Key Definitions

Dipak Mitra
Definition of Health
• The state of complete physical, mental and
social well-being and not merely the absence
of disease or infirmity (WHO, 1947)
Dimensions of Health
• The broad definition of health recognizes that
health encompasses biological and social
elements in addition to individual and
community well-being
• Health may be seen as an indicator of personal
and collective advancement
• It can signal the level of an individual’s well-
being as well as the degree of success
achieved by a society and its government in
promoting that well-being
Dimensions of Health
• This definition of health implies that issues
such as poverty, lack of education,
discrimination, and other social, cultural,
and political conditions found around the
world are essentially public health issues
Measures of Physical Health
• Life Expectancy at Birth
• Mortality
• Morbidity
• Disability
• Health Adjusted Life Years (HALY)
• Quality Adjusted Life Years (QALY)
• Disability Adjusted Life Years (DALY)
Life Expectancy at Birth
• Life expectancy at birth is defined as the
average number of years that a newborn
could expect to live if he or she were to pass
through life subject to the age-specific
mortality rates of a given period are held
• This measure only considers death, no
consideration of disease or disabilities
• Estimated using survival analysis (Life table
approach)
Health Adjusted Life Years (HALYs)
• This accounts for both mortality and morbidity
• Represents burden of disease in a population
and useful for comparison health between
populations
• Two common approaches to measure HALYs
are
– Disability-Adjusted Life Years (DALYs) and
– Quality-Adjusted Life Years (QALYs)
Disability-Adjusted Life Years (DALYs)
• Most common method used for estimating burden of
disease
• It measures the difference between the current state of
population health and an ideal situation, where
everyone reaches the age of standard life expectancy in
perfect health
• DALYs are based on an assumption that “time” is the
most appropriate measure for the burden of disease
• The greater the time lived with a disability, or with the
disabling results of an illness, or lost due to premature
mortality, the greater the burden of disease is
considered to be
Disability-Adjusted Life Years (DALYs)
• DALYs measure the total length of time that a
specific illness is disabling to an individual
over the course of his or her life
• When applied to a population, they are the
measure of the total disability incurred due to
a specific disease
• DALY = YLL (Years of Life lost due to premature
death) + YLD (Years lived with disability)
Disability-Adjusted Life Years (DALYs)
YLL (Years of Life lost due to
premature death
• YLL = N (number of deaths at age x) x L
(standard of life expectancy at age x in years)
YLD (Years lived with disability)

• YLD is measured by multiplying the number of

disability cases (i.e., incidence cases) by the
average duration of the disease or disability, with
a weighted value assigned to the type of disability
(disability weight)
• YLD = I (number of incident cases) x DW
(disability weight) x L (average duration of the
case until remission or death in years)
• YLD = P (number of prevalent cases) x DW
(disability weight)
Disability weights for DALYs
• DALYs use disability weights (0 = perfect health
and 1 = death) which are generated through
consultations with clinicians, experts or
community
• Disease-specific
Quality-Adjusted Life Years (QALYs)

• QALYs, as the name implies, measure both the quantity

and the quality of life lived
• They are typically used to analyze the cost-effectiveness
of clinical (or public health) interventions and for social
welfare improvement
• For example, QALYs can compare an intervention that
helps prolong life but has serious side effects (such as
permanent disability caused by radiation or
chemotherapy for cancer), with an intervention that
improves the quality of life without prolonging it (such
as palliative pain management)
Quality-Adjusted Life Years (QALYs)

• QALYs are calculated by multiplying the number of years

of additional life by an HRQL
• QALYs = additional number years of life x HRQL
• To estimate the cost-effectiveness of an intervention,
the cost is divided by the QALY
• The HRQL in QALYs is not linked to any particular disease
• It is based on values assigned by individuals about their
own health state (known as patient-based weights) or
on the values assigned by others about a particular
health state (community-based weights)
Quality-Adjusted Life Years (QALYs)

