Health Systems

Learning Objectives:

1. Describe health systems functions, processes
2. Understand primary health care
3. Consider challenges of human resources for health
4. Appreciate recent global policy initiatives:
   1. Universal coverage
   2. Code of Practice on International Recruitment

 

Health is a basic human right

Universal Declaration of Human Rights Article 25: everyone has a right to a standard of living adequate for the health and well being of themselves and their family, including medical care, social services and security in the event of sickness, disability or old age UN Convention on Economic, Social and Cultural Rights Article 12: everyone’s right to enjoy the highest attainable standard of physical and mental health

 

 

1. Health Systems, What are they?

SYSTEM:

• General systems approach: seeing the situation as a whole

“A set of interrelated and interdependent parts, designed to achieve a set of goals”

• Systems analysis: the separation of systems into components for further study, which usually consists of examining the influence of one or more components on system performance

Health Systems

‘The combination of resources, organisation,financing and management that culminate in the delivery of health services to the population‘ – Roemer 1991 Virtually all aspects of nature, society and human relations influence health The health system is bound by phenomena that culminate in health services ‘All the activities whose primary purpose is to improve health’ – WHO 2000

What are the goals of health systems?

1. ‘Adding years to life and life to years’

1. Provide services efficiently and equitably
   
   1. To improve the health of the population
   2. Respond to the expectations of the population
   3. Fairness of financial contribution

Functions of a health system:

1. Provide health services
2. Generate resources for health
   1. Raise money and provide staff, stuff, knowledge…

1. Finance health services
   1. Pay for delivery
2. Stewardship
   1. governing / regulating / policy making / enforcement

 

Levels of healthcare services:

Primary	Secondary	Tertiary
– individuals, families – village/community level: CHW/TBA 1/1000 – health centre – midwife, medical assistant 1/10 000 – curative, preventive, promoting, referral	– District hospital – Trained nurses, midwives, doctor 1/100 000	– Regional / national teaching hospital – High tech

As Tertiary care is usually “advance technology” it is the most expensive health service; however, the rich are the ones that fund their healthcare hence, we have this situation of:

• Inversion of health care expenditure to population served

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Major components of a Health System

1. Production of resources
   1. Human and physical (labour and intellectual)
2. Economic support mechanisms for financing both formation of resources and provision of services offered
3. Management methods
4. Organisation of programmes
5. Delivery of services

Health Needs (population) → (translates) → Health Results!

 

a. Levels of healthcare services

1. Health manpower/personnel
2. Facilities
3. Commodities
4. Knowledge

i) Manpower (human resource)

Physicians	Other independent health practitioners
Person who has completed course of studies in Medicine and has acquired qualifications to practice medicine (prevention, diagnosis, treatment, rehabilitation) using independent judgment Specialised training Continuing education	Dentists Opticians Pharmacists Psychologists Social workers Traditional healers Complementary therapists
Allied personnel supportive to independent practitioners	Direct service with nominal supervision
Nurses Nurse-midwives Laboratory technicians Radiographers Dieticians Record clerks Therapists: physio, occupational, speech Pharmacist Many more…	Community health workers Public health workers Environmental health Health promotion Administration Information specialists

2. Facilities (resource)	3. Commodities
Hospitals General ambulatory care units Special clinics Long term care facilities Environmental health protection Specialised units	– Drugs and biologicals – Medical supplies antiseptic, suturing, splints, lab reagents, xray film, linen, paper… – Medical equipment thermometers, syringes, refrigerators, laboratory equipment, diagnostics, surgery…

4. Resource: Knowledge

• Education
• Research
• Experience
• Dissemination

 

B. Economic support of Finance

Models of funding: (questions)

• Overall levels of funding
• Sources
• Who purchases healthcare?
• How are funds distributed?
• How are providers funded?

