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2.8.1 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512.8.2 The life course perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522.8.3 Life course and social class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532.8.4 Life course perspective in the study of population health. . . . . . . . . . . . . . 542.8.5 The life course health development framework . . . . . . . . . . . . . . . . . . . . . . 552.9. Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602.9.1 Core culture and subcultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 622.9.2 Culture and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632.9.3 Anomie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 632.10 Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642.11. Social change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672.11.1 Sources of social change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672.11.2 Modernity and Postmodernity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682.11.3 Globalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683 SOCIAL DETERMINANTS OF HEALTH AND DISEASE(Michaela Kostičová) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723.1 The history of social determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733.2 Models of social determinants of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743.2.1 The Dahlgren and Whitehead health determinants model . . . . . . . . . . . . . . 743.2.2 WHO Commission on Social Determinants of Health framework . . . . . . 783.3 Social determinants and health inequities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803.3.1 Mechanisms to social inequities in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 813.3.2 Socioeconomic and political context of health inequities . . . . . . . . . . . . . 833.3.3 Social determinants and health inequities between and withincountries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853.4 Recommendations on social determinants of health inequities in Europe. . . . . 894 MEASURING THE HEALTH OF THE POPULATION(Michaela Kostičová). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934.1 Health information system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 934.2 Demography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 964.2.1 Demographic data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 964.2.2 Demographic static. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994.2.3 Population changes – demographic dynamics . . . . . . . . . . . . . . . . . . . . . . . . 1014.2.4 Demographic trends and their implications for health and health care. . . 1114.3 Measures of population health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134.3.1 Life expectancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134.3.2 Summary measures of population health – HALE, DALYs . . . . . . . . . . . . . . 1144.3.3 Quality of life and health-related quality of life measures . . . . . . . . . . . . . 1224.3.4 Human development index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1245 HEALTH POLICY (Darina Sedláková). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1295.1 Health in foreign policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1305.2 Health policy and public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1315.3 Governance for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1335.4 Establishing health policy in a global society (Leonard Levy, Anthony Silvagni,Cecilia Rokusek) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1356

6 HEALTH SYSTEMS (Michaela Kostičová). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1436.1 Health financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446.1.1 Fiscal and health expenditure context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1446.1.2 Health financing functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1466.2 Typology of health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1506.2.1 The national health service (Beveridge model) . . . . . . . . . . . . . . . . . . . . . . 1506.2.2 The social health insurance model (Bismarckian model) . . . . . . . . . . . . . . 1516.2.3 The national health insurance model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516.2.4 Private health system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516.3 Health system in Slovakia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1537 COORDINATION/INTERGRATION OF HEALTH SERVICES DELIVERY(Darina Sedláková) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1577.1 Aims and benefits of CIHSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1597.2 CIHSD in practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1597.3 Improving health outcomes through the CIHSD . . . . . . . . . . . . . . . . . . . . . . . . . . 1608 QUALITY IN HEALTH CARE (Michaela Kostičová). . . . . . . . . . . . . . . . . . . . . . 1638.1 Definitions of quality of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1638.2 Dimensions of quality of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1648.3 Quality management in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1668.3.1.Quality measurement in health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1668.3.2 Quality assurance and quality improvement in health care . . . . . . . . . . . 1688.4 External models of quality management in health services . . . . . . . . . . . . . . . . 1688.4.1 ISO model – ISO 9000 standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1688.4.2 EFQM Excellence Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1698.4.3 Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1709 EXAMPLE PUBLIC HEALTH STRATEGY – STRATEGY TO COMBATTUBERCULOSIS (Ivan Solovič). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1739.1Global level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1739.2 Regional level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1789.3 National level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1799.4 Local level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1807

PREFACEThe social medicine as a scientific and interdisciplinary branch of medicine dealingwith the health of the population in broader social context is the concern of all healthprofessionals. This textbook is a study guide and makes no attempt to be a comprehensive description of social medicine. It was written to provide a framework for understanding this complex field. Our goal is to introduce students to the ‘social medicineperspective’, to provide them the holistic picture as well as to introduce them to themany specialized aspects of social medicine and to allow the students to start to placetheir practice within the wider social context of health, and determinants of health, ofthe community in which they work. The chapters cover topics which we hope will enable this goal to be achieved. Though the textbook is primarily written for undergraduate students of Master of Public Health program, it would be of use to medical studentsand postgraduate students as well.The textbook is divided into 9 chapters. The first chapter deals with the history ofsocial medicine and its scope and focuses on the concepts of health and disease, theirrelation to quality of life and determinants of health. The second chapter “Sociology”provides an overview of the basic terminology, concepts, principles and methods ofthe discipline in relation to the health of individuals and communities. The social determinants as the causes of health inequalities are discussed in the third chapter. Thefourth chapter deals with the demography as the basis for the assessment of the healthstatus of the population and special attention is also paid to the most commonly usedobjective as well as subjective measures of the population health. The way how healthcare is managed, organized and financed also influences the health of the population.The chapters five and six focus on health policy, health financing and health systemsand their role in shaping the health of the population. Organization and managemet ofhealth services is discussed in the seventh and eighth chapter with the focus on qualitymanagement and coordination and integration of health services. The last chapter is anexample of public health strategy for how to combat the current global public healththreat – the tuberculosis – on the global, regional, national and local levels.Michaela Kostičová9

