Cost-Effectiveness Thresholds in Global Health: Taking a Multisectoral Perspective

Good health is a function of a range of biological, environmental, behavioral, and social factors. The consumption of quality health care services is therefore only a part of how good health is produced. Although few would argue with this, the economic framework used to allocate resources to optimize population health is applied in a way that constrains the analyst and the decision maker to health care services. This approach risks missing two critical issues: 1) multiple sectors contribute to health gain and 2) the goods and services produced by the health sector can have multiple benefits besides health. We illustrate how present cost-effectiveness thresholds could result in health losses, particularly when considering health-producing interventions in other sectors or public health interventions with multisectoral outcomes. We then propose a potentially more optimal second best approach, the so-called cofinancing approach, in which the health payer could redistribute part of its budget to other sectors, where specific nonhealth interventions achieved a health gain more efficiently than the health sector’s marginal productivity (opportunity cost). Likewise, other sectors would determine how much to contribute toward such an intervention, given the current marginal productivity of their budgets. Further research is certainly required to test and validate different measurement approaches and to assess the efficiency gains from cofinancing after deducting the transaction costs that would come with such cross-sectoral coordination.     

Explaining the origins and distribution of health and disease: an analysis of epidemiologic theory in core Master of Public Health coursework in the United States

This article examines the epidemiologic theories taught most frequently in core social and behavioral science coursework in Master of Public Health (MPH) programs in the United States, identifies lacunae, discusses their implications, and recommends specific pedagogical changes. Course syllabi were identified through online search and instructor outreach between June and December 2016. Content analysis was conducted to identify most commonly taught theories. Analysis continued until theoretical saturation. Behavioral health theories predominate within our sample of core social and behavioral science course syllabi. Behavioral health theory represents 93% of the most commonly taught epidemiologic theories within our sample. Individual health behavior theory was the most commonly encountered, the most prevalent of which were the health belief model and the theory of planned behavior, both appearing in 83% of syllabi (n = 25). Theories of interpersonal health behavior were the second-most commonly observed, including social cognitive theory (77%, n = 23) and social network theory (67%, n = 20). Behavioral-ecological theory was present in 87% (n = 26) of syllabi. The fundamental cause theory (23%, n = 7) was the only commonly taught non-behavioral epidemiologic theory. The social determinants of health were referenced in 60% of syllabi (n = 18). Based on this sample, behavioral health theories drawn from psychological, behavioral science, health education, and medical literatures predominate in US-based core MPH pedagogy concerned with explaining the etiology and distribution of health, morbidity, and mortality. We recommend the inclusion of non-behavioral epidemiologic theory from disciplines more engaged with structural aspects of health.     

Impact of Maternal Health Behaviours and Social Conditions on Infant Diet at Age 1-Year: Results from a Prospective Indigenous Birth Cohort in Ontario,Canada

Background: Understanding the impact of maternal health behaviours and social conditions on childhood nutrition is important to inform strategies to promote health during childhood. Objective: To describe how maternal health sociodemographic factors (e.g., socioeconomic status, education), health behaviours (e.g., diet), and traditional health care use during pregnancy impact infant diet at age 1-year. Methods: Data were collected from the Indigenous Birth Cohort (ABC) study, a prospective birth cohort formed in partnership with an Indigenous community-based Birthing Centre in southwestern Ontario, Canada. 110 mother-infant dyads are included in the study and were enrolled between 2012 and 2017. Multiple linear regression analyses were performed to understand factors associated with infant diet scores at age 1-year, with a higher score indicating a diet with more healthy foods. Results: The mean age of women enrolled during pregnancy was 27.3 (5.9) years. Eighty percent of mothers had low or moderate social disadvantage, 47.3% completed more than high school education, and 70% were cared for by a midwife during their pregnancy. The pre-pregnancy body mass index (BMI) was <25 in 34.5% of women, 15.5% of mothers smoked during pregnancy, and 14.5% of mothers had gestational diabetes. Being cared for by an Indigenous midwife was associated with a 0.9-point higher infant diet score (p = 0.001) at age 1-year, and lower maternal social disadvantage was associated with a 0.17-point higher infant diet quality score (p = 0.04). Conclusion: This study highlights the positive impact of health care provision by Indigenous midwives and confirms that higher maternal social advantage has a positive impact on child nutrition.     

Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario,Canada: a qualitative inquiry

To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard’s concept of epistemological barriers and Raphael’s seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized.     

关于“政府购买城市社区公共卫生服务”的供方调查

目的：了解安徽省社区卫生服务机构开展政府购买公共卫生服务的现状、存在问题和原因,以及有关意愿。方法：问卷调查,结合现场调研和访谈。结果：部分公共卫生服务项目开展的较好,但由于社区卫生服务机构的能力有限、部分公共卫生职能没有下沉社区等原因,社区公共卫生职能需要进一步完善。结论：要利用市场机制促进政府购买公共卫生服务、加强社区公共卫生技术人员培养、协调适宜公共卫生服务下沉至社区、加强社会宣传力度。     

Leveraging Data and Digital Health Technologies to Assess and Impact Social Determinants of Health (SDoH): a State-of-the-Art Literature Review

