Faculty of Civil and Environmental

Engineering

Institut Teknologi Bandung

Anindrya Nastiti

anindrya@gmail.com

Health is not simply about individual behavior or exposure

to risk, but how the socially and economically structured

way of life of a population shapes its health

• Photo here

Context of Sociosphere

Demography and Public Health

Parameter of Sociosphere

Socio-borne Disease

Role of Women

Management

HUMAN

• Tool-making hands

• Stereoscopic view

ANIMAL

• Instinct

• Social - genetic

• The social environment refers to how people and communities

behave, their relationships, education and

occupation, and the conditions in which they live.

• It is important to note that elements of the social environment

overlap and interact with the natural environment.

• Poverty tends to increase people’s reliance on the natural

environment and may heighten the vulnerability to

environmental degradation.

• We do not know l we do not care

• 3 types of cultures

• Improving health

• Neutral

• Deteriorating health

River for raw water source

Toxic wastes is discharged

into the river

WHOSE

DECISIONS ARE

THEY ?

Dumping solidwaste in

water bodies is a

common practive in

developing countries

..also with this ‘common

practice’

Populations are dynamic, diverse,

heterogeneous

Demographic characteristics have major

impact on health

• the science that studies human population

• (Demos = population, Graphy = picture).

• Pure demography is largely concerned with answering questions

about how populations change and how these changes can be

measured.

• The broader field of population studies embraces the questions

of why these changes occur, and with what consequences.

Size Composition Distribution

• The health and health-care needs of a population cannot be measured or met without a knowledge of its size and characteristics.

• Demography is concerned with this essential ‘numbering of the people’ and with understanding population dynamics—how populations change in response to the

interplay between fertility, mortality, and migration.

• A prerequisite for making the forecasts about future

population size and structure which should underpin

healthcare planning.

• Health status of a community depends upon the dynamic

relationship between number of people, their composition&

distribution

• Planning of health services can be guided by demographic

variables, for example:

• How many health units do we need?

• How to distribute them in the community in order to be accessible to the

target population?

• What type of manpower is needed?

..is important because

• it is the base for many vital statistics.

• It has to be related to a place and a specific time.

• It takes an additional meaning when density ( number of the

population per km2) is taken into consideration

• A census is the enumeration at specific time of individuals

comprising the population within an area

• 1- De facto

• 2- De jure

De facto

• counting individuals wherever they actually are on the day the census is conducted.

• The de facto census is much easy, less expensive and more economic to apply than de-jure type.

The disadvantages include

• 1- Persons in transit may not be included

• 2- Provision of incorrect picture of the population

• 3- Vital rates may be distorted

De jure

• counting individuals at their legal permanent residence regardless to whether or not they are physically present at the time of the census.

• It gives a true figure.

The disadvantages include

• 1- Expensive in time and money

• 2- Some individuals may be counted twice

• 3- Information may be incomplete

• A bar graphs, one showing the number of males, the other showing the number of females. The bars represent age bands of 5 year-intervals.

Importance of studying population pyramids

• 1-indicate the stage of development that a certain country has reached.

• 2-indicate birth, mortality rates, life span, migration and wars.

• 3-indicate dependency rate

Developing countries Developed countries

Wide (high BR) Narrow ( Low BR) Base

Sloping.

(high mortality)

Not sloping (Straight ).

(low mortality )

Side

Short

(Low life expectancy)

Tall

(high life expectancy).

Height

Narrow

(few people survive to

old age)

Wide

(large numbers of people

> 60.

Apex

Low ( High births) High (low birth)

Median Age

Low High Old dependency

ratio

High Low Young dependency

ratio

Comparison between the Pyramids of developing & developed Countries

• Fertility is the actual reproductive performance of a woman or a group of women. A woman's reproductive period is roughly from 15 to 49 years of age.

• Fertility means the child-bearing performance of a woman, couple, or population. Generally only live births are included.

• Fertility indicators

• Crude birth rate

• General fertility rate

• Age specific mortality rate

• Total fertility rate

CHILDREN = UTILITY, COST vs CHILDREN = INVESTMENT

• The Crude Birth rate= The total number of live births in a year & locality X 1000

• CBR is a crude index of fertility as it relates births to total population

• Factors affecting the Live births

• Number of females specifically those 15-49 years

• The age of marriage

• Level of infant and preschool mortality rates

• Socioeconomic level of the country

• Economic value of children and lower expenses of rearing children

• Cultural and religious factors

• Knowledge, attitudes and motives for adopting or rejecting family planning

• Calculated as such, this rate represents the average number of

children a woman would have, if she passed through her

reproductive years bearing children at the same rates (of a

specific year) as the women in each age group.

• TFR =….children born/numbers of woman

• In developed countries the TFR is under 2.0. In developing

countries the TFR is over 6.0 per women.

