global health promotion
sjsaaorabi
Chapt5Slides.pptxAn Introduction to Health Systems
Chapter Five
Chapter 5: An Introduction to Health System
In this chapter we will be examining different aspects of health system and how health systems are organized.
1
What is Health System?
Components of Health System
Goals: Promote, restore or maintain health
The Ultimate goal of a health system is to promote, restore and maintain health. So we can define health system as organizations where all the activities are carried out with the intention of promoting, restoring or maintaining health. Anything that are related with such notion started from the agencies that plan, fund, and regulate health care; the money that finances health care; those who provide preventive, and clinical health services and the specialized person who provide specialized inputs through education are integral part of health system.
2
Agencies that plan, fund and regulate health care
The money that finances health care
Those who provide preventive health services
Those who provide clinical services
Those who provide specialized inputs into health care, such as the education of healthcare professionals and the production of drugs and medical devices
The Functions of a Health System
Goals:
Good health.
Responsiveness to the expectations of the population.
Fairness of financial contribution.
Functions:
Provide health services.
Raise money that can be spent on health, referred to as “resource generation.”
Pay for health services, referred to as “financing.”
Govern and regulate the health system, referred to as “stewardship.”
In addition to provide good health, other goals of health system include responsiveness to the expectations of the population and fair financial contribution. The main functions of a health system are to raise money for health services, provide health services, pay for health services, and engage in governance and regulation of health activities.
3
Health System Building Blocks
WHO has developed a framework for different parts of health system which include six building blocks. These include good health service delivery in the form of safe and effective health interventions, a health workforce which has the right number of trained staff in the right field, a health information system that effectively disseminate health information for monitoring, equal access to medical products, vaccines, and technologies, enough funding , and open and accountable leadership .
4
Outcome of health system
So do health systems really matter? What are the impacts we have seen after adopting an organized health system? Let us look at one of the health indicators-life expectancy. In developed countries life expectancies increased from 65 to 77 years and in low and middle income countries it increased from 40 to 64 years. So we can say that better health systems can effectively deliver treatments and prevention.
5
Simplified Categorization of Approaches to Selected Health System Issues
Adapted from Birn A-E, Pillay Y, Holtz TH. Textbook of International Health. New York: Oxford University Press; 2009.
How are Health Services Organized?
There is no ideal way to categorize the health systems. This table is one attempt to broadly categorize all the health systems exist now.
The first one of this table is the National Health Insurance. Countries like Canada, France, and Germany have this type of health insurance. In these systems all people are offered health insurance for an agreed package of service. It could be offered through government or different insurance providers through NGOs. The finance for the health insurance may come from general taxes as in the case of Canada, or may come from payroll tax contributions from employer and employees as in the case of Germany.
In national health insurance schemes, government usually use funds from general tax to buy the insurance for those who are not able to make contributions to the insurance scheme such as the unemployed. This type of system considers health as a right and most of the high income countries except USA follow this right. Some middle income and low income countries have adopted this principle and trying to implement it. System that follow National Health Service, except for few small private health sectors, government is the sole payer for the for the health care owns the health facility. This is the case for United Kingdom. In their model, the public insurance scheme is adherent to and linked with National Health Service and the constituent part of National Health raises their funds through general taxation. In pluralistic system, the one that exists in USA and most of the low and middle income countries public sector, private sector, not for profit all plays important roles. In this system, insurance can come in many forms and so many people could lack insurance. In this setting government may finance through general tax health insurance for special groups such as disabled, aged, and poor. Mostly people rely on private insurances that are financed by individual and employer contributions and substantial amount of finance comes from out of pocket expenditure.
6
National Health Insurance and National Health Service
National Health Service 1948: https :// www.youtube.com/watch?v=Tymq5CefW-E
The Basic Economics of National Health Insurance - Professor Richard D Wolff:
https ://www.youtube.com/watch?v=_ dxGdD830ZU
The first video here is a short clip from a film from 1948 by British Government introducing the original aims of the National Health Service
The second video explains the basic economics of National Health Insurance scheme.
