Description
Country is SOMALIA: This assignment asks you questions related to the economic context of your country with a special emphasis on health funding and health systems. Finances play a crucial role in public health and health systems: the amount of money invested into health care is likely a crucial determinant of services and the quality of services provided. Equally important is who pays for these services: are these government expenses, out-of-pocket costs or are international agencies funding large parts of the healthcare sector? In other words, who pays gives you an idea of how autonomous a country is or how big the burden on individuals is in case they fall ill.
Please label all figures included in your responses, including a brief descriptive title. Please include references/citations for each response below; these do not count towards your word limit.
Please respond to the guiding questions for each section below:
Section 1: What is the country’s general economic condition? Does it carry significant debt burden (e.g., % of GDP) and how does this impact the availability of services? (100-200 words, 1-2 figures) (4 points)
Tip: You can find information about national debt through the International Monetary Fund at site.. To analyze the impact on the availability of services you can go back to last week’s assignment.
Section 2: How reliant is the country on development assistance for health, meaning what percentage of total health funding comes from development assistance for health (DAH)? (50-100 words, 1 figure) (2 points)
Tip: The IHME Financing Global Health Tool provides helpful information on health funding and developmental assistance. https://vizhub.healthdata.org/fgh/Links to an external site.. Check out the `Spending sources` tab.
Section 3: How does the country’s debt burden impact the health systems sector? Does the government spend at least 15% of its GDP on health? Does the country benefit from external budget support or Highly Indebted Poor Countries (HIPC) initiatives? (50 -100 words) (3 points)
Tip: World Bank provides information on HIPC countries at https://www.worldbank.org/en/topic/debt/brief/hipcpart Section 4: Based on what you learned during the lectures and over the course of prior assignments, what types of changes with regards to health care and health systems would be most beneficial in your chosen country? (200-300 words) (6 points)
Tip: To answer this question, you will need to draw from the knowledge you gained during modules 3 to 6.
Rubric
Economic Context and Health Funding
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeSection 1- Describes country’s general economic condition and debt burden, including impact on health systems and services
– Provides 1-2 figures/tables with adequate labels
– Stays within word limits and cites references
4 pts
Full Marks
0 pts
No Marks
4 pts
This criterion is linked to a Learning OutcomeSection 2- Describes country’s reliance on development assistance for health, including data (% of total health funding from DAH)
– Provides 1 figure (adequately labeled) and stays within word limits
– Adequately cites references
2 pts
Full Marks
0 pts
No Marks
2 pts
This criterion is linked to a Learning OutcomeSection 3- Discusses how the country’s debt burden impacts the health systems sector.
– Describes the % of GDP spent on health.
Describes the role of external budget support or Highly Indebted Poor Countries (HIPC) initiatives in the country
– Provides 1 figure with adequate labels.
– Stays within word limits and cites references.
3 pts
Full Marks
0 pts
No Marks
3 pts
This criterion is linked to a Learning OutcomeSection 4- Discussion of specific interventions/types of interventions that would benefit the country
– Provides rationale for suggested intervention(s) and discusses their strengths and limitations
– Provides 1 figure and stays within word limits
– Adequately cites references
below is the reading you will also refer to
Unformatted Attachment Preview
The Social Determinants of Health: It’s Time to Consider the Causes of the Causes
Author(s): Paula Braveman and Laura Gottlieb
Source: Public Health Reports (1974-) , JANUARY/FEBRUARY 2014, Vol. 129,
SUPPLEMENT 2: Nursing in 3D: Workforce Diversity, Health Disparities, and Social
Determinants of Health (JANUARY/FEBRUARY 2014), pp. 19-31
Published by: Sage Publications, Inc.