• They are utilized in deciding priorities for health action, in

designing intervention programs and in the assessment of public

health problems and plans.

• = … Deaths/1000 individual in the specified year and locality.

• Population growth is obviously a function of the balance of

births and deaths and the extent of net migration.

• Most of this growth has been in the developing world where

currently about 98% of world population increase takes place (Population Reference Bureau 1999; UNFPA 1999).

• Many European countries are expected to experience real falls

in population size between 1998 and 2050, by which latter

date approaching a quarter of their populations will be aged

65 or more (US Bureau of the Census 1992; UNFPA 1999).

Growth rate (GR) = RNI + Net migration rate

• Stable population = have a fixed age structure (in which the proportion in each age group remained unchanged) and would grow at a constant rate

• Stationary population —one in which birth and death rates are constant and in balance and so population growth is zero theoretical constructs

From: Joseph A. McFalls, Jr. Population: A lively introduction, 5th ed, Population Reference Bureau Population Bulletin; 62(1), March 2007.

Source : UN

The Great Leap

The human population curve looks virtually identical to that of

virtually every other animal. Yet we no longer have the

predators, disease, or even intraspecific competition to keep our

population under control and lead to a dynamic equilibrium.

That begs the question, will our population succumb to density

dependent factors and crash or will we achieve an equilibrium

through an as yet unexplained factor

Hi CBR = Hi CDR ‘ High Stationary ‘

‘ Epidemics, Famine, Predators ‘

CBR > CDR ‘ Expanding Phase ‘

Agricultural Rev.

Industrial Rev.

CBR < CDR ‘ Low Stationary Phase ‘

- Insectisida

- Vaccines

- Antibiotics

Death Rate

Constant Birth Rate

No Food Supply

Famine

• Many populations in developed countries now have fertility at

or below the level required for long-term replacement, average

expectations of life at birth of 75 years or more, and near

universal survival to the end of the (female) reproductive span.

• Mortality changes are now the main motor of the further ageing

of the populations of a number of developed countries with

already old age structures (Preston et al. 1989).

A huge range of social, economic, cultural, and psychological

factors may influence decisions about family building strategies

and family size.

the proportion of women married (exposed to risk)

contraceptive use

induced abortion

postpartum non-susceptibility to conception (largely determined by breastfeeding practice).

• Substantial falls in death rates from infectious and parasitic diseases,

bronchitis, influenza, pneumonia, diarrheal diseases, and maternal

mortality are all the hallmark of the epidemiological transition.

• The decline in these causes of death, from which the young benefited

more than the old, and women more than men, meant that deaths at

older ages accounted for a larger share of all deaths.

• Chronic degenerative diseases, notably circulatory diseases and

cancers, are the predominant causes of death in low mortality

populations in all of which women live longer than men. As the risks of

degenerative disease are strongly age-related, relatively more

people are exposed to these risks in populations with old or ageing

structures.

From: Joseph A. McFalls, Jr. Population: A lively introduction, 5th ed, Population Reference Bureau Population Bulletin; 62(1), March 2007.

• Improved nutrition, better housing and living conditions, public

sanitation schemes, and specific public health initiatives, such as

smallpox inoculation and vaccination, all have their particular

adherents (Coleman and Salt 1992).

• A common thread linking most of these factors is their

relationship to overall social and economic development and

improvements in standards of living.

• During the twentieth century, developments in medical

technology and pest control offered the potential for

‘exogenous’ mortality decline less dependent on a particular

country’s level of income and development.

• In the developed world differentials in health-related behavior

are also strongly associated with income and education.

• In England, some 40% of men in households headed by an

unskilled worker smoke cigarettes, compared with 12% of men

from professional groups (Prescott-Clarke and Primatesta

1997).

• It has also been argued that societal factors—such as the extent

of income inequalities and degree of social cohesion—may

account for some of the differences in the overall level of

mortality (Wilkinson 1996).

• In all developed and the great majority of developing

countries, female life expectancy is now greater than male

• Waldron (1985) suggested :

• declines in causes of death specifically or primarily affecting

women (such as maternal mortality and respiratory

tuberculosis),

• gender differences in health-related behavior

• exposure to occupational hazards

• possibly greater susceptibility of men to stresses associated

with socio-economic changes, as causal factors.

• Fertility is predominant influence on age structure

• This difference is the result of sustained downward trends in

fertility which reduce the proportion of children in more recently

born cohorts in the population and so lead to a corresponding

increase in the proportion of older people (survivors of larger

cohorts).

Population pyramids

The young age structures of many populations in the developing world mean that these

populations have a huge built-in potential for growth.

China’s Age Distribution by

age and sex

1964, 1982, and 2000

• Population pyramids graphically illustrate both the future and the past of populations.