7
Categorizing Health Services
Dimensions used to examine health systems:
Approach of each type of health system to providing a basic package of health services as a “right.”
Who owns health facilities.
Manner in which insurance is operated.
Manner in which insurance schemes are financed.
The dimensions that were used in assessing different health systems (look in the previous slide) are- what kind of approach countries have adopted in delivering health service, who owns the health facilities, in what manner insurance is operated and how the insurance scheme is designed.
8
Low income countries
Most low-income countries have fragmented health systems that include both public and private providers(e.g. Bangladesh)
Middle income countries
Many middle-income countries have a system organized around a national insurance scheme (e.g. South Africa)
High income countries
Almost all high-income countries have a national health insurance system (e.g. Canada)
E.g. Middle income country: Cuba
Cuba is mentioned in global health a lot because of its significance success. The table presented here mentions the demographic, health and social indicators.
9
HIV/AIDS transmission is considered low, with an estimated prevalence in 2004 of 0.05%.
The benefits of the HIV/AIDS program, which includes triple antiviral therapy, are provided free-of-charge to all people living with the disease.
E.G. MIDDLE INCOME COUNTRY: CUBA
Cuba has successfully eliminated diseases that are considerable burden in other geographic location of the globe.
10
How are Health Services Organized?
Low and middle income countries have levels of health system organized by geographic area.
PMC for every 5000-10,000 people.
Secondary hospital for a district.
Tertiary hospital in large cities.
Health systems have three levels of health care: primary, secondary, and tertiary. Depending on the country, the public, private, and nongovernmental sectors participate in different parts of the health system. Most low- and middle-income countries have established a health system that provides each level of care on a geographic basis
11
Tertiary
provided by
an array of
specialist physicians
and
specialized hospitals
Secondary - provided by some specialist physicians and general hospitals
Primary - first point of contact
Typical Health System Services in Low-Income Countries By Level
This table displays the different levels of health care provided in different levels of health care system.
12
Primary Health Care
Declaration of Alma-Ata
Speaks of health as a human right
People’s right to participate in planning and implementation of health care
Outlines content of primary health care:
The concept of primary health care emerged from a historic conference in Alam-Ata, one of the important global health events, in the former USSR. This declaration takes into account two things. First, health is a human right and second people’s right to participate in the planning and implementation of health care. This document also outlined the content of primary health care which are mentioned above in five different boxes.
13
Essential and socially acceptable
Evidence based and universally available
Affordable and address the needs of the community
Linked through referral system
Reflection of key determinants of health
The Roles of the Public, Private, and NGO Sectors
Public
Stewardship of the system
Raising and allocation of funds
Establishing approaches to health insurance
Managing key public health functions
Private, For-Profit
Provision of services including non-licensed “medical practitioners”
Operation of health clinics, hospitals, services, and laboratories
Can partner with the public sector or work under contract to the public sector
NGO, Private Not-For-Profit
Community-based efforts to promote better health through education, improved water and sanitation
Carry out health services
Can partner with the public sector or work under contract to the public sector
Now let us see how public and private sectors take part in the health care financing. When public sector is the actor, it is responsible for the “stewardship” of the system, responsible for raising funds and allocating them. They are also responsible for financial protection from health cost which is known as establishing approaches to health insurance and for managing public health functions such as setting public health policies, enforcing regulations related to health and so on.
In private for profit setting sector health is more like a commodity. In some countries physicians operate in private for profit sector as it happens in most of the lower income countries. Hospitals, health clinics, laboratory may also operate under private sectors. The private for profit sector can operate on own financing and it can sell its service to the government. The third one is NGO-private not for profit mostly operates in low and middle income countries. NGOs could be small, may be local, national or international. NGOs work through community based efforts to promote better health.
14
Health Sector Expenditure
Total health expenditure as a share of GDP varies across countries.
Wide range of private sector expenditure as share of total expenditure on health.
Poorer countries have the highest private expenditure.
