Discrimination and health can be related in many different levles.

For example, on the individual level,

individuals may face higher stress and anxiety when there are feelings of discrimination and engage in
unhealthy behaviours – such as alcohol or overeating as coping mechanisms. Institutional or community
levels of discrimination can also affect health outcomes as they dissuade people from seeking help or
receive lower quality care –

Education and health – on the individual level, education can affect health knowledge, literacy, coping
and problem solving skills which has effects on diet, exercise, smoking and health or disease For
example, education level may mean lack of knowledge of available healthy diets, and the kind or
intensity of exercise or health benefits of exercise, and the lack of knowledge of the dangers smoking
can provide to the person. Work related – in working conditions there may also be exposure to hazards,
imbalance in work-life, control or demand

Educational attainment can affect one’s social standing, social networks, control beliefs which in turn
affects the individual’s capacity to deal with problems, handle stressors, engage in certain time of health
behaviors. Education may also be associated with economic resources, and perceived status, and social
support/norms for healthy behaviour is also influenced by the person’s closest social network and social
relationships, and the environment they find themselves in alsot

Work related resources include the lack of health insurance, sick leave, wellness programs to help
manage the mental health and people of lower education background may und

Income inequality and health

Socioeconomic status and health

Working conditions and health

Social networks and health

Affective sates and health (emotions, stress levels, psychological states)

Labor markets, employment policies

Social capital, social cohesion

Policies can protect against hiring discrimination – of which employment can affect the health status of
certain minority groups – discrimination by health providers against groups of people can decrease their
willingness to seek medical help –

Law to protect people from violence as a result of discrimination – protect the safety and well being of
minority groups -

Lack of work life balance – lack of time and attention to exercise to engage in healthy behaviors, income
> preference for less healthy alternatives which are cheaper – education – unaware of healthier
alternatives, stress coping behaviours apart from smoking and drinking alcohol which are health-adverse
behaviours policy put into place to ensure there are healthcare providers who are from the same race as
minority groups – as it trust is a important factor that decides health seeking behaviour, so such
intervention can help relieve some of the social discrimination and distrust against professionals from
other behaviours who maay not understand their way of life and culture – afterall diseases are the
interaction of the many risk factors that vary among the cultures, such as eating behaviours, availability,
food choices and etc

10 common social determinants – SES< discrminiation, income, social network, social resources, working
conditions, labour markets and employment policies, social capital, social cohesion and affective states

Social contexts play an important role in determining which emotions are likely to be experienced, how
they are expressed and what their consequences will be – especially for the minority groups for example
– and that how this can affect health, since distress can exacerbate certain illnesses and emotions may
incentivize or disincentivize health seeking behaviours of health-detrimental behaviours

The main mechanisms that affect health conditions in the population at the community and individual
level includes – behavioural and cultural – with regards to things like diet, lifestyle, preferences to
structural and materialistic – such as functional needs to being met, how income affects one’s access to
healthcare of which is part of the 4 hypothesis why income or race affects one’s health so much

Diet hypothesis – where diet is decided by not onl behavioral, cultural, but also environmental and
based on cost and access – structural/materialistic problems, as well as how diet is viewed in the
neighbourhood or in the family is based on the education level, income and SES of the person – poor
education on healthier lifestyles

The difference in health outcomes between people of high SES and those of low SES can be determined
by the amount of health-beneficial behaviours and health-debilitating behaviors one is more likely to
and less likely to take part.- part of the behavioral hypothesis

There is also the psychosocial stress hypothesis, where people of lower incomes, marginalised
group/race or lower education perceive relative poverty and are stressed out - (psycho-social
mechanism)

SES is a fundamental cause of health inequalities – education, income, occupational status/prestige, the
fundamental social cause of health inequalities has 4 criteria, namely how the cause influences multiple
diseases, cause affects these diseases through multiple risk factors, involves access to resources and can
be reproduced over time

Gender difference – biological factors such as higher male mortality rates from early stages o life, certain
neonatal disorders more common in male babies, hormonal differences and genetic differences

But more obviously, social and behavioural factors such as masculinity – aggression and more averse to
risky behaviours, high risk occupations, occupational competition and stress to induce unhealthy
behaviors, and difference in health seeking behaviours

Gender equality – including in labor market activities and health behaviours , more women are taking up
stressful jobs and are undertaking more unhealthy behaviours, men’s improvement in lfe expectancy,
decline in women’s longevitity – due to economic downturn, long term unemployment, sense of
despair- associated with rise in chronic diseases due to smoking, obesity, high blood pressure,
painkillers, dirnking and suicide (associated with high stress as well)
Biomedical definition of disease is often missing the patient’s perspective of his own disease – no
definition of the patient’s interpretation of the disease

Social roots and care resources are not

And disruptive effects of diseases are not observed

Job – how does chemotherapy affect the persons’ life, can a normal person get back to normal routine
after chemotherapy for example? – emphasise medical sociology role to play to improve doctor
appropac to improve patient experiences

Who decies what is an illness? Medical professionals, society or you?

There is varying ways of which individuals respond to bodily indications, how they monitor internal
states, define and interpret symptms, make attributions, take remedial actions and utilize various soures
of informal and formal care.

Indvidiuals react to diseases differently by

1. How they respond to bodily indications

2. How they monitor internal states,
3. How they define and interpret symptoms, how they make attributions
4. Or how they make remedial actions and
5. Utilize various sources of informal and formal care
6. Influenced by social, cultural and psychological factors

Sick role – rights and regulations surrounding illness that could shape the behaviour of doctors and
patients – formulated by Parsons – strong proponent of structural functionalism – why isit we do not
face chaos everyday, how is the society functioned to help maintain life – doctors are important as
gatekeepres to the sick role – sign of authority and power in control of societal life

Illness as deviance and sick role is a mechanism of social control – health is important for functioning of
social system – cannot fulfil role if sick – deviance from norm

Sick role – health is essential and in the absence – affect the function of societies

Key function of doctors and medical practice – help maintain optimal level of health in society –
diagnose and identify and prescribe these people the sick role – temporary exemption from their
ordinary role obliations and return people to health

Medical practice is society’s social control apparatus and heavily regulated – MC to be exmpted from
work

