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Health Systems overview

Dr. Unaib Rabbani

Learning Objectives
To understand the notion of Health system Difference between Health system and Health care system Evolution of health system Goals and functions of health system Health systems performance assessment

Economic system
A collection of economic units, agents, and institutions that interact coherently; adapting and adjusting to the social and physical environment


Health System
Definition: all the activities whose primary purpose is to promote, restore or maintain health
Professional delivery of Personal medical care Traditional healers Home care of sick Health promotion Health prevention Environmental interventions to improve health

Economic systems that are concerned with human health

Health Care System

Definition: Refers to provision and investment in the health system for preventive, curative and palliative interventions
Also refers to chemicals, devices, and services used by people to improve their health

Building Block of Health System

1. 2. 3. 4. 5. 6. 7. Primary health service delivery system Health workforce Leadership and governance to assure quality Health systems financing Supplying medical products and technologies Health systems information Physical Infrastructure

WHO health system conceptual framework (modified)

Instrumental goals Intrinsic goals

Health system is as old as mans deliberations to protect health Traditional practice can. . . Thousands of years
Chinese medicine 3000 years

Organized health system - - - a century ago Before 19th century hospitals were run by charitable organizations 19th century industrial revolution- - recognition of workers health

Germany 1883 - - law requiring employers to contribute to health coverage of low wage workers- - 1st example of state mandated social insurance Late 1800s - - Russia - - network of provincial hospitals 2nd world war destroyed health infrastructure but lead to development of new as well
national emergency service became in 1948, the National Health Service

Costa Rica 1941 put foundation of universal health insurance Post war period states adopted modern modern comprehensive health systems with heavy state participation India developed five year health plan

Generations of Health System

1st Generation
Foundation of national health care system Changing economical conditions Rising costs, increased burden, increase in out of pocket expenses on health Disparities between social classes and urban rural areas

2nd generation
Promotion of primary health care Disease control projects were launched Emergence of community health workers Inadequate funding, insufficient training and equipment, poor referral system, continued investment in the tertiary care Mismatch between demands and needs

3rd generation
New universalism
High quality of delivery of essential care Cost-effective Universal

Priority interventions Thorough training Regulated and guaranteed finance and subsidies Adequate health care personnel, capital and resources

Goals and Functions of Health System

Better health is raison dtre of health system Health is not a commodity Need for health care is unpredictable

Goals of Health System

Improving the health of the population they serve; Responding to peoples expectations; Providing financial protection against the costs

of ill-health.

Improving the Health

Defining goal for the health system Average level of population health Distribution of health within the population

Second intrinsic goal is to enhance the responsiveness of the health system to the legitimate expectations Two key sub-components:
Respect of persons Client orientation

Fair Financing
Common goals for all systems Key Challenges
households should not become impoverished or pay an excessive share of their income in obtaining needed health care poor households should pay less towards the health system than rich households

Fair financing begins from an ex post perspective

Stewardship Creating resources
Investment and training

Collecting, pooling and purchasing

Delivering services

Sets the context and policy framework Usually (but not always) a governmental responsibility Generates appropriate data for policymaking

Creating resources
Assembling of essential resources for delivering health services Human resources medications, and medical equipment Generally outside the immediate control of health system policy makers

Revenue collection: collection of money to pay for health care services
General taxation Development Assistance for Health Mandatory payroll contributions Premiums Direct household out-of-pocket expenditures

Risk pooling Strategic purchasing

Service Delivery
Most visible product of the health care system Delivering health services is thus an essential part of what the system doesbut it is not what the system is

Measuring Goal Achievement

Provide decision-makers with evidence: to inform strategies for health system development e.g. financing arrangements, provider regulation to inform implementation of programmes by local, regional and national managers to monitor progress towards national targets for health and health systems

Health system performance: Conceptual issues and Challenges

Measuring performance of health system building blocks
macro-level (national) micro-level (sub-national, district).

Influence of non-health system determinants on health outcomes Measuring performance

over time in country between countries within countries

Health systems performance assessment

Developing a categorization and a series of measures of key factors that may explain variation in health system performance is a very different task than articulating the goals of health systems. Any list is provisional

Measures for health status

Probability of dying before age five years or between ages 15 and 59 years Life expectancy

Measure of responsiveness
Respect for persons
Respect for dignity Confidentiality Autonomy

Client orientation
Prompt attention Quality of amenities Access to social support networks Choice of provider

Measures of fair financing

Fairness of financial contribution (FFC) Index
Measures inequality in the distribution of household financial contributions. Pakistan . . . .0.949 .. . .rank 63

Household catastrophic health expenditure

Proportion of households facing expenditure due to health payments that account for more than 40% of the annual subsistence (non-food) spending of the household.

Cross-system goals for the health system

How much does the health system help or hinder education Democratic participation Economic production etc. Need ad hoc analysis and evaluation

Health system building blocks: Assessment tools

Health system building blocks Governance Financing Examples of assessment tools and instruments Health system governance framework Essential public health functions National health accounts Health expenditure surveys Fairness of financial contribution index Health workforce surveys Health workforce observatories



Health system analysis

Health technology assessment Medicine pricing surveys

Service provision

HIS assessment tools

Health system analysis