Bangladesh needs to focus on social determinants of population health

The US Agency for Healthcare Research and Quality defines the emergency department (ED) as the hospital department responsible for the provision of medical care to patients arriving there at any time in need of immediate care. ED of a hospital provides 24-hour care to patients who need critical medical attention. In most hospitals in Bangladesh, EDs -- particularly the Government Medical Colleges and tertiary care hospitals-- appear to be very busy, crowded, and often quite chaotic.  Supervising, managing an ED, and providing care there is a daunting task. The healthcare professionals look overwhelmed and exhausted while attending to the very large number of care seekers. This begs these questions to be answered: 1) do all the patients in Bangladesh who go to ED always really need emergency care? 2) Given other options for receiving care, would they still go to ED? 3) Is the emergency care capacity for the population really so low, and more EDs should be built?

According to a recent US Centres for Disease Control and Prevention report, about 4 in every 5 adults in the USA visited the ED because of a lack of access to other providers. The report also indicated that those with public health insurance and those who were uninsured had higher rates of ED visits compared to the privately insured.  These findings are not new and have been consistent in many other research studies conducted with national, state, and regional data in the US and other developed countries. In Bangladesh, the private health insurance scheme is mostly offered by a few large employers in the formal sector or purchased by individual clients, and only a fraction of the total population is covered through this. Confidence in public hospital outpatient service quality is also low. Many ED visits may be unnecessary and avoidable in Bangladesh as well. One way for Bangladesh to deflect the heavy patient load from ED is to make its primary care delivery system extensive, effective, affordable, efficient, and accessible. The other way is for Bangladesh to focus on social determinants of health to reduce the need and use of acute healthcare including ED visits.

According to the World Health Organisation, health outcomes are predisposed by two sets of determinants - medical or clinical determinants of health and social determinants of health (SDH). The social determinants of health are the non-medical factors that influence health status and outcomes. These are the conditions in which people are born, grow, live, work, play, and age, and the wider set of forces and systems that impact those conditions of daily life. If a government focuses on improving these conditions, the incidence and prevalence of acute health conditions will decrease, and thereby the need to seek immediate and complex healthcare will be less. These forces and systems include economic policies and systems (job creation, strong private sector, unemployment insurance), development agendas (poverty alleviation, human capital), social norms (prejudice against women, ethnic or religious minorities, or persons with disability), social policies (social safety net, security, education) and political systems (democracy, local government).

Previous research showed evidence that SDH can be more important than health care services and access, or individual-level health behaviour and lifestyle choices in influencing health. For example, many studies suggest that social factors account for one-third to more than half of all determinants of health. In addition, research estimates that the contribution of sectors outside health outcomes exceeds the contribution from the health sector. They state SDH are mostly responsible for the health inequity and avoidable differences in health status seen within and between regions and countries.

Poor health outcomes because of a lack of understanding and inadequate investments in these SDHs can have a costly effect in the long run, for example by needing and accessing higher ED visits. An absence of a functioning primary health care system is also largely responsible.

A number of studies assessed other barriers such as patients' misperception of the severity of the medical problem, convenience, greater trust in the ED, or dissatisfaction and lack of trust with primary care services for non-urgent ED use. However, only a few studies investigated or modeled culture or language that could account for or contribute to ED use and how it differs by the socio-demographic profile of the population.

The potential benefits from medical expenditures in the hospitals are undermined by the government's low interest and investments in SDH. Thus, a better understanding of what these SDHs are and how they influence population health, improve health outcomes, and reduce unnecessary healthcare use mostly at tertiary care facilities are much needed for the health professionals, healthcare providers, and policymakers in Bangladesh.

Dr. Hasnat M Alamgir is a Professor and Chair of Public Health at IUBAT- International University of Business Agriculture and Technology, Dhaka. [email protected]