Patients and doctors – right to be comptent and tackle medical problem in a objective way and neutrally
– without any need to take into account the

Sick person is not held responsible for the illness – temporarily excused from normal social roles, and
obligations – expected to seek medical advice and cooperate, and want to get well (obligations of the
sick patient) obligation and rights
Sick role can be broken down if there is malpractice, lack of trust in the doctor, if the doctor was
incompentent or was crossing boundaries into tabooed areas

Medical malpractice – analytical abtrraction – not very application in the real world because its ideal

Traditional one-on-one interaction between patient and physician

Physician nowadays are not the only gatekeepers and criciticisms are as follows – if patients are at
home, or if patient is target of preventive measure (covid circuit breaker) or it is a hospital setting where
the physicians work in team, therefore the doctor himself is not the only gatekeeper

Sick role applies to acute diseases

Chronic disedase? Disease without cure? Mental illnesses – breakdown of sick role theory and not
fulfilling the sick role theory where they do not seek medical advice to get well

Patietns do not conform to obligations of sick role because of social contexts – working despite sick due
to poor economic conditions for example. The sick role has a narrow focus on the patients in the middle
class, where they value individual responsibility, values for good health and return to normality, and
does not consider those who live in poverty=

Experiences of symptoms are also influenced by culture – illness experience is varied across different
groups of people

Expansion of sick role theory – not only structural functionalism at play for sick role theory, but society
can also decide what is an illness – there are roles individuals and societies plays in determining illness

Variation in sick role do exists – depending on the illness, and depends on the their perceived
seriousness of the disease, stigmatization and labels which are influenced by the social norms and
cultural traditions (reflection of it) labels also influence on how a person is treated

Labelling theory considers the definition of illness to be a subjective matter – differ from culture and
change over time. Homosexuality was once considered a mental illness – and the application can be
influenced byy one’s social position. Social position can affect illness labels

Stigma refers to negatively defined condition that has a deviant status, involves political process related
to macro-social issues such as power, discrimination, and the distribution of resources in society there
can be expanded definitions, there are different types of illnesses which must consider the extent of
stigmatization and deviation from normality

Conditional sick role – the normal type of role where illness provides temporary exemption from role
responsibilities (parsons sick role)

But there are unconditionally legitiamate, such as cancer where illness provides permanent and
unconditional exemption from role responsibilities due to hopelessness of condition

Illegitimate sick role, such as epilepsy, where there are some exemption from role responsibilities, but
there are additional privileges and may carry social stigmatization – suffers from lack of understanding
of a disease and have stigmatization, kids with epilepsy may be alienated or marginalised. (presence of
stigmatization) – different consequences for different individuals, and depends on the label that is
applied on the deviant’s health disorder by others, illnesses have socially created labels, and the
oconcept has been strictly theoretical and not tested, and there is differences in the way people define
themselves as being sick.

It focuses on the society’s labelling of diseases and the determination of how these diseases are
defined? Not so sure

Social construction of illness – relevant framework to describe the illness experience

Illness narratives also inform politicians on the effects of the illness and the lived experience so as to
guide policy making and to be aware of the effects of the disease

Contingent narratives, moral narratives – try to shower as competent, active and socially engaged and
try to close the gap between previous ssel before illness and after experiences of illnesses

Illness narratives help patietns to deal with altereted situation and sometimes fundamental disruption
which illnesses can careate – helps to address why me, why now and what can be done – elps to inform
clinical practice as well,

Narrative medicine – methodology of clinical intervention based on communicative competence,

showcase that doctors not only know how to diagnose but also listen to what the patient has to say, and
is almost as important as evidence based practice – meanings attached to symptoms

Key takeaway – distinguish between disease and illness, when we take about disease – tend to talk
about the abrnomalities or physiological dysfunction but sickness is a social state which signifies an
impaired social role for those who are ill, and illnesss is a subjective state, pertaining to a person’s
psychological awareness of having a disease and usually causing that persn to modify his/her behaviour

Illness – the subjective state of which one perceives psychologically to be in a state of deviance from
normal happening in the body of the thinker is socially constructed. This is so because the expression of
symptoms is shaped by cultural and moral values, experienced through interaction, shared cultural
traditions, shifting frameworks of knowledge and relations of power

Social constructionism of illness is influenced by

1. Shared interaction within the community/society

2. Cultural traditions
3. Changing framework of knowledge
4. Relations of power
5. Expression of symptoms is shaped by cultural and moral values, experienced through interaction
with other people, and influenced by particular beliefs about what constitutes health and illness
6. Shaped by cultural and moral values
7. Influenced by particular beleifs on what constitutes health and illness

Illness has been constructed differently, premodern where illness is the outcome of moral failings and
modern times is the result of organic disturbances within and individual human body

How and by whom illness is t be treated and subjective experience and meaning of ill are expected to be
different in the 2 settings
Culture bound illness – is it constructed based on eyes of western explorers? Maybe it is a cultural
tradition instead of a construction of illness based on experience of western explorers

Internet addiction – socially constructed disease and also has influence application of the disease status
of addiction may be influenced by one’s soclal position – someone who is addicted to gaming versus a
professional gamer who earns money and who is a well known name or branded

History of medical profession – used to lack sufficient good quality education, often profit-driven schools
and doctors at the time didn’t believe in experimental science and distrusted laboratory – as well as
poor quality education. 1. Rises in medical education 2. Improvements in medical knowledge has helped
promote the rise of physicians in power ( power/ knowledge) as they perfected the medical gaze, and
sought the view of the human body for intervention and control, medical education sought to 1) provide
basic sciences and clinical sciences exposure 2) didactic instruction where the lecturers will teach and
the students will receive the lessons 3) taught by full time faculty in mny different departments and 4)
clerkship years under trained professional as part of the education

Rise in power of physicians was also linked to the strength of associations and unions – of which sought
to control the power and were legalized to have authority and autonomy – power to correct medical
offences or those guilty of offences, requiring medical education that were approved by them and
allowed privileges – all of which led to the prestige and power physcians have

Priority areas – need for more GPs, improved skills in geriatric, palliative and integrated care, soft skills
in communication, ethics patient safety and professionalism – due to the fact that it is a patient-doctor
r/s, team-baed, research n tech and cost effectiveness