• The structure of the Russian, Estonian, and Ukrainian populations, shows the legacy of

high male mortality in the Second World War, and high mortality in both sexes during

the collectivist period.

• The 1998 populations of Russia and the Ukraine show severe indentations at age 50 to

54 years, reflecting low fertility and high infant deaths during the period of

collectivization, famine, and purges in the 1930s.

farming

money

Trading

Cash

Nomadic

• Primary producer

• Industry

• Merchant

• Professional

Rural

Sub Rural

Urban

• Migration is the change of residence of a person or group of persons for better life and higher standard of living.

I- Internal migration the movement within the boundaries of a given country.

• 1 - Rural - Urban migration.

• 2 - Movement of nomads.

• 3 - Movement of temporary and seasonal nature.

• 4 - Movement between and within urban areas.

II- External migration

• a) Permanent migration

• b) Temporary migration: It is the migration over the borders of one society to another for the aim of working for a number of years, with the intent of an eventual return to the motherland.

LOSS

• Pollution

• Density

• Malnutrition

• Spread of disease

• Slum area

• Psychological stresses

“The world’s poor once huddled largely in rural areas. In the modern world they have gravitated to the cities.” (Gerard Piel, 1997)

• Is that right? • Is it good or bad news for poverty

reduction? • A positive force in poverty reduction as

rural workers take up more remunerative urban jobs?

• Or the unwelcome forbearer of new poverty problems as economic disadvantages become more dense?

Source: UN Department of Economics and Social Affairs, Population Division (2006)

• Problems in American

cities in the late 19th and

early 20th century

included:

• Housing: overcrowded

tenements were

unsanitary

• Sanitation: garbage was

often not collected,

polluted air

• Transportation: Cities struggled to provide adequate transit systems

• Water: Without safe drinking water cholera and typhoid fever was common

• Crime: As populations increased thieves flourished

• Fire: Limited water supply and wooden structures combined with the use of candles led to many major urban fires – Chicago 1871 and San Francisco 1906 were two major fires

Harper’s Weekly image of Chicagoans fleeing

the fire over the Randolph Street bridge in 1871

informal

housing and

enterprises

usually squat

on

marginalized

and

vulnerable

lands

• Land conversion and its health effect

• Migration of diseases

• Endemic area of disease

Crude Death Rate

Crude Birth Rate

Infant Mortality Rate

Population Pyramid

Education

Load of dependency

Gross Domestic Product / GNP

Life Expectancy

Literacy Rate

• In the developing countries

of the world a third of all

deaths occur among

infants and children aged

under 5 years; deaths of

those aged 65 or more

account for a slightly

lower proportion.

• In the developed world,

by contrast, deaths of

elderly people aged 65

or more account for 72 %

• Breastfeeding

A girl in Lesotho is likely to live 42 years less than another in Japan.

Every month, one billion

people turn 60.

• Many of the most common chronic conditions reported by the

growing proportions of older people, such as musculoskeletal

and sensory impairments, may have serious implications for

health status but are not directly life-threatening and do not

feature as prominent recorded causes of death.

• prolongation of the process of dying rather than an extension

of healthy life

Source of data: calculated from the UN World Population Prospects, 2008 revision (http://esa.un.org/unpp/)

Source: Marmot Review (2010) Fair Society, Healthy Lives http://www.ucl.ac.uk/gheg/marmotreview/Documents/finalreport

“What matters in determining mortality and

health in a society is less the overall wealth of

the society and more how evenly wealth is

distributed.

The more equally wealth is distributed, the

better the health of that society.”

----- British Medical Journal 312, 1998

• 35 per cent of all deaths in low- and middle-income countries

• 6 per cent of deaths in high-income states.

Communicable diseases, maternal

and perinatal conditions, and

nutritional deficiencies

• 54 per cent of deaths in low- and middle-income countries

• 87 per cent in high-income ones (WHO 1999).

non-communicable diseases

Communicable diseases

Infectious pathologies/ transmissible diseases due to their potential of transmission from one person or species to another by a replicating agent (as opposed to a toxin).[

Non-communicable diseases

a disease which is not contagious. Risk factors such as a person's lifestyle, genetics, or environment are known to increase the likelihood of certain non-communicable diseases. 50% are a result of poor lifestyle (drug use, alcohol and tobacco use, diet, lack of exercise or stress management.)

Income &

Social Status

Culture Gender

Social support Networks

Education

& Literacy

Social

Environments

Employment &

Working Conditions

Personal Health Practices

& Coping Skills Physical

Environments

Biology &

Genetic Endowment

Healthy Child

Development

Health Services

Maternal deaths

In 2005, 530 000

women died of

maternal causes.

99% of these deaths

occurred in

developing countries.

