Throughout history, knowledge and practices on the health of populations have had different names: medical police, public health, social medicine, community health, and preventive medicine. To what extent is the Brazilian collective health, established in the 1970s, identified with and differentiated from these diverse movements that preceded it? The analysis of the socio-genesis of a social field allows us to identify the historical conditions that made possible both theoretical formulations and the achievement of technical and social practices. Collective health, a product of transformations within the medical field, constituted a rupture in relation to preventive medicine and public health and hygiene, being part of a social medicine movement in Latin America that, in turn, had identification with European social medicine in the 19th century. Focused on the development of a social theory of health that would support the process of sanitary reform, collective health has been built as a space involving several fields: scientific, bureaucratic, and political. Thus, it brought together health professionals and social scientists from universities, health care services, and social movements. Its scientific subfield has developed, and the sanitary reform project has had several successes related to the organization of a unified health system, which has ensured universal coverage for the population in Brazil. It has incorporated into and dialogued with several reformist movements in international public health, such as health promotion and the pursuit of health equity. Its small relative autonomy stems from subordination to other dominant fields and its dependence on the state and governments. However, its consolidation corresponded to the strengthening of a pole focused on the collective and universal interest, where health is not understood as a commodity, but as a right of citizenship.
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Collective Health: Theory and Practice. Innovations From Latin America
Ligia Maria Vieira-da-Silva
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Social Welfare in India
Shrivridhi Shukla and Arpita Gupta
India’s rapid economic growth is accompanied by economic inequality, poverty, and a range of social issues, thus, raising important questions concerning the breadth and depth of social protection and promotion policies prevalent in the country. The social welfare system in India is different for the formal and informal sectors of the economy. It consists of two largely parallel systems. With respect to the formal economy or the organized sector, it operates directly through the government, state-owned enterprises, and/ or private corporations that provide reasonably strong social protection to their employees through mandatory legislations spanning aspects such as payment of gratuity, employees’ provident fund, and the employees’ state insurance fund. In contrast, the informal or the unorganized sector is covered through a fragmented system of welfare schemes and benefits provided by the central government and the respective state governments.
Along with tracing the historical evolution of India’s welfare system, this article outlines the constitutional place of welfare in the country. With respect to the informal sector of the economy, it provides an overview of some of the key promotion and protection-orientated welfare policies and schemes, including those that address poverty, unemployment, education, health and food insecurity. Further, it discusses the barriers experienced by people in accessing welfare benefits, such as corruption and bureaucratic hurdles, and challenges faced by the government in welfare provision, such as scale of operation and identification of the target population groups. Finally, it assesses the country’s welfare system in light of the Global Social Protection Floor Initiative of the ILO-UN.
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Economic Evaluation of Medical Devices
Michael Drummond, Rosanna Tarricone, and Aleksandra Torbica
There are a number of challenges in the economic evaluation of medical devices (MDs). They are typically less regulated than pharmaceuticals, and the clinical evidence requirements for market authorization are generally lower. There are also specific characteristics of MDs, such as the device–user interaction (learning curve), the incremental nature of innovation, the dynamic nature of pricing, and the broader organizational impact. Therefore, a number of initiatives need to be taken in order to facilitate the economic evaluation of MDs. First, the regulatory processes for MDs need to be strengthened and more closely aligned to the needs of economic evaluation. Second, the methods of economic evaluation need to be enhanced by improving the analysis of the available clinical data, establishing high-quality clinical registries, and better recognizing MDs’ specific characteristics. Third, the market entry and diffusion of MDs need to be better managed by understanding the key influences on MD diffusion and linking diffusion with cost-effectiveness evidence through the use of performance-based risk-sharing arrangements.
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The Evolution of Transgender Policies in the United States
Emilia Lombardi
In the United States, increasing numbers of transgender people are coming forward and working to change legislation to better protect their lives and identities. These changes have come over a long period of time with the work of transgender people and allies. Societal acceptance and support for transgender people has evolved, first in the provision of medical resources allowing for physical changes, and later in legislation supporting and protecting people’s ability to publicly and legally express their gender. However, these changes have not been always been to benefit transgender people as others sought to control and limit people’s ability to express nonnormative genders. Policy changes occur in reaction to transgender people, but at the same time, transgender people have been working to allow themselves the freedom to express their genders freely.