Gender, ses and race – more females and males as time passes, more diverse but majority are from
upper-middle class and upper, but gender discrimination still exists, though not in NUS

One major goal of professionalization is to be free from public control and self-regulatory and allowed to
rely on internal control mechanisms – peer review, hospital review and board of medicine in each state

But is not effective – strong unwritten code of not making reports, hospital – need to maintain public
image and state boards – varying state powers and not all state boards maintain the same level of
control , but now there is managed care, corporation involvement, changes in doctor-patient r/s, and
govt regulation to control costs

Promotion of preventive care,c eiling on payments and lost power in health policy since govt does not
gain from favourign AMA instead of the public, managed care to control cost – shift power away from
individual doctors and are more restrictive in deciding medical procedures. It is meant to cost-save, by
incentives, review of medical necessity, beneficiary cost sharing, selective contracting with supply and
intensive management of high cost cases. 1. Control the cost of supplies 2. Incorporate cost-effective
treatments by incentives 3. Diluting the power of the physician to choose specific services, 4. Controls
on lengths of stay and admissions – not only based on doctor’s decision

Profit makni corporations – employees – contractual agreement, no complete physician control, medical
malpractice and patient’s increasing power in say of the doctor’s authority, patient-doctor r/s, more
equal due to ample health info, direct-consumer advertisement
Deprofessionalizm – consumerism, govt and corporate regulation – weaken its powers to self control
and be free from evaluation or autonomy, greater accountability and constraints on exercise of power
by doctors from govt, - cost, corporates – in deciding treatment as they can be salaried and contracted
and patients who have a bigger voice now.

General healthcare funding

1. Direct payments to state, country or municipality

2. National health insurance
3. Private or voluntary health insurance
4. Out of pocket payment
5. Donation to charities

Health insurance can be

1. Provided by non-profit fund

2. Government agency or
3. Profiting corporations (commercial)

Health insurance pays for medical expenses and covers disability and long-term care, can be purchased
as a group (firms) or individually

The continually rising healthcare costs in the US can be attributed to

1. Aging population
2. Medical technologies
3. Defensive medicine
4. Self-referrals
5. Medical entrepreneurialism
6. Administrative costs

As the population ages and chronic diseases rises, cost also increases, and is not unique to the US,
however US is the one country that spends more on highly expensive technologies at end-life care,
where most other countries do palliative care and allow death to occur, and drugs are expensive more
than other countries

Medical technologies – medical providers – best possible care, hospitals have fierce competition to
attract top physicians and makers of equipment promote this competition – purchasing of equipment to
incentivize top talents in the competitive scene, and huge incentive to use it and earn the revenue used
to buy these expensive technologies

More tests and being conducted in order to protect themselves in malpractice suits - more costs and
less genuine benefit

Physcians refer patients to facilities that they are financially connected to, where they charge high fees
and more procedures to benefit the physician

High administrative costs as there are over 1.3k insurance companies in US, where key part of the
problem is biling and there are many different configuration of benefits – most of it is spent on running
the system, regulatory reporting, biling and clerical matters where billing is most important
 1. Running the healthcare system
2. Billing
3. Regulatory reporting
4. Clerical matterse

Medical entrepreneurialism – invest in health for profit – rapidly growing industry, encourage
unnecessary, inappropriate and over use of health care resources through marketing and advertising
techniques – pharmaceutical, medical products and insurance companies benefit from this –

Traditional reimbursement method of fee for service causes no cost saving incentive and cost control
mechanisms where payer, provider and insurer has no need to be cost-conscious and lead to many
provision of unnecessary services and increased healthcare costs > leading to cost containment
strategies such as managed care and prospective payment system

Organizational tool – autonomy and control of public hospitals – public ownership allow legally private
firms the autonomy they operate in a competitive environment and yet be within the government’s
reach – can control hospital costs without resorting to regulations such as controlling user harge
physician charge, number of beds in the different classes.

Tax financning – transfer to public hospitals to subisize cost of care and tax emptions foe mdisave
contributions community health assistants cheme + pioneer generation package to subsizie outpatient
management of low income household sand reduce co payment for elderly singaporeans

Medisave, medishield and medifund – meanstested and low cost basic insurance scheme

Out of pocket is deliberate, no free healthcare and outpatient is largely OOP – mitigated by lower prices
through government owned clinics – economy of scale and cost cutting management practices

Lower prices have the flow-on effect of driving down prices at private lcinics – due to competition for
pricing

Active regulation of all sectors – tight control over access to services, rely on demand and supply side
controls – so that they are more cost conscious and judicious MOH monitor biling practises and raises
alarm, and SMC regulates and licenses HCP, and the biling they do

There Is price transparency in Singapore – average prices are posted and online calculators are available
to help consumers calculate medisave/medishield limits to help them decide on healthcare procedures

In summary, singapore’s healthcare costs is managed through

1. Organizational measure – where there is public ownership in legalised private hospitals for
government control without use of onerous regulations – on charges for patients, allocation of
resources and cost-management strategies
2. Tax financing aims to provide equity of care, especially to those who need it most while ensuring
cost-efficiency so that the efficacy of the healthcare ensures access by patients – community
CHAS ( health assistance scheme) and pioneer generation pakcage
3. Out of payment is ensured but mitigated through heavily subisizised government owned
polyclinics which provide low cost services, as an attempt to drive down private care payments
as a form of latent competition
 4. Price transparency to help guide patient decisions on healthcare procedures so that they can
decide for themselves

Comparing between healthcare systems, the countries have to decide out of their historical, economic
and cultural factors as to

1. What is the extent of government control or autonomy of the healthcare system will they
prefer, and what should the government involve themselves in?
2. What is the extent of both public and private healthcare system, what should be the ideal
relationship between the government, employers, insurers and providers?
3. What is the optimal number of doctors within th system, such as distribution of general
practitioner vs specialist physcicians?
4. There are different cost and equitable distribution, what is the commitment to healthcare
technologies
5. How can we increase healthcare costs most reasonably?
6. Evaluate the healthcare system based on cost, quality, accessibility and how the most
disadvantaged people are being treated in the society

The healthcare system typology differs from fee-for-service, socialized, socialist and decentralised health
system, differing in these aspects

1. Direct regulation by the government

2. Direct payment to providers
3. Access of healthcare
4. Presence of private sector
5. Ownership of healthcare facilities and professionals.