3 Models of Health Systems
(OECD 1987)

1. National Health Service (Beveridge Model)	2. Social Insurance Model (Bismarck model)	3. Private insurance model
universal coverage, national general tax financing,   national ownership and/or control of factors of production (see UK)	compulsory universal coverage generally within framework of Social Security, financed by employer and individual contributions through non-profit insurance funds (see Germany)	employer based or individual purchase of private health insurance coverage financed by individual and/or employer contributions (see USA)

 

C. Management of Healthcare Services

1. Planning
2. Administration
3. Regulation
4. Legislation

 

D. Organisation of Programmes (health)

• Ministries of Health
• Other government agencies with health functions
• Voluntary bodies
• Enterprises
• The private market

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3. Challenges of Human Resources for Health

What is good Healthcare? Who should get what healthcare? How to distribute resources fairly?

Evaluating health systems

• Quality
• Equity
• Targets: Is it doing what it is supposed to do?

Dimensions of Quality

Effectiveness

Efficiency

Equity

Accessibility

Acceptability

Relevance

Maxwell 1984

 

Definition of quality in health care

UK	US
doing the right things to the right people at the right time and doing things right the first time The New NHS	“the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” Institute of Medicine, US

 

Equity

What constitutes fairness of financing or access?

Horizontal equity	Vertical equity
Equal treatment of equals individuals with same condition should have equal access to services	Individuals who are unequal should be treated differently consumers should be charged according to ability to pay

 

‘Should we use the Vertical or Horizontal programmes?’

Vertical: WHO 1946-1977

• Smallpox, malaria, TB
  • Why did smallpox programme work?
• Return for vertical programmes in last 10 years
  • Roll Back Malaria, Stop TB

Specific disease related

• ? efficiency
• ? sustainability

Broader determinants

Sector wide approach

In the “developing” countries, the economic inequality is usually quite high. Vertical equity would then be more “finacable” as the rich aid the poor; allowing for more to receive healthcare. Attaining the same level of “quality-of-lifespan”

 

What is Primary Health Care? (models)

Primary health care Chinese model 1957 Arusha declaration 1967 Alma Ata 1978 Consider Sri Lanka, Kerala

Concepts: emphasis on preventive services rural / peripheral services appropriate services: low tech intersectoral collaboration (eg sanitation) community participation

Local Concoction; Folk medicine – Traditional Medicine

• Formal traditions
• Folk medicine and healing
• “Eclectic market medicine”
• Internationalised treatments and healing

Should we follow the local practices in healthcare?

Medicines

WHO model list of essential drugs has been updated every 2 years since 1977 Most recent: 340 active substances Promoting rational drug use WHO Standard Treatment Guidelines Training materials

 

Healthcare Reforms

• Demand outstrips resources everywhere; hence reforms are important to advancement

A. Increased efficiency	B. Managing demand better	C. Managing public expectations
Encouraging more Cost-effective care incentives	Priority scoring systems to ensure the most severely ill have greater access to care	Debate, Awareness of limitations

 

Objectives of Reformation:

1. Better access with better cost control
2. Greater efficiency and patient choice
3. Evidence based policy and practice with new ideas and innovation

Alma Ata “The right of people to participate individually and collectively to health care planning and implementation” Declaration of Alma Ata http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf World Health Report 2008 stresses need to return to Alma Ata principles Waves of reform 1940s-60s: setting up of national health systems 1970s: promotion of PHC 1990s: cost effectiveness 2008: Now More Than Ever… 2010: Health System Financing: universal coverage

 

Shortcomings of healthcare delivery

1. Inverse care
2. Impoverishing care
3. Fragmented / fragmenting care
4. Unsafe care
5. Misdirected care

 

Primary Healthcare (PHC) in Developing Countries:

Not as cheap as it seemed:

• Whole systems weren’t considered initially:
  • eg estimates of cost of measles vaccine for an individual at peripheral level did not consider supervision, transport etc

Hoped for resources to develop PHC failed to materialise:

• Debt, oil crises
• Structural adjustment programmes

PHC strategy 1978-1982	Selective PHC 1983-1992
ELEMENTS: Education Local disease control EPI MCH Essential drugs Nutrition and food supply Treatment of common diseases and injuries Sanitation and safe water	UNICEF: GOBI-FFF Growth monitoring Oral rehydration Breast feeding Immunisation Feeding programme Family planning (finances) Female education (mothers)