Stable URL: https://www.jstor.org/stable/23646782
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Public Health Reports (1974-)
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Nursing in 3D: Diversity, Disparities, and Social Determinants
The Social Determinants of Health: It’s
Time to Consider the Causes of the Causes
Paula Braveman, MD, MPHa
Laura Gottlieb, MD, MPHb
ABSTRACT
During the past two decades, the public health community’s attention h
drawn increasingly to the social determinants of health (SDH)—the factor
from medical care that can be influenced by social policies and shape he
in powerful ways. We use “medical care” rather than “health care” to ref
clinical services, to avoid potential confusion between “health” and “hea
care.” The World Health Organization’s Commission on the Social Determ
nants of Health has defined SDH as “the conditions in which people are
grow, live, work and age” and “the fundamental drivers of these conditi
The term “social determinants” often evokes factors such as health-related
features of neighborhoods (e.g., walkability, recreational areas, and accessibil
ity of healthful foods), which can influence health-related behaviors. Evidence
has accumulated, however, pointing to socioeconomic factors such as income,
wealth, and education as the fundamental causes of a wide range of health
outcomes. This article broadly reviews some of the knowledge accumulated to
date that highlights the importance of social—and particularly socioeconomic—
factors in shaping health, and plausible pathways and biological mechanisms
that may explain their effects. We also discuss challenges to advancing this
knowledge and how they might be overcome.
“University of California, San Francisco, School of Medicine, Department of Family and Community Medicine, Center on Social Disparities
in Health, San Francisco, CA
bUniversity of California, San Francisco, School of Medicine, Department of Family and Community Medicine, Center for Health and
Community, San Francisco, CA
Address correspondence to: Paula Braveman, MD, MPH, University of California, San Francisco, School of Medicine, Department
of Family and Community Medicine, Center on Social Disparities in Health, PO Box 0943, 3333 California St., Ste. 365, San Francisco, CA
94118-0943; tel. 415-476-6839; fax 415-476-5219; e-mail .
©2014 Association of Schools and Programs of Public Health
Public Health Reports / 2014 Supplement 2 / Volume 129 O 19
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20 O Nursing in 3D: Diversity, Disparities, and Social Determinants
A large and compelling body of evidence has accu- the country’s relative ranking has fallen over tim
mulated, particularly during the last two decades, that A recent report from the National Research
reveals a powerful role for social factors—apart from and Institute of Medicine has documente
medical care—in shaping health across a wide range U.S. health disadvantage in both morbidity
of health indicators, settings, and populations.1-16 This tality applies across most health indicat
evidence does not deny that medical care influences age groups except those older than 75 years
health; rather, it indicates that medical care is not the applies to affluent as well as poor Americans
only influence on health and suggests that the effects non-Latino white people when examined separ
of medical care may be more limited than commonly Other U.S. examples include the observat
thought, particularly in determining who becomes sick while expansions of Medicaid maternity care
or injured in the first place.4’6,7,1718 The relationships 1990 resulted in increased receipt of prenata
between social factors and health, however, are not African American women,36,37 racial disparities
simple, and there are active controversies regarding key birth outcomes of low birthweight and
the strength of the evidence supporting a causal role delivery were not reduced.38 Although import
of some social factors. Meanwhile, researchers increas- maternal health, traditional clinical pren
ingly are calling into question the appropriateness of generally has not been shown to improve
traditional criteria for assessing the evidence.17,19-22 in newborns.39″44
The limits of medical care are illustrated by the
work of the Scottish physician, Thomas McKeown,
THE IMPACTS OF SOCIOECONOMIC
who studied death records for England and Wales
AND OTHER SOCIAL FACTORS ON
from the mid-19th century through the early 1960s.
MOST HEALTH OUTCOMES
He found that mortality from multiple causes had
fallen precipitously and steadily decades before the A number of studies have attempted to
availability of modern medical-care modalities such impact of social factors on health. A review
as antibiotics and intensive care units. McKeown nis et al. estimated that medical care was re
attributed the dramatic increases in life expectancy for only 10%-15% of preventable mortalit
since the I9th century primarily to improved living U.S.;45 while Mackenbach’s studies suggest
conditions, including nutrition, sanitation, and clean percentage may be an underestimate, they affi
water.23 While advances in medical care also may have overwhelming importance of social factors.25,
contributed,23-26 most authors believe that nonmedical nis and Foege concluded that half of all
factors, including conditions within the purview of tra- the U.S. involve behavioral causes;18 other e
ditional public health, were probably more important;24 has shown that health-related behaviors are
public health nursing, including its role in advocacy, shaped by social factors, including income, edu
may have played an important role in improved living and employment.46,47 Jemal et al., studying
standards.27 Another example of the limits of medical death data, concluded that “potentially avoida
care is the widening of mortality disparities between tors associated with lower educational stat
social classes in the United Kingdom in the decades for almost half of all deaths among working-age
following the creation of the National Health Service in in the U.S.”48 Galea and colleagues conducted
1948, which made medical care universally accessible.28 analysis, concluding that the number of U.S.