Where fee for service systems have limited direct regulation and direct payment, access is also limited
based on the payment abilities of the patient, widespread private sector and limited ownership by
government – probably only public hospitals and patients under medicare or Medicaid

In socialized systems, the system is under direct regulation, direct payment is made and access is
guaranteed, ownership is by government and presence of healthcare sector is limited, and private sector
has some ownership

In socialist systems, there is direct regulation, direct payment to providers, ownership of facilities is
public only, public access is guaranteed and private care is unavailiable

For decentralised, there is indirect regulation, indirect payment to providers, there is private and public
ownership of facilities, guaranteed public access and limited private care

Ancient humans – thought disease was the intervention of gods, spirits or devils

Development of shamans who conducted trial and error experiments

Egyptian civilization – evolution of physicians into specialists

Greek evolution – where medicine finally moved away from the supernatural into the natural – where
there are 4 elements and the body has 4 humoral elements – hot blood cold phlegm dry yellow bile and
black bile wet of which must be in balance for the person to be healthy
Ancient rome – the first concept of public health, where aquedocts were built and sanitation was
required of the people, and galen, father of experimental physiology first made extensive contributions
to the understanding of the anatomy – brain, bones skins muscle and were dominant for the next 12
centuries

Later into the medieval era, due to the control of the church and Christianity, medical practice was
limited to the clergy and seen as averse to the faith, illness was seen as good as it tests one faith in god,
illness occur as a form of punishment (Monastic medicine)

Scholastic medicine (2nd half of the medieval era), where monks were forbidden from practising
medicine and medicine is the area of clergy and universities began to play an important role in
education of physicians – where earliest hospitals were set up, and where black death first began

Medicine in the renaissance – modern anatomy, modern physiology and father of immunology Edward
jenner

Germ theory of disease – microorganisms cause disease, growth and reproduction can cause disease –
environmental and hereditary factors can affect the severity of the disease

Biomedical model 1. There is a specific etiology 2. There can be specific lesions or signs found which
alter the anatomy and physiology of the body and the combination gives rises to symptoms observed

Critique of the biomedical model is that it focuses too much on the individual etiology but excludes
medical problems such as chronic diseases which require patients to treat the whole health of the
person as a whole, not singular diseases caused by specific pathogens

Biopsychosocial model – interlink between biological, social and psychological to explain diseases

Biomedical model – 1. It made doctors focus on individual presentation of diseases in patients and
exclude the social and psychological factors of the patient, and excluding the morals or culture that the
patient is found in.

Sociological imagination is the awareness of the relationship between the personal experience and the
wider society, to be able to relate the individual experiences and understand that it is the result of a
historical process happening within a larger social context

Social epidemiology – focuses on the social causes of health outcomes and behaviours, emphasising on
the social structure and material conditions

Social psychology of health and illness – it is the effect of psychological processes that
mediate/moderate the social causes or consequences of health outcomes and behaviors. Social
psychology of health and illness talks about the social psychology that affects the health behaviors and
health outcomes in people, emphasising on culture and meaning.

Sociology of medicine refers to issues linked with healthcare delivery, healthcare experiences, medical
knowledge, health inequality, - critical theoretical perspective and emphasizes the institutions of
medicine that give rise to health services.

Sociology in medicine is the issues within medical treatment, professions and marketing of healthcare –
applied research questions
Healthcare financing generally done through taxation in the state, county or municipality, national
health insurance, private or voluntary health insurance, OOP or donation to charities

Private market health system – America, where there is little or no government internvention and are
made by private medical facilities, providers with consumers.

Private market is used to utilise competition, where the best, most cost effective company will thrive
and provide the best healthcare with limited resources – and this assumes that this is the most equitable
approach to providing healthcare – and has led to the development of higher quality medical schools,
technologies and healthcare.

Employer-based insurance was commonplace in the US insurance market, simply because it provided a
edge over other companies who did not do so, to attract talent and additional incentive for workers to
work harder, plus since they are registering in huge groups, they can negotiate for lower rates and this
competition for firm-registered insurance drives up competition to increase efficiency of these insurance
companies. However, this meant that some people who do not have full employment or unable to pay
for one are left without access to healthcare, to which they deem it as acceptable in a capitalist
economy. Blueshield Bluecross was unable to survive as a non-profit status – prompting public insurance
such as social security, medicare, Medicaid – for the older people and people with low income

For elderly under medicare, they are covered for hospital services, hospice care, and have to pay
premiums to receive coverage for physician visits, and its coverage is extended to end-stage renal
disease patients, permanently disabled and their dependents. Skilled nursing services, home health
services are also subsidized. D and C means patients under medicare can leave the traditional fee-for-
service medicare and get their insurance privately managed, and there is a new prescription drug
benefit available through private companies

Medicare and Medicaid challenges include – incentive to overuse and provision of unnecessary services

There was lack of cost control mechanisms, and the usual method coverage was that it followed the
traditional fee-for-service mechanism, where the doctor would prescribe whatever that costed and bill it
to the country – no incentive to be cost effective on both patients, physicians and insurers as they all
benefit from using more. They used moreunnecessary services because it does not cost them to do so,
but causing healthcare costs to go up immensely.

Prospective payment system shifts the financial risk and burden from the medicare to the hospital, but
this means that patients are more likely to be kicked out of the hospital earlier and readmission is then
an issue. Even despite tying a predetermined rate to the patient to lower costs. Managed care then
came as a strategy to control cost – through monitoring and observing patient, provider and insurer
behavior

Reasons for increasing healthcare cost in America – defensive medicine, medical entrepreneurialism,
administrative costs, aging population and physician self-referrals to benefit themselves and new
medical technologies.