ObjectiveIdentify how novel datasets and digital health technology, including both analytics-based and artificial intelligence (AI)-based tools, can be used to assess non-clinical, social determinants of health (SDoH) for population health improvement.MethodsA state-of-the-art literature review with systematic methods was performed on MEDLINE, Embase, and the Cochrane Library databases and the grey literature to identify recently published articles (2013-2018) for evidence-based qualitative synthesis. Following single review of titles and abstracts, two independent reviewers assessed eligibility of full-texts using predefined criteria and extracted data into predefined templates.ResultsThe search yielded 2,714 unique database records of which 65 met inclusion criteria. Most studies were conducted retrospectively in a United States community setting. Identity, behavioral, and economic factors were frequently identified social determinants, due to reliance on administrative data. Three main themes were identified: 1) improve access to data and technology with policy – advance the standardization and interoperability of data, and expand consumer access to digital health technologies; 2) leverage data aggregation – enrich SDoH insights using multiple data sources, and use analytics-based and AI-based methods to aggregate data; and 3) use analytics-based and AI-based methods to assess and address SDoH – retrieve SDoH in unstructured and structured data, and provide contextual care management sights and community-level interventions.ConclusionsIf multiple datasets and advanced analytical technologies can be effectively integrated, and consumers have access to and literacy of technology, more SDoH insights can be identified and targeted to improve public health. This study identified examples of AI-based use cases in public health informatics, and this literature is very limited.     

Is Exposure to Income Inequality a Public Health Concern? Lagged Effects of Income Inequality on Individual and Population Health

Objective. To examine the health consequences of exposure to income inequality.
Data Sources. Secondary analysis employing data from several publicly available sources. Measures of individual health status and other individual characteristics are obtained from the March Current Population Survey (CPS). State-level income inequality is measured by the Gini coefficient based on family income, as reported by the U.S. Census Bureau and Al-Samarrie and Miller (1967) . State-level mortality rates are from the Vital Statistics of the United States ; other state-level characteristics are from U.S. census data as reported in the Statistical Abstract of the United States .
Study Design. We examine the effects of state-level income inequality lagged from 5 to 29 years on individual health by estimating probit models of poor/fair health status for samples of adults aged 25–74 in the 1995 through 1999 March CPS. We control for several individual characteristics, including educational attainment and household income, as well as regional fixed effects. We use multivariate regression to estimate the effects of income inequality lagged 10 and 20 years on state-level mortality rates for 1990, 1980, 1970, and 1960.
Principal Findings. Lagged income inequality is not significantly associated with individual health status after controlling for regional fixed effects. Lagged income inequality is not associated with all cause mortality, but associated with reduced mortality from cardiovascular disease and malignant neoplasms, after controlling for state fixed-effects.
Conclusions. In contrast to previous studies that fail to control for regional variations in health outcomes, we find little support for the contention that exposure to income inequality is detrimental to either individual or population health.     

Why reduce health inequalities?

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair.Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone.Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable.Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective.Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis.We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.     

‘Punching above their weight’: a qualitative examination of local governments’ organisational efficacy to improve the social determinants of health

Objective : The World Health Organization calls upon local government worldwide to play a greater role in improving public health by improving the social determinants of health. This research aimed to determine how local governments in Victoria, Australia, conceptualised their organisational efficacy to address public health with reference to their statutory obligations. Methods : Sixteen in‐depth interviews were conducted with Victorian local government health planners. Thematic analysis was used to determine the importance of state health priorities and the perceived organisational efficacy of local government to address health via social determinants. Results : While there were disparities between state and local priorities for health, local government believes it can make an important contribution to improving health through ‘upstream’ approaches. Conclusions : Victorian local government has strongly adopted the socio‐ecological model of health and is aware of the important role that its diverse policy and program areas play in creating healthy communities. The Victorian State Government’s priorities, which adopted a more ‘downstream’ approach, were less influential. Implications for public health : State governments’ priority settings should be responsive to local governments’ unique local knowledge of health priorities. There is value in legislating a social determinants role for local government, provided it is supported by state and national government policies that facilitate public health.     

Urban Planning and Health Equity

Although the fields of urban planning and public health share a common origin in the efforts of reformers to tame the ravages of early industrialization in the 19th century, the 2 disciplines parted ways in the early 20th century as planners increasingly focused on the built environment while public health professionals narrowed in on biomedical causes of disease and disability. Among the unfortunate results of this divergence was a tendency to discount the public health implications of planning decisions. Given increasingly complex urban environments and grave health disparities in cities worldwide, urban planners and public health professionals have once again become convinced of the need for inclusive approaches to improve population health and achieve health equity. To make substantive progress, intersectoral collaboration utilizing ecological and systems science perspectives will be crucial as the solutions lie well beyond the control of any single authority. Grounded in the social determinants of health, and with a renewed sense of interconnectedness, dedicated and talented people in government agencies and communities who recognize that our future depends on cultivating local change and evaluating the results can come to grips with the enormous challenge that lies ahead to create more equitable, sustainable, and healthier cities worldwide.     

The Water Surrounding the Iceberg: Cultural Racism and Health Inequities

Policy Points

• Cultural racism—or the widespread values that privilege and protect Whiteness and White social and economic power—permeates all levels of society, uplifts other dimensions of racism, and contributes to health inequities.
• Overt forms of racism, such as racial hate crimes, represent only the “tip of the iceberg,” whereas structural and institutional racism represent its base. This paper advances cultural racism as the “water surrounding the iceberg,” allowing it to float while obscuring its base.
• Considering the fundamental role of cultural racism is needed to advance health equity.