Health sector is an important part of the economy in all countries and its outcome depends on government’s willingness to allocate the financial resource in that area. Total health expenditure is measured as a share of GDP of that country.
15
Total Health Expenditure as a Percentage of GDP and Private Expenditure on Health as a Percentage of Total Expenditure of Health
Source: World Bank http:// data.worldbank.org/indicator/SH.XPD.PUBL/countries/1W?display=map Accessed Jan 14, 2016.
From this table it is evident that health expenditure as a share of GDP varies across the countries. It could be as low as 2.4 for Indonesia, 2.6 for Pakistan, 3.4 for Bangladesh but the majority of the health spending in these countries occurs in private health sector. In contrast, countries like Costa Rica, Denmark and United States spend 10-16 % of their GDP on health but comparatively spent less (except USA) on private health expenditure.
16
Selected Examples of Health Systems: High income countries
Germany
“Social insurance scheme”
Organized around insurance funds financed by employers and employees
Funds serve as an intermediary to organize and pay for services
Funds have contracts with associations of physicians and hospitals
Government regulates health system
Now, we will examine some examples of health system in various countries. The first one in this series is Germany, a high income country, which is also the first country to have “universal health insurance program” otherwise known as “social insurance scheme”. This system is organized by “sickness fund” where employer and employee make equal contributions (depending on the salary), government makes contribution for those who are unemployed or retired. These funds act as intermediary and pay for the different kind of services provided by health care workers or hospitals. The beneficiary receive the care at free of cost most of the time and for some services may pay co-payments. The sickness fund covers 90% of the population and 10% of the population has private health insurance.
17
| Indicator | Year 2010 |
| Life expectancy | 80 |
| Infant mortality rate | 3/1000 live birth |
| Under 5 mortality | 4/1000 live birth |
| Crude birth rate | 8/1000 live birth |
| Maternal mortality ratio | 7 |
| Total expenditure on health as % of GDP | 11.6% |
| Private expenditure on health (as % of total expenditure) | 22.9% |
| Government expenditure on health | 77.1% |
Germany, cont.
(no audio)
18
HIGH INCOME COUNTRY:
THE UNITED STATES
Combination of public and private financing
Overwhelmingly private provision of care
50% of financing comes from Medicaid, Medicare, Veterans Administration, and Worker’s compensation
Remaining 50% of financing comes from individuals and their employers
Types of health insurance vary greatly
Many people lack insurance (15%)
Question: What is Obama care? How is it working as a part of the United State’s health
care system?
In the United States, almost 50% of health financing comes from public fund namely Medicaid, Medicare, veterans administration, and worker’s compensation. Another 50% are through private fund mostly from employers and employee both contributing to the cost. The plan of insurance varies greatly, some plans allow patients to see any doctor, and others require that they only see the doctors the plan is contracted with. Some plans are under health maintenance organizations that provide a set of agreed service for its member for an annual charge. The US system is the only high income country in the health care system that is not founded on the principal that health is a right and everyone should be treated irrespective to their ability to pay. As a result of this a good number of people are uninsured.
19
| Indicator | Year 2010 |
| Life expectancy | 78 |
| Infant mortality rate | 7/1000 live birth |
| Under 5 mortality | 8/1000 live birth |
| Crude birth rate | 14/1000 live birth |
| Maternal mortality ratio | 21 |
| Total expenditure on health as % of GDP | 17.9% |
| Private expenditure on health (as % of total expenditure on health) | 46.9.9% |
| Government expenditure on health (as % of total expenditure on health) | 53.1% |
USA, cont.
(no audio)
20
Middle-Income Countries: COSTA RICA
Federal government controls most of the health sector directly
Country is divided into Health Areas served by health teams
Social Security Administration owns most hospitals
Financing provided by taxes
Participants receive most services for free
Like UK, the health sector of Costa Rica is regulated by federal government. The Costa Rican Social Security Administration (CCSS) owns most hospitals. Most doctors are employed through public sector even though they do private practice. People, who are working in formal sector of the economy, are require to participate in the social security administration which is financed by taxes from wages and government’s general tax fund. Everyone contributes to the fund of CCSS, employer, employee, government. All the residents of the country have access to universal health care. Poor are covered by government and informal sector workers could join the CCSS with fees that depend on their income. Government has divided the country in health areas each of which has nine health team serving 4000 people.