Singapore’s tools include organizational, fiscal and regulatory and informational. While healthcare
companies are private, the government has a part ownership of these facilities, allowing them to control
the direction of the health care systems without implementing onerous regulations. Furthermore,
taxation schemes and reimbursement policies through CHAS, pioneer generation package help to ensure
equity for its populace who are less able to pay for healthcare services. There is also medisave,
medishield and medifund to help mitigate the healthcare costs, where there is means testing in
medifund, and OOP is heavily mitigated by subsidized prices at polyclinics which provide latent
competition for private owned clinics to lower their prices. There is active regulation by monitoring
biling practises, and the SMC dishes out punishments on physicians who do not follow regulations and
overcharges or overtreat. Price transparency helps patients calculate their treatment

The reason why hospitals emerged as medical technology centers was due to the discovery and use of
anti septic measures, such as clean and properly ventilated rooms, sterilized surgical instruments and
sanitary practises among healthcare professionals, advancement in medical knowledge

Essentially in the dual line of authority there is the tension between the clinical orientation and the
business orientation of the hospital, both of which is essential to provide cost-effective treatments and
remain competitive in providing quality healthcare and ensure ccess

Bureaucracy is highlighted by the strict hierarchy, strict rules and regulations, specialised requirements,
fixed areas of responsibilities and competencies, regulator remuneration, promotion based on objective
criteria and recruitment based on merit – authority remains in the office and post rather than with the
person, and is rational and impersonal based on criteria of merit and objectives

Advantages of multiple-chain hospitals over independent hospitals in a private market

1. Enhanced ability to negotiate for better prices with insurance and technology companies
2. Cost sharing for expensive technologies
3. Elimination of duplication of services
4. Economies of scale in purchasing

For-profit hospitals business strategies – cost-shifting where people who can pay help to pay more to
account for those who cant.

Cream-skimming by locating in more affluent neighbourhoods so that the less affluent do not use their
services or conducting wallet biospies, and redirecting those less affluent to other non profit or public
hospitals “patient dumping”

Public hospitals are troubled by an increased number of patients who are unable to pay due to patient
dumping as well as competition for patients who are able to pay who are going for better services in
private hospitals who shun away less affluent patients

Autonomy was meant to increase competition amongst hospitals so that the best will thrive and engage
in cost-effective practises, but control by government is still required to ensure access, as when quality
goes up cost of services goes up. Quality goes hand in hand with price, as with talent, expensive
technologies which require regulation by the government to ensure costs. Access also has to be
regulated so that poor patients are not shunned away due to lack of ability to pay.
Increasing healthcare costs, increasing exposure to alternative perspectives of medical care, clinical
approaches that places primary responsibility on the individual than the professional –

Patients and CAM – there is psychotherapeutic value in the treatments they strongly believe they can
get, and every medical treatment must be considered in the context of the patient, whether they
strongly believe in it.

Skepticism of CAM Is often because these practitioners may not obey by conventional practises, such as
evidence-based medicine and their medical theories do not follow conventional theories such as the
biomedical model or the germ theory, following theories of yin and yang for example, and the alignment
of the joints to ensure internal balance. Truth is, that the body has the power to heal by itself more
often than not, and the value of CAM has psychotherapeutic values, and often time they focus on the
hoslitic well being of the patient, including mentally, spiritually apart from physically which often times
biomedical model places too much of an emphasis on. Conventional western medicine may not have
adequately addressed the needs of the patients with regards to problems like pain management, but
also have a role to play in serious illnesses like heart attack, renal failure and the like, but minor aliments
may go undertreated. The efficacy is not so easily determined for CAM, but the reasons why may include
lower costs, higher satisfaction, cooperative active processes and many aspects of CAM can be applied
in conventional medicine, such as working with the patient to hoslitically improve the physical, mental,
spiritual and social makeup of the patient. Biomedical model has a strong focus on the physical well
being and causes that cause deviance in this normal workings in the body, without emphasis on the
psychosocial factors and health is also the high-level wellness is also a positive physical-emotional state,
core features of CAM – health as high level wellness, vitalism, holism and cooperative healing

There is positive effects of religion on health – calming, anti-anxiety effects, high level of religious
commitment can have positive effects and are acknowledged by most physcians – and it is important to
not alienate patients with high levels of religious commitment

Factors influencing the patient’s health seeking behaviors – framework of knowledge such as limitation
of self-help, subjective state or perceived state of illness and the need for help, understanding of the
disease through interaction ( to explain social factors and symbolic interactionism on the illness or sick
role of people), pressure from family/friends, interferene with social or physical or vocational work –
perception of the illness refers to interference with the quality of life as well and social triggers need to
be considered, such as the social situation, weekdays + when symptoms appear around people increase
likelihood of seeking help

More expensive treatment, increase in health-related information for self help, moving treatment away
from professionals and towards individuals to increase individual responsibility in ensuring health and
expansion of alternative medical approaches and the exposure to it via the internet is widespread – such
as acupuncture, faith healing, chiropractor

Core features of CAM which complement conventional therapy includes – holism, vitalism,
interconnection between the mind, body and spirit (bio-psychosocial model sign of it in western
literature), cooperative healing – active process of healing and working with the patient
The decision for the individual to prefer self-care over consulting health care professionals is
multifactorial, where self-care has recently risen in prominence due to self-help groups’ rise and
movements. This is due to the ease of availability of health-related information on the internet, and the
ease of spread of personal narratives of illness experiences and what went well or bad for patients. As
part of symbolic interactionism, the interaction of patients with similar conditions or symptoms start to
learn from one another and inherit similar body of knowledge and influence and it has subsequent
effects on health-seeking behaviours of these patients, where they may prefer to obtain their own
information, do self-screening eams, formultae clear goals and preferences and manging one’s own
illnesses with select medication treatments that are alternative to conventional medical system such as
chiropractor, acupuncture, religious health – check.

There is also the backdrop of increasing healthcare costs and exposure to alternative medical
approaches available on the internet. Health-seeking behaviors also depend on factors such as age,
gender, race or SES. Females are more likely to seek professional help because of prior experiences with
reproduction, more illness incidence, more receptive to conventional healthcare and willingness as well
as difference in gender roles. Women may be more free than men who are occupied with earning wages
for the family, where women are more free to seek help as they may not be employed, for example. SES
– influences the time available to them to seek health or whether they have access to medical care,
public hospitals, clinic sites are usually more busier than usual, and is higher opportunity cost for them
to earn more wages to work. As the trade-off of seeking health care is greater in the poor than the rich,
they are less likely to seek medical care. Individual factors influencing health seeking behaviors include
1. Social background 2. Perceived interference of the disease in daily life, social/personal relations or
pressure from family and friends. The social situation is important, where people are more likely to seek
help if it is observed more by people around the patient or it happens during the weekdays.