1 INTRODUCTION TO SOCIAL MEDICINEMichaela Kostičová1.1 What is Social Medicine?Social medicine is a scientific, interdisciplinary branch of medicine that studies thehealth of the population and the system of health care in broader social context (Figure1.1). Social medicine contributes to understanding the determinants of healthand how best to apply that knowledge to improve the health of the population.Social medicine as part of public health is orientated towards health problems ofpopulation groups, their characteristics and determinants and the possibility of theircontrol. The scientific and methodological base of social medicine is primarily epidemiology together with biostatistics as well as social psychology, sociology, law, economy,managerial sciences, philosophy and history.Social medicine is based on three fundamental questions:1. What is the health of the population?2. Why is it so?3. How to improve health?Figure 1.1 Study and analysis of health status in relation to health care and health system inbroader social environment contextSource: Holčík, 200510

Social environment is as important as the physical and biological environmentin relation to health and disease. The effect of social environment on health is clearlyreflected in the differences in the health of the populations between and within countries. In view of the variety of the factors involved, it may be more appropriate to usethe term psychosocioeconomic environment. This environment is unique to manand includes cultural values, customs, habits, beliefs, attitudes, morals, religion, education, income, occupation, standard of living, community life and the social and politicalorganizations.The aims of social medicine are: To study man as a social being in relation to his total environment (social and physical); To pay particular attention to those forces in the socioeconomic sphere that directly or indirectly affect individual and population health.Over time the term “social medicine” took on varied meanings as it was adapted todifferent societies and diverse social conditions. Nonetheless, certain common principles, which were formulated in the nineteenth century by R. Virchow and his colleagues, underlie the term:1. Social and economic conditions profoundly impact health, disease, and the practice of medicine.2. The health of the population is a matter of social concern.3. Society should promote health through both individual and social means.As was published by Sidney and Emily Kark, two physicians who practised socialmedicine in the first community health-oriented center in South Africa established in1940, “Social medicine is interested in the health of people in relation to their behaviour in social groups and as such is concerned with care of the individual patient as amember of a family and of other significant groups in his daily life. It is also concernedwith the health of these groups as such and with that of the whole community as a community”.The task of teaching social medicine is to build a set of concepts and skills for the students that will enable them to ask the right questions and to tackle the health problemsof the population they serve. But physicians cannot practice social medicine alone, theymust be part of a collaborating team drawn from a broad range of health professionalsand community groups. Professor W. Hobson in his article “What is social medicine?”published in the British Medical Journal in 1949 said and it is also true today: “In theteaching of medicine the accumulation of facts has been pursued, to the neglect of thestudy of man in his environment. The humanism of medicine is often lost in a welter oftechnical detail. Social medicine is a branch of medicine which provides a connectinglink with the wider humanities. Its philosophy should permeate all branches of medicine, for its implications cannot be divorced from any branch of medical learning”.1.2 History of Social MedicineOnly in the eighteenth century, largely through the fundamental work of Germanphysician and hygienist Johann Peter Frank (1745-1821), , widespread attention wasfinally paid to the influence that poor lifestyle and social conditions exerted on health.Frank called “poverty the mother of disease.” He described in the nine-volumes book acomplete system of “medical policy”, a forerunner of “public health”.The systematic study of the relationships between society, disease, and medicinebegan in the nineteenth century. Poor working conditions, periodic economic slumps,unemployment, lack of housing, and poverty and destitution all created an environ11