• Respondents are asked to assign a numerical value to what

they would be willing to sacrifice in order to return from
poor to perfect health, where a year of perfect health is
given a value of 1 and death is considered to be 0
• If the year is not spent in perfect health (e.g., living with
chronic pain), the value is between 1 and 0. This score takes
into account five dimensions: a) mobility, b) pain or
discomfort, c) self-care, d) anxiety-depression, and e) usual
activities
• This means that QALY estimates are able to integrate
psycho-social as well as biomedical aspects of the burden of
a disease
Use of QALYs and DALYs

• QALYs can provide an indication of the benefits gained from a

medical intervention in terms of quality of life, but their usefulness
is controversial
• It has been argued that serious ill health may be considered worse
than death
• Others have noted that what is considered perfect health varies by
culture and society.
• Furthermore, QALYs lack the sensitivity to compare two competitive
but similar drugs or to evaluate treatment for less severe health
problems
• The effects of chronic diseases, where quality of life is a major issue
but survival is not, are also difficult to address using QALYs
Use of QALYs and DALYs

• In such cases, disease-specific measures such as DALYs

may be more appropriate
• Another criticism of QALYs is the lack of weight on
emotional or mental health problems, and the impact
of these problems on the quality of life of individuals
and their families
• Similarly, because QALYs rely on measures of age,
context, and responsibilities in different life stages,
they can be difficult to quantify if a preventative
measure will not have an effect on health outcome in
the short term
Use of QALYs and DALYs

• Despite these limitations, QALYs are one of the few

tools that allow for comparisons between interventions
or across diseases
• Using QALYs for decisions on resource allocation helps
to articulate the choices to be made between
competing medical therapies or technologies
• Nevertheless, researchers caution that QALYs should
not be used in isolation, because they do not capture
all the domains and aspects of healthcare
Top Countries with the Longest Life
Expectancy
Name Total Male Female
Hongkong 85.158 82.254 88.042
Japan 84.91 81.784 87.966
Macau 84.552 81.598 87.49
Switzerland 84.112 82.256 85.898
Singapore 83.934 81.898 86.024
Spain 83.864 81.136 86.554
Italy 83.856 81.728 85.846
Australia 83.792 81.906 85.684
Iceland 83.37 81.966 84.782
South Korea 83.354 80.294 86.276
Measures of Mental Health
• In contrast to physical health, measures of
mental health are limited
• Mental conditions
• Depression Disorder, Distress
• Behaviors
• Suicide, Drug or alcohol abuse
• Perceptions
• Perceived mental health status
• Satisfaction
• With life, work, relationships
• Services received
• Counseling, drug treatment
Mental Health
• Mental health problems are frequently
associated with social problems
• For example, with easy access to guns, mental
health often contributes to gun violence in both
public and private settings
Measures of Social Wellbeing
• The most commonly used measure of relative
social well-being is socioeconomic status (SES)
• An SES index typically considers such factors as
education level, income, occupation, asset
ownership
• Quality of life is another common measure and
may include the ability to perform various roles
(self-care, family care, social functioning),
perceptions (emotional well-being, pain
tolerance, energy level), and living environment
(pollution levels, crime prevalence)
Measures of Social Wellbeing
• A third set of social well-being measures, often
used by sociologists, is composed of
• Social contacts and Social resources
• Examples of social contacts include visits with
family members, friends, and relatives and
participation in social events, such as
membership activities, professional conferences,
and religious gatherings
Measures of Social Wellbeing
• The social contacts factor can be used as an
indicator of social resources by determining
whether an individual can rely on social contacts
for needed support and company and whether
the people involved in these contacts meet the
individual’s needs for care and love
Definition of Public Health
• "the science and art of preventing disease,
prolonging life and promoting health through
the organized efforts and informed choices of
society, organizations [public, non-profit and
private], communities and individuals“
• “Protecting Health, Saving Lives—Millions at a
Time”
Public Health Vs Clinical Care
Approaches