Self-help groups – increased exposure of alternative medical approaches, health information, healthcare
costs, increased influence from people with similar conditions through the internet (symbolic
interactionism) > leading to specific social construction of diseases in certain parts of the world in certain
internet societies, influence their views on conventional medical care and alternative medical care.
Apart from self-help groups, factors that influence health-seeking behaviours include age, gender, race
and SES. Gender differences are – receptivity of healthcare, gender roles, prior experience and incidence
of diseases, and perhaps more sensitive to illness states and more open to entering the sick role to seek
conventional medical care. SES – income, opportunity cost, busier public hospitals and clinics
(overcrowding). Other influences include friends, family and close social support which influence their
views, and their individual perception of disease influence for them to view the disease as an illness, a
subjective state for them to seek health care for.

Chirpractor first faced objection from the medical association as the practice did not require rigorous
medical education and training, and had different schools of thoughts for treating medical illnesses,
where in chiropractor, it is the subluxation, misalignment of joints that lead to the imbalance of flow of
energy in the body to cause signs and symptoms of disease. They also believe that the body is strong
and capable of self-healing, versus in the biomedical and germ theory of diseases in conventional
medical care where the root cause of diseseases lie in pathogens or in the imbalance or dysregulation of
the workings in the human body. Health is the absence of symptoms in medical doctors,, where in
chiropractor, ill health si the result of failure of homeostasis of the body. Lack of licensure and rigorous
medical training + perception of erosion of autonomy and professional control over health matters of
the population by the medical doctors and by AMA. However, licensure and upgrading medical training
and the acceptance of it in most private insurance comapnies soon helped to solidify the placing of
chiropractor as alternative medical care or even complementary, though millions of people still do not
believe in it – the power of societies’ influence on what works apart from what can be considered
illnesses.

Medical schools of thoughts tried to explain acupuncture in convention medical thinking, in terms of
biomedical model, and arranging for acupuncture to be placed under the jurisdiction of medical doctors,
so that the power and authority of AMA will not be eroded, however success and recognition of world
health organizations and government helped to prove the legitimacy of acupuncture and is now one of
the more accepted alternative medical approaches. The school of thought of acupuncture is the idea
that the body must be whole, there is aholistic system in which health is understood only in the context
of the relationship between the human body and nature, and there must be balance between yin and
yang, and imbalance leads to blockage of flow of chi within the body, where the insertion of fine needles
into acupuncture points help to redict and stimulate chi so that the imbalances between the human
body and the nature is fixed

Religion – has proven effects to improve symptoms in patients due to the bio-psychosocial model,
where symptoms can be relieved or worsened depending on the psychological state of the patient.

Psychic healing is 1. Activating innate recuperative forces 2. Transferring positive healing energy 3.
Serving as a conduit between god and the patient to faith healing 4. Serving as conduit for cosmic
energy to the patient, approaches varies 1. Self treatment through prayer 2. Treatment by laperson who
can communicate with god 3. Treatment by official church leader 4. Healing by person or by group of
persons who practice full time without major religious afflilation or 5. 4 with religious affiliation,
Christian church.

Christian church healers who have been doing for 3 years can apply to board of education for 6 day
course to be awarded csb bachelor of Christian science degree – of which is not rigorous at all –
skepticism by the society, faith healing does not cure and delays necessary medical care for those In
need – in the case of Idaho state where ther are many faith healing extremists –

Key perspectives and ideas – health as high level wellness, vitalism, holism, interpenetration of spirit
mind and body ( there is a great relationship and never treat one without the other) , there is a
ecosystem and united by a force or flow of energy throughout the body, holism – holistic, physical,
mental, spiritual and social makeup, cooperative healing – active healing process where the doctors
work with instead of on the patient

CAM use has also been contributed by the lack of efficacy of conventional medical approaches, cost or
the inadequacy in fulfilling the mental, social and spiritual needs of the patient, and there is
psychotherapeutic value in those approaches. Though, many conventional medical doctors have viewed
some of these CAM as dangerous out of concern of the public health, or the fear that these medical
approaches can undermine the authority and profits the conventional medical system can get. Few ways
CAM can be shut down is through the use of legal channels to accuse them of endangering public health
without the use of extensive research, studies and medical education, or through public campaigns to
raise awareness of the dangerous of faith healing and the need for appropriate treatment for some
conditions – though it has a incentive to do out of self-interest as well.believe in the care – valuable care
for the patient. Rapid rise and popularity – conventional western medicine has a part – inadequate
address and wellness aindustry has helped fill in the gap through the use of supplementation and etc

Factors shaping healthcare systems and health policy – the physical environment, historical and
situational events, cultural norms and values, and the structure of society including politica, economic,
demographic and social factors.

Challenges – rising demand for healthcare in terms of lowercost and higher quality

Limited challenges, higher cost of care, trends in population aging, pressure, conflict, competition
between different stakeholders – providers, investors, insurers, pharm industry, medical device
companies, consumers, voters, politicians

Health disparities within and across country

What is the optimal level of involvement of the national government in the health system? Should there
be both private and public healthcare sectors, what is the optimal relationship between the
government, employers, insurers and providers?

What is the optimal number of doctors within the system? What should be the distribution between
primary care physicians and specialists?

Given considerations of cost and equitable distribution, what is the optima lcomitment should be made
to the incorporation of medical technologies, how can increases in healthcare costs most reasonably be
controlled?

How can increases in healthcare cost most reasonably be controlled, how much should we pay for
medical technologies to be incorporated, what is the ideal number of doctors and the distribution of
specialist and general practitioners, should there be both private, public sectors in healthcare and what
is the ideal relationship between the government, insurers, providers and employers? What is the
optimal level of involvement of the national government in the healthcare provision in the population?