ment that had a significant impact upon people’s health. This study – and the forms ofmedical practice derived from it – became known as “social medicine”.The beginning of the history of social medicine is connected mainly with the namesof German and French physicians. During the revolutionary years of 1847 and 1848, theFrench doctor and orthopaedist Jules Guérin (1860-1910) published a series of articles in the medical journal called Medicine sociale describing the link between socialand health conditions and was the first to use the term social medicine.The founder of social medicine is considered to be Rudolf Virchow (18211902), one of the great pathologists of the nineteenth century, most notably contributing to the understanding of disease at the cellular level. He was also keenly aware of thesocial origins of illness. In 1848, while working as a staff physician at the Royal CharitéHospital in Berlin, he investigated an outbreak of typhus in the Prussian province of Upper Silesia. Virchow identified social factors, such as poverty and the lack of educationand democracy, as key elements in the development of the epidemic. The experienceled him to the concept of “artificial epidemics” arising in periods of social disruption.Virchow also wrote these often quoted sentences: “Medicine is a social science and politics nothing but medicine on a grand scale.” And, “If medicine is really to accomplish itsgreat task, it must intervene in political and social life.”Virchow’s understanding of the social origins of illness comprised the source of thebroad scope that he defined for public health and the medical scientist. Virchow alsoenvisioned the creation of a “public health service”, an integrated system of publiclyowned and operated health care facilities, staffed by health workers who were employed by the state.In the late nineteenth century the striking advances made in pathology and microbiology made social factors seem less germane in the aetiology of disease. In Europeancountries, with the defeat of political socialism in 1848, the interest in social medicinealso declined and was generally considered to be not relevant in the prevailing politicalclimate. Nevertheless, after the turn of the century, due to the increasing dissatisfactionwith the health care, particularly of the underprivileged segment of the population,more writers pointed at the social conditions as the cause. In Germany, Alfred Grotjahn (1869-1931), a general practitioner in the worker’s district of Berlin, was very influential in the preparation for the social changes that took place with the revolution of1918. His book on “Social Pathology” emphasized the aetiological relationship betweensocial condition and disease, and it advanced, even beyond the borders of Germany, theunderstanding and acceptance of social medicine as relevant for the practice of medicine. The results of his studies formed the basis for a new scientific branch which wasfirst termed Social Pathology and Social Hygiene and later Social Medicine.The interwar years witnessed a wide variety of international developmentsin social medicine as an academic discipline. Within international health organizations in the interwar years, supporters of social medicine as an academic disciplinetried to undermine any exclusive focus on clinical medicine and pushed towards muchbroader social agendas. From the time of its establishment, the governing committee ofthe League of Nations Health Organization (later World Health Organization) prioritized the development of social medicine. The international social medicine movement before the Second World War aimed to create a new social role for medicine in order to grapple with the epidemiological transition, from infectious to chronic diseases,created by economic and social developments in the twentieth century. The interdisciplinary program between medicine and social science would provide medicine withthe intellectual skills needed to analyze the social causes of health and illness.It is important to mention that also Latin America, during the twentieth century,developed one of the most active centers of social medicine. Two of its most prominent12

members – Salvador Allende and Che Guevara – are known primarily for their political engagement. In the 1930s, Allende, a public health physician, served as Chileanminister of health. He produced an analysis of the social origins of disease and sufferingin Chile. Che Guevara, an Argentinian physician, joined Fidel Castro’s insurrection inCuba, eventually becoming minister of the economy in the revolutionary government.Echoing Virchow, Che saw politics as medicine on a grand scale. Latin American socialmedicine developed a rich body of theoretical and practical work examining the relationship between health and society. It emphasizes praxis: developing a close relationship between theory and practice. Practitioners have been involved with communityorganizations, unions, and political movements; many others fell victim to political repression.In the United States, a broad concept of social medicine was also developed, however the term was not adopted by American medical schools because of the conservativeviews of the medical profession.After World War II, a strong movement for social medicine developed in the United Kingdom. The relation between health inequities and social conditions beganto be the matter of investigation in the 1980s and several studies, mainly Black reportand Whitehall study, from that period are considered to be the milestones in the history of social determination of health. They pointed out that social position in society isan important determinant of social inequities in health – the higher the social position,the better the health – and that this social gradient runs right across society. In the late1990s the social determinants and health equity were embraced as explicit policy concerns and we will focus on this topic in Chapter 3.1.3 Health and diseaseThe aim of social medicine is to improve the health of the population by understanding and influencing the determinants of health. To meet this goal, it is importantnot only to identify determinants of health, but also to analyze their effectiveness andto know the relation between them and the way they are influencing the health. If wewant to study the determinants of health and causes of diseases, we should answer several i

This textbook is from the series of textbooks listed below. The aim of the textbooks, funded by ESF-OPE, is to provide students of the study program Master of Public Health (MPH) at Comenius University in Bratislava with information and knowledge of public health issues. Biology and Genetics for Public Health