The PHSF model and the organization of information

In this chapter, we present information on health, prevention and care. Significant trends are highlighted, as are the fields in which clear regional or international variations exist, with a view to identifying where improvements can be made.

Since the first PHSF in 1993, the information referred to above has been organized according to a conceptual model: the ‘PHSF model’. In the PHSF model, health status is interpreted as the outcome of a multi-causal process with various determinants. This model is an adaptation of that put forward by the Canadian minister Marc Lalonde (Lalonde, 1974), which places public health in the centre of four groups of determinants: (1) endogenic or person-related characteristics (genetic, biological), (2) lifestyle, (3) physical and social environment and (4) health care (including preventive action). The PHSF model differs from the Lalonde model insofar as it more explicitly reflects the various (causal) relationships, such as the interactions between the determinant groups and the various types of preventive intervention.

Figure 2.1 illustrates the PHSF model in more detail (expanding upon the simplified illustration in subsection 1.3). The Health Status block shows how diseases and afflictions can result in reduced functional capability, reduced quality of life and sometimes death. Together, these effects can be expressed in terms of healthy life expectancy. The Health Status block is considered in subsection 2.1. The Determinants of Health block identifies three groups of determinants that are external to the care domain: environment, lifestyle and person-related factors. These are discussed in subsection 2.2. The three elements of prevention (health protection, health promotion and disease prevention) each have their own particular relationships with the three external determinant groups, and these are described in subsection 2.3. The Care block covers matters such as quality and accessibility, which influence health, plus matters that are also primarily the consequences of health status, such as facility usage and cost. These matters are dealt with in subsections 2.4 and 2.5. The external developments identified in the diagram are developments that, although they take place outside the health domain, do influence health status via the determinants. Finally, the Policy block includes not only health and care policies that are intended to influence the determinants of health, particularly through preventive initiatives and the provision of care, but also integrated health policy, namely policy that seeks to address matters in other domains (covered by the External Developments block), which influence health.

The model illustrated below is not quite the same as the one used in the context of the three previous PHSFs (1993, 1997, 2002). Revision of the model was motivated mainly by the wish to better reflect the dual role of care and integrated health policy. This general model provides a structure for the information presented in the PHSF. Some of that information is qualitative, while other information is quantitative. For example, the link between education and health at the neighbourhood level, or the importance of national coverage for certain preventive measures, may be considered purely qualitative. Typically quantitative information includes data on the incidence or prevalence of particular diseases (part of the Health Status block), the percentage of people taking sufficient physical exercise (part of the Determinants of Health block), or the vaccination rate in the child population (part of the Prevention and Care block).

Figure 2.1: Extension of the conceptual model of public health (see figure 1.1).

This chapter considers a small number of key statistics. Underlying studies, detailed information and references to supporting data sources may be found on the following websites: the National Compass on Public Health (www.nationaalkompas.nl), the National Atlas of Public Health (www.zorgatlas.nl) and the Cost of Illness (www.costofillness.nl).