Does the country believe healthcare is a right or a privilege? US > strong principle of individualism, social
justice approach to its healthcare system rather than a private market for most countries, healthcare is a
right, and that government is more effective than the private market in allocating healthcare equitably
and ensuring that no one gods ewithout needed healthcare – there is a mismatch in information and
knowledge between consumers and providers – and that mismatch in information causes supply to
create its own excess demand, where doctors can order unnecessary tests or technologies to help
provide care for the patients, where the patients also have no choice, under the authority of the doctors
to pay for services – but changing with the era – there is check on cdoctors through medical associations
and people can report doctors for overcharging and overtreating – malpractise suits to keep thjem in
check, though pharma have contract with some doctors and that influences the decisions they have, and
governments are not in favor of the autonomy of the doctors over increased costs – though tagging a
price to each patient visit or stay in a hospital is not ideal since it only shortens the stay in the hospital
and not help with the quality of care where readmission to hospital has been high with the change of
traditional fee-for-service method to prospective medical system.

Singapore’s direction – ebnhance affordability and financial protection, increase efforts for health
promotion and disease prevention, promote healthy aging, beyond healthcare to health (preventive
strategies such as disease prevention, healthy lifestyle), beyon hospital to community to focus on
healthy aging and beyond quality to value, enhancing affordability and financial protection to ensure
access, increasing telehealth, use of datasets and information technology for the best value technology
and treatment methods, press on the methos of personal responsibility

4D – delay lighting up, deep breathing exercises, drink a glass of water or milk ,distract with something
else. To deal with tiredness, drink a cup of ginger ore herbal teal, eat small meals asnd sleep regularly,
relax with soothing music, pre empt family, do light exercises, sugar free cough drops, managing weight

Social class is decided by income/wealth, occupational prestige/status or education(skills and

knowledge), where working class people have low power, middle class have mid level power and
corporate level have high level and highstatus, upper class have high level and high status, ans owns
economic means/ownership of capital

Institutions include family, education system, firms, insurance companies and family norms and law –
structure of which how people organize themselves – in family, divorced, married, non marital union or
single, educational system streamlines people into specific areas of work, age-graded, time scheduled,
school types and streams, occupational structure – conventional, institutionalized occupational
activities, conventional occupational activities, employment status and qualification group

Firms – internal function and hierarchical division of labor career ladders and boundaries for job shifts
between firms and enterprise

Human beings act towards things on the basis of the meanings that htest things have for them, where
meaning can be drived from social interaction one has another, and through an interpretative process
used by the person in dealing with things he encounters, and is also what the person would think about
the person (reflect about how his behaviour will be on other people before going on it) – social reality is
constructed basedon micr-level interactions by individuals on basis of shared symbolic meanings, it can
portray what people with illnesses experience, and the related interpretative approaches offer ideal
tools

The illness experience is how they respond to bodily changes, monitor internal states, define and
interpret symptoms, make attributions, take remedial actions and utilize various sources of informal and
formal care, and is influenced by social, cultural and physiological conditions –

Sociological imagination – awareness of the relationship of the individual with the wder society –
une,ployment could be the result of factors, historical process and social cultural interactions within a
larger social context.

Choice is socially influenced, decisions of many university students – by influence of their parents, social
norms and the economy

Social system or the lackthereof is a form of buffer against life events – the function of social support,
structures of institutions to help safeguard the poor and the less fortunate against catastrophic life
events, insurance companies?

Different kinds of theories – labelling theory, symbolic interactionism – social constructionism, conflict
theory, sociological imagination, life course theory – effect of institutions, inconnection, structural
constructionism, biomedical perspective, early life evets
The foulcodian perspective denies the traditional history of medicine of increasing progress on
understanding of the diseae towards increasingly valid knowledge of disease because of the
interrelation between knowledge and power, and knowledge whether based on science or people’s
experience have equal validity.

Illness experience is how they experience the disease, how they interpret their symptoms, respond to
bodily changes, utilize social resources, make attributions and define and interpret symptoms (how they
see it), how they feel it

The sick role is important as a social mechanism to allow people who are sick temporary exemption to
allow them to recover for them to return back to normal health, and has to be heavily regulated, where
medical practice is part of society’s social control apparatus

Problems with sick role theory – people can define sick role behaviours for themselves even if its not
agreed upon with the physician – social constructionism, illness experience, limitation of the biomedical
model, contested illnesses

Sick role theory limitations – acute/chronic, narrow focus on middle class, managed care team instead of
one to one, varied experiences and assignment of sick role to themselves, assumption of competency of
the doctor and willingness of the patient to comply, medical malpractises

Variation of the sick role – how they impute seriousness of their disease, stigmatization, labelling
(reflection of social norms and cultural traditions, where lavbels influence how a person is treated –
internet addiction labelled as people who are in need of help and unable to control their urges or focus
on societal expectations

Variations in sick role – the perception of state of illness is subjective and is influenced by social/cultural
values and norms, where they decide how ill they are based on what they believe and how they
interpretate it, variations in sick role do exist depending on one’s illness, and the illness label is
ubjective, where it is reflective of social norms and cultural traidtions, where labelling decides on how
the person is treated, the labelling theoy considers the perception of a disease to be a subjective matter
rather than decided upon by the medical professional as there being objective causes and interaction
within the human body to cause certain types of symptoms and a prescribed way of treatment, illness
definitions are not fixed in at least 2 important ways, where illness perception can vary across culture
and time, and application of the illness label may change according to the person’s social position
there is varying degree of stimgatiztion of illnesses as part of the labelling theory, and there is
conditional sick role, unconditionally illegitimate and illegitimate, deviation from normality and extent of
stigmatization of persons with the disease. Different consequences for individual, and treatment
depends on the label applied to the health disorder – socially created labels, sbut strictly theoretical and
fails to explain the different ways people define themselves as sick and in need of professional medical
care

Contingent narratives – narratives that deal with the onset of the disease, practical and descriptive,
dealing with events and the immediate impact

Core narratives – heroic, comeid,c didactic, heroic, tragic, epic

Moral narratives – frames the speaker as competent, active and socially engaged and try to close the
gap between before and after the disease, and the current self after experiences of illness – how did the
illness help the person grow as a person or change

Narrative medicine – effective in helping to lower the symptoms of patients

Nightingale – modern nursing practises – asceptic technique, record-keeping, evidence based practice,
patient centered care, use of data to inform decision making, patient asssessments