Son preference

UNFPA estimates

that, due to son-preference, at least

60 000 000 girls

are missing in

Asia

Feminisation of HIV

In Sub-Saharan

Africa, 76% of

young people

newly infected by HIV

are female.

Violence against women

Women and girls are

the most frequent

victims of violence

within the family

and between

intimate partners.

In many developing countries,

women in the top income bracket

are twice as likely as the

poorest women to use modern

contraceptives. As a result poor

women are more likely to have

unintended pregnancies.

The poorest women are almost

three times less likely to have

skilled care at delivery and up

to six times more likely to die

during pregnancy and childbirth

than richer women.

EDUCATION HEALTH

Combined-approach

Regulation

Service Education

• Multidiscipline

• Bottom Up

• Long-term

Example of Solving Health Problems Related to Sociosphere Condition

Family/Community Based care

Care of the newborn and special care for Low Birth Weight

Early, exclusive & prolonged breastfeeding + complementary feeding

Use of Insecticide treated nets, safe water sanitation & hygiene practices

Oral Rehydration with Zinc for diarrhoea

Community management of pneumonia, malaria , neonatal sepsis,

severe malnutrition

HIV/AIDS Prevention & Care; Care & Support for orphans

Population Oriented Schedulable Services

Micronutrient supplementation and

Immunisation of children and mothers

Ante- and Post-Natal Care + family planning

Preventing Mother-Child Transmission AIDS

Individual oriented non schedulable Services

Skilled attendance during delivery

Case management of diarrhoea, pneumonia, malaria, neonatal sepsis, severe malnutrition, very low birth-weight, HIV/AIDS and TB

Emergency Obstetric and Newborn Care

Problems at the service delivery level.

Problems at the system or sector level.

Problems at policy-setting level.

Poor relation between disease burden and choice

high-impact interventions.

Inequitable allocation of financing.

Inadequate and unpredictable funding.

Poorly trained and undersupplied human resources.

Constraints on supply chain management and capacity.

Distortion of national priorities due to excessively vertical,

funding channels.

Existing resources remain insufficiently MDG oriented in their

health-focused components.

Fragmentation and large transaction costs from badly aligned

funding channels

Poor governance and insufficient accountability for MDGs-

linked to insufficient staffing, expertise and resources to

produce results-based plans.

Macro-Level: Policies and Fiscal Space

Meso-level:Health system & other

sectors

Strengthening Services, Systems & Policies for MDGs

MDGs :- Malnutrition- U5MR- MMR- Malaria- HIV/TB- WASH

MDGoutcomes

Micro-level:Families/

Communities

Population

Oriented

services

Individual

oriented

services

Family

behaviours

6. Leadership &governance

5. Health systemsfinancing

4. Medical products

3. Health information system

2. Health workforce

1. Service delivery

· SWAP

Protection of

Household Revenue

Continuum of Care

· Budget

Support

· Medium

Term

Expenditure

Framework

· PRSP

MDG focused +

Child friendly

National Health &

Nutrition Policies

Health System

Building Blocks

Expanding the

Fiscal &

Policy Space:

Family/

Community

based Care

Developed by World bank and UNICEF,

An evidence-based approach to planning, costing and budgeting.

Includes all health related MDGs: 1c, 4,5,6,7.

Provides comparative scenarios for country level policy dialogue.

Captures the key information about the demography, epidemiology,

health system, intervention coverage and costs.

Helps the user analyze the implementation bottlenecks that constrain the

health system, and devise adequate strategies.

Estimates the expected increase in coverage and health outcomes

obtained (decrease in mortality, etc.).

Calculates the estimated additional (marginal) costs required.

Identifies the potential sources and limitation of financial resources (fiscal

space).

1. What new actions? (new vaccines, new drugs)

2. For whom? (geographic/poverty targeting)

3. By whom? (public/private partnerships)

4. How? (supply and demand mix)

5. At what item cost? ( drugs, salaries, infrastructure)

6. Who pays? (public, out-of-pocket, donors)

7. How financed ? (PBF, CCT, insurance)

8. How sustained ? (impact of economic crisis on fiscal space)

UNICEF

Type your title in this FOOTER area and in CAPS

Steps in MBB: Results-Based Planning, Costing

& Budgeting

Step 1: Analyzing Equity, Health & other Systems Design and epidemiology To prioritize and Package High Impact Interventions

Step 4: Estimating Marginal Cost of removing bottlenecks

Step 3: Estimating Impact on MDGs 1c,4,5,6,7

Step 2: Analyzing System Wide Supply & Demand Bottlenecks for equitable coverage and selecting strategies to remove these

Step 5: Budgeting and analyzing Funding sources and Fiscal Space

Why treat people ...

then send them back to the conditions that

made them sick?