Investing in Health
World Development Report 1993: World Bank

• DALY – attempt to define a unit of health: measures burden of disease.
• Cost effectiveness analysis (DALYs gained per $ spent) should guide spending priorities

Agenda for Action

Foster an enabling environment to improve health Pursue policies that benefit the poor Expand investment in education, particularly females Improve government investments in health Reduce expenditure on tertiary care facilities Facilitate involvement by the private sector

 

Health system reforms 1993-2000

• World Bank Report 1993: Investing for Health
• Decentralization of management and financial responsibility

• Increase and diversification of fees for public service
• Shift to more privately financed and privately provided services
• Awareness of costs: cost benefit analysis

 

Evidence on PHC (reform has benefited population)
population health is better in geographic areas with more primary care physicians individuals who receive care from primary care physicians are healthier	association between the special features of primary level care (eg preventive care) and improved health in the individuals who receive these services reductions in infant/child mortality

 

Features of healthcare	Planning Healthcare Services
Access Use Experience Influences on other sectors	Need Capacity to benefit Demand Expressed need Use

• Does use reflect need?
  • Services are funded –> use the service without needing it; Use > Needs
  • Inability to get to service, Use < Needs

 

Access: (3 As)

Availability	Affordability	Acceptability
Location Transport   Waiting time	Costs of seeking care Households’ ability to manage costs Impacts on household livelihoods	Social/cultural distance between healthcare systems and users Fit between lay and professional health beliefs Patient-provider engagement/dialogue Influence of health care organisational arrangements on user responses to services

 

Other impacts of health systems

Other then the improvement of health of the population, healthcare also impacts other systems

Economics:

1. Employment
2. Workforce structures and practices

Social:

1. Empowering socially disadvantaged
2. Enabling dialogue

 

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4. Appreciate recent global policy initiatives:

Re-distributive health systems

1. Goal: Universal Coverage
   
   1. Public funding plays a central role
   2. No / very low fees for public services

1. Set of comprehensive services offered
2. The private sector complements the public sector

Universal Health Coverage

means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

I.e. Vertical Equity

“We also recognise the importance of universal health coverage to enhancing health, social cohesion, and sustainable human and economic development”

Rio Declaration on Sustainable Development 2012

 

The Big Issue

Demographic and epidemiological change Global burden of disease, ageing, non-communicable disease Prevention   Quality, Access and equity

Stewardship Governance Human resources Financing rationing

Why should we help people globally? (healthcare)

Impact of poor health:

1. ‘Negative spillovers’
   1. Individuals, communities, countries
   2. Spread of diseases
   3. Social disparity

1. Society has a vested interest in ensuring that poor people have access to health care
   1. Labour force = economics

Constitution of WHO 1948

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition…”

The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.

The achievement of any State in the promotion and protection of health is of value to all. (even other countries)

Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. (epidemics across the globe)

Causes of poor health outcomes:

1. Access to services (not nearby)
2. Nutrition (lack/absence of proper food – no fresh produce – mcdonalds etc..)
3. Safety (civil wars/society)
4. Environment (unclean)
5. Lack of Knowledge, literacy, health seeking behaviours
6. Stress: social status

Implementation:

Minimum package?

• Prioritise low cost interventions of demonstrated cost effectiveness:
  • Focus on Group I diseases and some of II (NCD) and III (trauma)
  • $60 per person (2012 estimate)

• Health policy on effects outside health system:
  • Infrastructure, agriculture, social protection, tobacco

Affordability:

Individuals	Country
What can poor people afford? Cash flow Even a tiny user charge can reduce access for poorest!	What can a country afford? If GDP is $300 (eg Ethiopia) Public services cost about 20% = $60 all public services: education, infrastructure, electricity, etc as well as health… Abuja Declaration: 15% of total budget to health means $9 in Ethiopia $60>>>$9: External Assistance Needed!

 

 

 

 

Global Code of Practice

1. Minimise negative impact of out-migration from source countries
2. Protect migrant workers

Health Labour Markets; Increasing Mobility