Using more recent data, Martinson found that although in 2000 attributable to low education, racial
health overall was better in the United Kingdom than tion, and low social support was comparable wi
in the United States, which lacks universal coverage, number of deaths attributable to myocardial in
disparities in health by income were similar in the two cerebrovascular disease, and lung cancer, respec
countries.29 Large inequalities in health according to The health impact of social factors also is
social class have been documented repeatedly across by the strong and widely observed associations be
different European countries, again despite more a wide range of health indicators and meas
universal access to medical care.30-32 individuals’ socioeconomic resources or social
Another often-cited example of the limits of medi- typically income, educational attainment, or r
cal care is the fact that, although spending on medical an occupational hierarchy. In U.S. as well as Eu
care in the U.S. is far higher than in any other nation, data, this association often follows a stepwise
the U.S. has consistently ranked at or near the bottom pattern, with health improving incrementally
among affluent nations on key measures of health, such position rises. This stepwise gradient pattern
as life expectancy and infant mortality; furthermore, noted in the United Kingdom.28,50 Although
Public Health Reports / 2014 Supplement 2 / Volume 129
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SDH: Considering the Causes of the Causes O 21
on the socioeconomic gradient has been more limited enees in experience
in the U.S., the results of U.S. studies have mirrored are socioeconomic; f
the European findings. Figures 1-5 illustrate a few could harm the hea
examples using U.S. data, with social position reflected nomic levels by acting
by income or by educational attainment. Using national interactions, even in
data, the National Center for Health Statistics’ “Health, intent to discriminate.5
United States, 1998” documented socioeconomic gra- disparity in birth o
dients in the majority of numerous health indicators educated women.59
measured across different life stages.51 Braveman and legacy of racial dis
colleagues confirmed those findings using recent U.S. through psychobiologic
data.52 Both Pamuk et al.51 and Braveman et al.52 found discriminatory incide
that socioeconomic gradient patterns predominated How do widespread
when examining non-Latino black and white groups gradients in health
but were less consistent among Latino people. Minkler tors are important inf
and colleagues found dramatic socioeconomic gradi- between poverty and
ents in functional limitations among people aged 65-74 centuries.63″65 Ob
years. This finding is particularly remarkable because opposed to a simple th
income gradients generally tend to flatten in old age.53 erty line) of socioecon
As illustrated in Figure 5, and in both Pamuk et al.51 health indicators sugge
and Braveman et al.,52 these socioeconomic gradients tionship, adding to
in health have been observed not only in the U.S. factors—or factors clo
population overall, but within different racial/ethnic a causal role. Although
groups, demonstrating that the socioeconomic differ- health are rarely dispu
enees are not explained by underlying racial/ethnic the effects of incom
differences. Indeed, most studies that have examined the socioeconomic s
racial/ethnic differences in health after adjusting for income-health or educ
socioeconomic factors have found that the racial/ reverse causation (i.e.,
ethnic differences disappeared or were substantially and/or lower educationa
reduced.54″56 This does not imply that the only differ- health often results
Figure 1. Life expectancy in the U.S. at age 25, by education and gender, 2006a
Educational attainment
■ Less than high school
■ High school graduate
60.3
■ Some college
■ College graduate
Men
Women
“Source:
Department
of
Health
on
socioeconomic
status
and
he
www.cdc.gov/nchs/data/hus/2
the
Robert
Wood
Johnson
Fou
Public Health Reports / 2014 Supplement 2 / Volume 129
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22 O Nursing in 3D: Diversity, Disparities, and Social Determinants
Figure 2. Infant mortality rate in the U.S., by mother’s education, 2009a
Educational attainment
■ Less than high school
■ High school graduate
■ Some college
■College graduate
“Source: Mathews TJ, MacDorman MF. Infant mortality statistics from the 2009 period linked birth/infant death dataset. Natl V
2013;61:1-28. Also available from: URL: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf [cited 2013 Feb 14]. Reporte
P, Egerter S. Overcoming obstacles to health in 2013 and beyond: report for the Robert Wood Johnson Foundation Commissio
Flealthier America. Princeton (NJ): Robert Wood Johnson Foundation; 2013.