Major changes first began when scientists and medical professionals became interested in medical technologies such as hormones and its affects on people’s bodies. It was these discoveries that also interested people who felt dysphoric about their gender expression and saw these procedures as being able to reduce their pain and improve their lives. The movement to utilize surgical techniques soon followed. As more people sought these services, medical professionals developed guidelines to identify those who would benefit from the procedures and how to utilize these technologies safely to help people transition from one gender to another. As more people were able to transition, policies arose to prevent or limit people’s ability to express their identity, but transgender people and allies also organized to counter this movement and propose policies that are more supportive and protective for them.
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Financial Protection Against Medical Expense
Owen O'Donnell
Financial protection is claimed to be an important objective of health policy. Yet there is a lack of clarity about what it is and no consensus on how to measure it. This impedes the design of efficient and equitable health financing. Arguably, the objective of financial protection is to shield nonmedical consumption from the cost of healthcare. The instruments are formal health insurance and public finances, as well as informal and self-insurance mechanisms that do not impair earnings potential. There are four main approaches to the measurement of financial protection: the extent of consumption smoothing over health shocks, the risk premium (willingness to pay in excess of a fair premium) to cover uninsured medical expenses, catastrophic healthcare payments, and impoverishing healthcare payments. The first of these does not restrict attention to medical expenses, which limits its relevance to health financing policy. The second rests on assumptions about risk preferences. No measure treats medical expenses that are financed through informal insurance and self-insurance instruments in an entirely satisfactory way. By ignoring these sources of imperfect insurance, the catastrophic payments measure overstates the impact of out-of-pocket medical expenses on living standards, while the impoverishment measure does not credibly identify poverty caused by them. It is better thought of as a correction to the measurement of poverty.
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Health Care Reform
Cynthia Moniz, Stephen H. Gorin, and Terry Mizrahi
National health care reform in the United States, from its introduction into the public policy agenda at the turn of the 20th century through policy debates and legislative proposals more than a century later, has achieved limited success with universal coverage for health and mental health services. Opposition to government-sponsored health care has always been present. The extent of the opposition has depended on the type of reform proposed and the era in which it occurred. Medicare and Medicaid reform in the 1960s greatly expanded access and coverage for older adults and low income individuals and families. But, the first true effort to reach universal coverage occurred with the passage of the Affordable Care Act in 2010.
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Health Care Social Work
Shirley Otis-Green
Health social work is a subspecialization of social work concerned with a person's adjustment to changes in one's health and the impact this has on that person's social network. Social workers in every setting must be ready to assist individuals and families adjusting to illness and coping with medical crises. This entry provides a brief overview and history of health social work and describes the settings and roles where this work is practiced. Significant challenges and opportunities in clinical care, research, education, and policy are discussed. Standards and guidelines for quality practice are then noted.
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Improving Post-Acute Care Quality for Older Adults in the U.S.: Nursing Homes and Beyond
Caroline P. Thirukumaran and Brian E. McGarry
Medical and surgical post-acute care (PAC) encompasses the rehabilitative and palliative health services that individuals typically receive following a stay in an acute care hospital and is a critical source of post-hospitalization care for Medicare-insured patients undergoing surgeries such as hip and knee replacements, or with medical conditions such as septicemia or severe sepsis. PAC, commonly delivered through skilled nursing facilities (SNFs), has long been prone to quality issues, and national policies are routinely reformed to improve their quality. Yet reform initiatives are often hampered by challenges related to the measurement of quality and the way in which PAC, especially in SNFs, is financed. Moreover, the lack of clear guidelines about the optimal PAC setting (e.g., institution vs. home) and the clinical and social characteristics of patients that may benefit from a particular setting has resulted in PAC being a source of wasteful spending. These challenges have been heightened by extensive payment reforms following the passage of the Patient Protection and Affordable Care Act and the COVID-19 pandemic. These changes have the potential to upend the status quo of the PAC business model, with wide-ranging potential implications for older adults’ access to high-quality rehabilitative care. The determination of value in PAC settings has commonly used Medicare claims and assessment data; focused on metrics such as readmissions, length of stay, spending, and transition to the community; and relied on reporting through the Care Compare website. The advances in PAC-focused reforms and the growing emphasis on care coordination have motivated promising initiatives such as standardization of metrics across PAC settings; the use of accountable care organizations and episode-based bundled payments for PAC reimbursement; the use of telehealth; and other innovations that are positioned to encourage the delivery of high-quality rehabilitative care.
