elementary habits and behaviour. The major health problems are related significantly to change in life-style, such as malnutrition, obesity, heart disease, accidents, drug and alcohol abuse, suicides and homicides. The achievement of optimum health demands adoption of healthy way of living.

8.4 Socio-economic Status

The health of an individual is closely related to his economic status and his social organization

(i)The hazards of poverty: Poverty leads to sickness by depriving man of his needs of adequate nutrition and shelter and by exposing him to the hazards of poor sanitary conditions. Poverty predisposes to diseases due to malnutrition. It also predisposes to crime, violence, drug abuse, depression and alcoholism.

(ii)  The hazards of affluence: It can also contribute to illness as can be seen by the high incidences of heart disease, hypertension, obesity, diabetes and mental illness in the upper socio-economic groups.

8.5 Health Services

The health of workers is strongly influenced by the quality and availability of health services, for example:

(i)  Immunization program influencing the incidence of particular diseases

(ii)  Provision of safe water supply can solve the problem of water borne diseases

9. Role of Anthropology in Public Health

Anthropology is the cross cultural study of medical systems and the study of bio-ecological and socio-cultural factors that influence the incidence of health and disease now and throughout human history. The areas where the medical/physical anthropologists do research are human evolution, anatomy, paediatrics, epidemiology, mental health, drug abuse, definition of health and disease, training of medical personnel, medical bureaucracies, hospital organization and operations, the doctor patient relationship and process of bringing scientific medicine to users of traditional medicine (Gartaulla, 2008; Cockerham, 2000; Annandale, 1998; Freidson, 1976).

The Physical and medical anthropology can be studied as a bi-polar process whose one pole is biological in which one studies human growth and development, role of disease in human evolution and study of disease of ancient man. The second is sociocultural pole where one studies traditional medical systems, illness behaviour, doctor patient relationship, introduction of western medicine to traditional societies and in between this there is epidemiology and cultural ecology (Coleman, 1994). So, medical anthropology encompasses the study of medical phenomena as they are influenced by social and cultural factors and social and cultural phenomena as they are influenced by these medical aspects. Another definition states that medical anthropology is concerned with the biocultural understanding of man and his works in relation to health and medicine (Durkheim, 1982) Anthropology also studies the relationship between human evolution and disease in the past, the biological and cultural determinants of disease, health and health care, the basis and effectiveness of traditional health care systems and suggests ways to integrate modern medicine into traditional societies. Hence, medical anthropology doesn’t study the relationship of individual person to disease but studies the relationship between the biological and cultural characteristics of a group(ethnic or racial) and its resistance of susceptibility to various diseases in view of different genetic constitution (Marx, 1973). It studies the traditional medical systems but not the modern systems of medicine. It helps to understand the disease prevalence and susceptibility to the genetic make-up of a man belonging to a particular race or ethnicity, impact of disease on human evolution and the impact of these inherent ethnic and racial differences on the functioning and acceptability of health care (Martin, 1987).

10. Role of Anthropology in Health System Development

Role of Anthropology in Health System Development Public health as seen from the eyes of comprehensive primary health care mentioned in Alma Ata declaration covers the following aspects that can be analyzed from social and anthropological perspective (McKeown, 1976)

• It sees health as a process in human development and states that it cannot be achieved in isolation without associated socio-economic development.
• It strongly affirms that health which is the complete state of physical, social and mental well being and not merely the absence of disease and infirmity is the fundamental human right and to achieve the highest level of health should be a world-wide social goal.
• For health it lays emphasis on all the aspects of health care that is, preventive, promotive, curative and rehabilitative.
• Its shape is determined by social goals like quality of life and maximum health benefits to the greatest number of people and advises to attain these goals by social means like community participation.
• It lays emphasis on essential health care which is accessible, affordable and acceptable by the people and with their full participation. This health care has to be scientifically sound and socially acceptable. It requires co-ordinated efforts from all other related sectors.
• It is based on the economic, socio-cultural and political conditions of a country and it promotes equity.

    11. Health and Management

A problem being experienced in probably the majority of countries across the world is that the public health function is still not receiving firm enough support at political level. Even where that commitment appears to exist, and there are signs of a new-found commitment to public health, under-resourcing of the public health infrastructure and capacity prevents public health from playing the strong role advocated for it. As a consequence, the levels of health achieved by populations are seriously below what could be obtained if application of current knowledge in public health was pursued more vigorously through a stronger public health approach and infrastructure (WHO, 1999).

Modern public health practice is considerably more complex in the 21st century than it was 100 years or so ago when some of the great advances in public health were achieved. It includes not merely scientific and technical practice but also the knowledge and skills to build effective coalitions and partnerships for health and collectively to manage actions for health improvement. This applies to both national and international health efforts. This focus on managing for health has been described as public health management (PHM) (Alderslade 1990; Alderslade and Hunter 1994; Hunter 1997; Hunter and Berman 1997; Hunter 1999).