Modern nursing practices – asceptic practice, evidence based practice, record keeping, use of data to
inform decision making, patient assessment, patient centered ccare

Modern healthcare practices – advocacy for public health and sanitation – disease prevention was
essential through improvements in public health and clean water, proper sewage systems, healthy living
conditions, establishment of public health departments, policies and programs to prevent disease and
promote health, demonstrate through extensive data on mortality rates and statistical analysis to
demonstrate the impact of poor sanitation and hygiene on health outcomes – social determinants of
health helped establish the field of medical sociology –

Pathologicalization of everything – where human difference is being diagnosed as problems that need
diagnosis and treatment

Individualisation of social problems – turning social problems into clinical entities

Expansion of the medical authority in controlling the populace

Medical definition of normality will increasingly create “proper” social norms

Pros and cons of medicalisation – shift the blame away from people and cause some deviant behaviours
to be less stigmatizing and require less punishment, though it hides the social problems and structures
that allow it to occur in the first place, and there is increasing medical authority in controlling the lives of
the people, by obscuring the social forces it may lead to the individualisation of social problems

Features of medicalisation – it is bidirectional, based on social culture factors as well as can change over
time and it is a continuum rather than a binary definition

Features vs types vs warnings against medicalisation

Types – medicalisation of everyday problems of living, medicalisation of natural life events,

medicalisation of deviance *deviant behaviours and enhancement in healthy people

Why do some illnesses exist in some places and not in others, why do they appear and then disappear,
do different cultures have different kidns of illness experiences? Beyond fixed physical realities, illnesses
have phenomena shaped by cultural traditions, shared cultural traidtions, shifting frameworks of
knowledge and social experiences

How and why did particular ideas of illnesses become dominant in particular places and how they
marginalize alternative ideas? What factors help explain why one society defines illness in moral terms
and another in oanatomic abnormality, what are the key consequences for the society at large and for
individuals?
Why do illnesses appear and disappear, why are they contained in certain places and not in others, do
cultures have didferent illness experiences, to what extent are they, beyond physical realities, shaped by
social experience, cultural traditions and shifting frameworks of knowledge?

How do dominant ideas become dominant and how do they marginalize alternative ideas? Why are the
factors that cause people to lean more towards a certain idea, for example in moral terms as opposed to
anatomic abnormality?

What are the key consequences for the society at large and for individuals?

Pharmaceuticalisation = medicalisation but specifically requiring drug therapy

Changing medical belief systems can have huge effects, especially how, ny whom illness is to be treated,
subjective experience and meaning of being ill to differ dramatically between those 2 types of society,
premodern and modern day

Health indicators – self-rated care, life mortality, life expectancy at birth and prevalence of diseases

1. Cause multiple diseases or is part of risk factor of diseases

2. Reproduced over time
3. Involves access to resources that can assist in avoiding health risk and minimize consequences of
disesaes

SES – education, income and occupation status/prestige

The 4 mechanisms that may explain the health disparity

1. Artifact
a. Mostly debunked since it argues that the association is not a real representation, is a
statistical anomaly from the way dtata is colleted – but more evidence shows otherwise
2. Selection
a. People are recruited to social classes based on their health, but largely dismissed since
debilitating illness tend to strike at later years down the road where social classes have
already been decided.
3. Behavioral and cultural
a. Health behaviors, social network, social capital and social cohesion
4. Material and structural
5. Psyscho-social
6. Life course theory

What is a characteristic of contested illness?

1. There is lack of consensus among medical professionals about the biological nature of the
disease
2. Instead of being diagnosed by health professionals through biomedical markers, it is often done
so through patient presentation of symptoms .
3. Diagnosed by exclusion
4. Most often experienced by females
5. It can vary on a spectrum from being entirely false and discredited to being fully legitimate
 6. Living with contested illness means not only living with medical uncertainty and skepticism, but
also managing a range of chronic and debilitating sytmpoms
7. Patients want medicalisation to have help and treatment available to them
8. Social constructionism ties both medicalisation and contested illness together, where contested
illness is a illness not medicalised but desires to be medicalised – illness categories are socially
constructed, and not automatically ascertained from scientific or medical discoveries

There is a rise in prevalence of contested illnesses because

1. There is a change in patient-physician relationship, where physician’s diagnosis provides the

patient a treatment protocol and legitimises the patient experience, and the diagnosis helps to
give meaning and consolation to the patient’s symptoms,as a result of th need for diagnosis,
many medical specialites as at least 1 functional diagnosis such as fibromyalgia.
2. Public interolance of medically unexplainable but highly common symptoms, such as pain,
fatigue, mood and sleep disorders
3. Lay knowledge production and the ermgence of illness identities and communities
4. Bureaucratic and instititutional demands – such as insurance coverage for medical treatment,
access to healthcare resources

Bureaucratic and institituional demands and practices –

Hospital as a bureaucratic organization – because there is fixed hierarchy, extensive rules and
regulations, responsibilities and post are held by people with competence and based on competence,
regular renumeration, promotion based on objective criteria and recruitment based on merit

Fixed areas of responsibility based on competence

Weber’s concept – rational and impersonal division of labor, principels of office hierarchy and fixed and
official reas of jurisdiction government by laws or administrative regulations, owkr tasks are specialized,
interaction between hierarchy of offices with designated hcannels of communication and autuhority is
baed on written and recorded orders, authority is attached to the office and not the person in the office,
and when the person is nolonger in it the authority goes away.

1. Concept of bureaucracy is the fact that there is impersonal and rational division of labor
2. Through principles of office hierarchy and fixed and official – of which there exists written and
recorded orders
3. Authority stays with the post and not the person

Impersonal, rational division of labor and characterized by principles of hierarchy governmened by laws
or administrative regulations, work tasks are specialized and there is interaction within the hierarchy
through written and recorded orders and designated channels of communication

1. Designated channels of communication

2. Hierarchy with written and recorded orders
3. Specialized tasks
4. Division of labor is done rationally and impersonally
5. Authority to issue orders stays with the post and not the office

Dual line of authority

 - Hospital administrator vs medical director and both are responsible to a board of trustees

Hospitals prefer enforced cooperation of its patients through the patient sick role, with authority nd
depersonalization