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Health services as determinants of population health 

Health services as determinants of population health
Chapter:
Health services as determinants of population health
Author(s):

Martin Gulliford

DOI:
10.1093/med/9780199218707.003.0013
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date: 20 June 2019

This chapter evaluates the relationship between health services and public health and asks ‘what is the role of health services in improving population health?’. Traditional thinking in public health has been sceptical of the value of health services at improving health. This stems from recognition of the importance of wider determinants of health, the limited effectiveness of healthcare interventions, and the importance of iatrogenic illness. A number of efficiency-oriented strategies have been developed to increase the health gains from healthcare including needs assessment, health technology assessment and cost-effectiveness analysis, implementation research to promote the uptake of research findings, and strategies to improve the organization and delivery of healthcare. Estimates suggest that healthcare now adds about 5 years to life expectancy at birth in high-income countries. Application of similar techniques to the health problems of middle- and low-income countries suggests that about a quarter of the overall burden of disease in these countries could be prevented through implementation of packages of low-cost but highly effective interventions. Investment in these health interventions would be justified by the economic benefits associated with improved population health. Implementation of the essential package of care approach is hampered by the relative or absolute lack of health services for poor populations in middle- and low-income countries. The distribution of health services in middle- and low-income countries generally shows substantial pro-rich inequity and the financial costs of accessing healthcare may further impoverish poor households. Primary care, with its emphasis on universality and affordability, has been successfully implemented in some countries with favourable health outcomes. In high-income countries, where universal coverage and equitable access to primary care have been more widely achieved, pro-rich inequity exists in accessing preventive medical interventions and specialist care for more serious illnesses. These inequities may contribute to some adverse health outcomes in lower socioeconomic groups. Public health specialists should advocate principles of efficiency and equity and contribute to realizing these through participation in processes of needs assessment, health technology assessment, quality improvement, and facilitating access to needed healthcare for all groups.

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