It is clear that public health practice in both developed and developing countries needs sustained political support and substantial development. In particular, there is a dearth of appropriate public health training and dissemination of public health experience and practice. To address these issues, a workshop, jointly organised by the World Health Organization Non-communicable Disease and Mental Health Cluster, and the University of Durham, England, was held at the University of Durham (Hunter 1997; Hunter and Berman 1997).

The workshop focused on public health management and on how it might serve as a unifying concept, linking policy-makers’ newfound interest in public health with the ability of public health practitioners, wherever they may be located, to secure the desired policy goals.

To this end, the following issues were considered:

• exploring the concept of public health management;
• the importance of public health management for all countries;
• the implications of public health management for chronic disease management;
• public health management at a national policy level and at local operational level;
• to describe the skills and competencies required of managers and practitioners working in public health management;
• implications for education and training.

    12. Why Health Management is Important

Neither managers nor public health professionals appear to be doing a good job in improving the public’s health if judged by the evidence from many countries, both developed and less developed. This shows the widening health gap between sections of society, in particular between those who are affluent and those who are poor. The gap is growing faster in some countries than others but nowhere is it closing despite the efforts of governments and their renewed commitment to the public health function.

Moreover, concerns about food safety and the environment have contributed to a widespread sense that public health issues have not been given sufficiently high priority by governments. Even within health care systems, public health practitioners seem unable to make things happen to improve the health of their populations.

In contrast, health care managers can make things happen even if they do not always know why they are doing it beyond the need to attend to the latest fad or fashion favoured by their political masters and mistresses. This may include restructuring whole health care systems, building another hospital regardless of whether or not it is needed, or developing some other health care facility to improve access and/or reduce waiting lists. Even where countries have clearly articulated health strategies, these do not appear to drive their health care systems in a different direction But unless they do they will cease to count at the end of the day. For the most part, the resources available for health, and the attention devoted to it from policymakers, remain largely directed at acute health services. All too often, health services are viewed as predominantly sickness services. These observations apply fairly consistently around the world. In the evaluation of Health-for-All in the 21st Century (HFA21) (1979-1996) which was based on three major evaluations, the failure to achieve equity in access to all primary health care elements and the unbalanced distribution of and weak support for human resources were two key barriers to health for all implementation.

13. Distinguishing features of public health management

• is multi-sectoral and professional
• combines knowledge and action
• has epidemiology at its core
• is influential across all health determinants
• involves public health reporting, leading to health strategy development
• communicates with politicians, professionals and the public
• is influential organisationally and financially
• lies at the heart of the civic society.

    14. Roles of public health management

• advocacy and management roles
• knowledge and action
• managerial capacity and infrastructure
• networking to create partnerships across organisations and disciplines
• broad involvement of people and skills
• infrastructure and curricula for education
• evidence based policy and practice
• an outcome based focus
• a national agenda for health and health services research.

   15. Summary

• The Constitution of WHO (1946) states that good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.
• There is also increased understanding of how health fits into a wider cross-sectoral, cross-border and globalized framework.
• Four key values guide efforts to address health issues.
• A health determinant is a force or element that affects health, either positively or negatively.
• Global health refers to widespread health impacts that affect large numbers of people across boundaries of geography, time and culture.
• Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole.
• Public health professionals monitor and diagnose the health concerns of entire communities and promote healthy practices and behaviours to ensure that populations stay healthy.
• The focus of a public health intervention is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors, communities and environments.
• Health of workers is often taken for granted and its value is not fully understood until it is lost.
• Health of workers has been traditionally defined as ‘absence of disease’ and disease as deviation from the biochemical norm.
• Development in social sciences revealed that disease is both a biological and social phenomenon.
• Physical health is a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body.
• Mental health is a state in which the individual feels a sense of perfect well being and of mastery over his environment.
• Social health is a state in which the individual’s capacities for participation in the social system are optimal.
• The physical and mental traits of every human being are to some extent determined by the nature of the genes at the moment of conception.
• Environment has a direct effect on the physical, mental and social well-being of those living in it.
• Health is related closely to life style, which includes ways of living, personal hygiene, elementary habits and behaviour.
• A problem being experienced in probably the majority of countries across the world is that the public health function is still not receiving firm enough support at political level.
• Role of Anthropology in Health System Development Public health as seen from the eyes of comprehensive primary health care mentioned in Alma Ata declaration.
• It is clear that public health practice in both developed and developing countries needs sustained political support and substantial development.
• Neither managers nor public health professionals appear to be doing a good job in improving the public’s health if judged by the evidence from many countries, both developed and less developed.