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Religion, Aging, and Public Health
Jeff Levin and Ellen Idler
Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology.
Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.
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Public Health and the UN Sustainable Development Goals
Claire E. Brolan
The COVID-19 crisis—the most catastrophic international public health emergency since the Spanish influenza 100 years ago—provides impetus to review the significance of public and global health in the context of Sustainable Development Goal (SDG) achievement. When countries unanimously adopted the 17 SDGs in September 2015, stakeholders had mixed views on global health goal SDG 3 (Good Health and Well-Being). Concern arose over the feasibility of achieving SDG 3 by 2030 when countries pursued its nine targets and four means of implementation with sixteen other ambitious global goals. Nonetheless, health surely cuts across the SDG framework: for instance, the underlying health determinants are expressed in many goals as is urban and planetary health. Although health (and its different constructions) is central to overall SDG achievement, SDG success depends on a paradigm shift toward whole-of-government policy and planning. Indeed, the 2030 Agenda echoes calls for a Health in All Policies (HiAP) approach to public health programming. This depends on another paradigm shift in public health tertiary education, practitioner training, and policy skills development within and beyond ministries of health. Added to this are the underlying problematics around SDG health financing, human resources for health, health target and indicator localization for equitable country responses that leave no one behind, strengthening civil registration and vital statistics systems for inclusive and accountable health implementation, and the sidelining of human rights from SDG metrics. While COVID-19 has derailed SDG efforts, it could also be the ultimate game changer for intergenerational human and environmental health transformation. Yet strong global health governance and rights-based approaches remain key.
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Health Workforce: Situations and Challenges in Latin America, the Caribbean, and Brazil
Maria Helena Machado, Renato Penha de Oliveira Santos, Pedro Miguel dos Santos Neto, Vanessa Gabrielle Diniz Santana, and Francisco Eduardo de Campos
The greatest challenge in the development of universal health systems worldwide is to increase organization, training, and regulation of the health workforce (HWF). To accomplish this, the World Health Organization (WHO) has pointed out several strategies utilized since the beginning of the 2000s.
One of the world regions with the greatest internal HWF disparities is the Americas, more specifically Latin America and the Caribbean. Brazil is another of the countries in this region that presents great inequities in its HWF distribution, although its Unified Health System (Sistema Único de Saúde, or SUS), created after 1988, is one of the largest universal health systems in the world. It is worth noting that Latin America, the Caribbean, and Brazil historically have high levels of social inequality and have recently become regions severely affected by the COVID-19 pandemic.
Despite some advances in the formation and distribution of HWF in Latin America and the Caribbean in the last 10 years, structural problems persist in the health systems of several countries in this region, such as Brazil. The COVID-19 pandemic aggravated some problems such as the distribution of specialized health workers in intensive care units and the precarious working conditions in several public health services that were organized to face the pandemic.
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Indigenous Health Policy
Ian Anderson and Kate Silburn
The United Nations estimates that there are more than 476 million Indigenous peoples across the globe, which is almost 7% of the world’s population. Although Indigenous peoples are defined in a variety of political and cultural ways, there is increasing recognition of the seven defining criteria for indigeneity as set out by UN Permanent Forum on Indigenous Issues. Globally, Indigenous peoples tend to do less well than benchmark populations in health and social outcomes—although the degree of difference varies markedly between countries.
Of the vast range of different in-country policy and service responses that address these inequalities, the collection of accurate and relevant data on Indigenous peoples is key to monitoring their health outcomes.
Health and data researchers and policymakers have advocated for stronger Indigenous governance of both the data and health system responses. To achieve this, they have increasingly engaged a variety of global governances systems. Principally, but not exclusively, this advocacy has targeted UN mechanisms such as the Permanent Forum on Indigenous Issues and the Human Rights Council Expert Mechanism on the Rights of Indigenous Peoples.
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Health for All and Primary Health Care, 1978–2018: A Historical Perspective on Policies and Programs Over 40 Years
Susan B. Rifkin
In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning.
Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.