health could limit educational achievement, evidence the effects of socioeconomic factors that a
from longitudinal and cross-sectional studies indicate “upstream” (i.e., closer to underlying or f
that these do not account for the strong, pervasive causes)76 from their health effects
relationships observed.67 Links between education and stream” (i.e., near where health effects a
health, furthermore, cannot be explained by reverse
causation because once attained, educational attain- MULTIPLE MECHANISMS EXPLAIN
ment is never reduced.
The aforementioned evidence reflects associations
IMPACTS OF SOCIOECONOMIC AND
OTHER SOCIAL FACTORS ON HEALTH
that by themselves do not establish causation. However,
the observational examples cited as illustrations are Despite countless unanswered questions, kno
backed up by extensive literature employing a range the pathways and biological mechanisms co
of techniques (e.g., multiple regression, instrumental social factors with health has increased expone
variables, matched case-control designs, and propensity during the past 25 years. Mounting evidence
score matching) to reduce bias and confounding due causal relationships between many social—
to unmeasured variables.34’71719 This knowledge base socioeconomic—factors and many health o
is also enriched by natural experiments,3,36,68,69 quasi- not only through direct relationships but also
experiments,70 and some, albeit limited, randomized more complex pathways often involving b
controlled experiments.71″74 The overwhelming weight cial processes.77
of evidence demonstrates the powerful effects of socio- Some aspects of socioeconomic factors
economic and related social factors on health, even nected to health via responses to relatively
when definitive knowledge of specific mechanisms rapid-acting exposures. For instance, lead i
and effective interventions is limited. Accumulated in substandard housing contributes to low
knowledge also reveals, however, that the effects of any function and stunted physical development in
given social (including socioeconomic) factor are often children;78,79 pollution and allergens, also mo
contingent on a host of other factors.17,75 The third mon in disadvantaged neighborhoods, can exac
section of this article discusses challenges in studying asthma.80,81 Socioeconomic and other social fa
Public Health Reports / 2014 Supplement 2 / Volume 129
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SDH: Considering the Causes of the Causes O 23
may contribute to worse health through pathways that outlets and few recreati
play out over relatively short time frames (e.g., months to poorer nutrition and l
to a few years) but are somewhat more indirect. Fac- health consequences of the
tors affecting the social acceptability of risky health these conditions generally
behaviors are a case in point. For instance, exposure The strong and perva
to violence can increase the likelihood that young socioeconomic factors a
people will perpetrate gun violence;82 and the avail- can reflect even more
ability of alcohol in disadvantaged neighborhoods can ways, which may or may
influence its use among young people, affecting rates as key mediators or mode
of alcohol-related traumatic injury.83 Socioeconomic showed that the associat
factors can influence sleep, which can be affected by hood poverty and adu
work, home, and neighborhood environments, and to be explained not only
which can have short-term health effects.84’85 Working deficits, but also partly
conditions can shape health-related behaviors, which, Cutler et al. described wid
in turn, may impact others; for example, workers with- by educational achievem
out sick leave are more likely to go to work when ill, behavioral risk factors su
increasing the likelihood of disease spread to cowork- Children growing up
ers or customers.86 taged neighborhoods face greater direct physical chal
In addition to these relatively rapid health impacts, lenges to health status and health
the effects of socioeconomic and other social factors they also often experience emotion
on health-related behaviors can influence disease stressors, such as family conflict a
outcomes that only manifest much later in life. from chronically inadequate reso
Neighborhood socioeconomic disadvantage and depression, anxiety, and other negative emotional
higher concentration of convenience stores have been states, however, has not completely explained the
linked to tobacco use, even after adjusting for several effects of social factors on health.92
individual-level characteristics, such as educational Several recent reviews93″98 have described the bio
attainment and household income.87 Lower availability logical “wear-and-tear” resulting from chronic expo
of fresh produce, combined with concentrated fast-food sure to social and environmental stressors, commonly
Figure 3. U.S. children aged
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