Clinical Care Public Health

• Treatment of Disease • Health Promotion
– Healthy lifestyle
• Restoration of Health
• Health Protection
• Prevent Recurrence – Policy and legal issues
• Disease Prevention
– Risk reduction
– Health System
Functions
Determinants of Health

Living and working

conditions
Work Unemployment
environment
Water & sanitation

Education
Health care
services

Agriculture and
food production
Housing
Age, sex and
constitutional
factors
Multiple Determinants of Health

Policies and Interventions

Behavior

Physical Social Environment

Individual
Environment

Biology

Access to Quality Health Care

Determinants of Health
Definition of Public
• You can refer to people in general, or to all the
people in a particular country or community,
as the public
• Public means relating to the government or
state, or things that are done for the people by
the state
Definition of Policy
• A policy is a decision made by an authority
about an action-either one to be taken or one
to be prohibited—to promote or limit the
occurrence of a particular circumstance in a
population
• Policy is expressed in norms, practices,
regulations and laws affecting the life of the
population which together provide shape,
direction and consistency to decisions made
over time
Definition of Public Policy

• Public policy—decision making that affects the

general population or significant segments
thereof-is meant to improve the conditions
and general welfare of the population or
subpopulations under its jurisdiction
Definition of Public Policy
• Public policy is the sum of the decisions that shape
society
• It provides a framework for the development of, for
example, industrial and agricultural production,
corporate management, and health services
• It determines the range of options from which
organizations and individuals make their choices, and
thus directly influences the environment and
patterns of living
• Public policy is a major determinant of the health of
the population
Public in different context
• Although public policies are intended to serve
the interests of the public at large, the term
public has different interpretations according to
the political context in which it is applied
• For example, policymakers tend to be most
responsive to the views and wishes of
constituents who are politically active and
communicate directly with their representatives
Types of Political System
• Democracy
• Republic
• Monarchy
• Communism/Socialism
• Dictatorship
Definition of Health Policy
• Miller (1987, 15) defined health policy as “the
aggregate of principles, stated or unstated, that . . .
characterize the distribution of resources, services,
and political influences that impact on the health of
the population.”
• Health policy is policy that pertains to or influences
the attainment of health
Definition of Health Policy
• Health policy provides a framework for health-
promoting actions covering the social, economic, and
environmental determinants of health
• Health policy can be viewed as a set of decisions about
strategic goals for the health sector and the means for
achieving these goals
Healthcare Policy
• Healthcare policy refers to that part of health policy
pertaining to the financing, organization, and
delivery of care
• Healthcare policy may cover the training of health
professionals; licensing of health professionals and
facilities; administration of public health financing
programs, deployment of electronic health records;
efforts to control healthcare costs; and regulation of
private health system
Healthcare Policy
• Whereas predominant goal of health policy is to
improve population health, the goals of healthcare
policy are typically to provide equitable and efficient
access to high-quality healthcare services
Health Planning
• Health service planning is a process of
identifying key objectives and choosing
among alternative means of achieving them
• While the process implies a rational set of
actions, the reality of planning is often quite
unpredictable
Policy and Law
• Laws are set standards, principles, and
procedures made for ensuring justice in society
• Policies can be called a set of rules that guide
the actions of government or any organization
• Policies are only documents not laws
• Policies must comply with the laws
• Enforcement of law is mandatory but for policy
this is not applicable
Policy and Plan
• Plan is a course of action intended for future
• Policy is a set of rules and regulations. It is set of
future actions which are needed to achieve a specific
objective. It is a set of principles which are needed to
govern the future actions
• Plans are made within the boundary of the policies
• Policy is the guideline to achieve the objective.
Planning is about making plans on how to achieve the
objective
• Plans are made at all levels from strategic level to
operational level but policy is made by the senior level
management
Thanks