21
| Indicator | Year 2010 |
| Life expectancy | 79 (2011) |
| Infant mortality rate | 9/1000 live birth |
| Under 5 mortality | 10/1000 live birth |
| Crude birth rate | 16/1000 live birth |
| Maternal mortality ratio | NA |
| Total expenditure on health as % of GDP | 10.9% |
| Private expenditure on health (as % of total expenditure on health) | 31.9.9% |
| Government expenditure on health (as % of total expenditure on health) | 68.1% |
Costa Rica, Cont.
(no audio)
22
Middle-Income Countries BRAZIL
Three Parts
Publicly owned services at the federal, state, and municipal levels, as well as the military
Private sector services contracted by the public sector
Private sector services paid for by individuals or corporate health insurance
Brazilian health system has three main parts. The first service is federal, state, municipal and military level which are publicly owned and publicly financed.
The second sector is private but is contracted by public sector. Both of these two sectors operate under Unified Health System. The third part of the health care is private sector paid by individual and corporate health insurance. In Brazilian health care system, municipalities offer primary and secondary level of care and state provided tertiary level of care.
23
| Indicator | Year 2010 |
| Life expectancy | 73 (2011) |
| Infant mortality rate | 17/1000 live birth |
| Under 5 mortality | 19/1000 live birth |
| Crude birth rate | 16/1000 live birth |
| Maternal mortality ratio | NA |
| Total expenditure on health as % of GDP | 9% |
| Private expenditure on health (as % of total expenditure on health) | 53% |
| Government expenditure on health (as % of total expenditure on health) | 47% |
Brazil, cont.
(no audio)
24
Low-Income Countries INDIA
Tiered public sector network including health sub-centers, primary health centers, community health centers, and hospitals
Large private sector which accounts for about 80% of all healthcare expenditures
Two large government insurance schemes, but mostly for public sector employees
Most people lack insurance
Video: India’s healthcare system: https :// www.youtube.com/watch?v=RNM1BsTSzvs
The lowest level of health service in India is a health sub center which serves 3000 to 5000 people. Sub centers are staffed by one male and one female worker. Primary health care center serves 20,000-30,000 people and are staffed with a physician, a nurse, a female multipurpose worker, a health educator, a laboratory technician, and an assistant level staff. Community health centers serve 80,000-120,000 people and are staffed with a physician, a pediatrician, a gynecologist and a surgeon as well as a number of paramedical staff. Each community health center has a hospital with 30 beds, a laboratory and X-ray facilities. At the top of the health care system are fully fledged hospitals of varying size and complexities. Those are free of charge. In addition to public health care system, India has large private health care system which accounts for 80% of all health care expenditure. There are two large government insurance schemes. One serves federal employees and other is open to public. Private sector organizations and both the employer and employee make contributions to the scheme.
25
| Indicator | Year 2010 |
| Life expectancy | 65 (2011) |
| Infant mortality rate | 48/1000 live birth |
| Under 5 mortality | 63/1000 live birth |
| Crude birth rate | 22/1000 live birth |
| Maternal mortality ratio | 200 |
| Total expenditure on health as % of GDP | 4.1% |
| Private expenditure on health (as % of total expenditure on health) | 70.8% |
| Government expenditure on health (as % of total expenditure on health) | 29.2% |
India, Cont.
(no audio)
26
Low-Income Countries: Tanzania
Largely managed and provided by public sector
System includes village health posts, dispensaries for primary care, health centers, district hospitals, regional hospitals, and tertiary hospitals
Basic package of health services may be provided for free
Some low-income countries, however, do have an active private sector
Tanzania’s health system is largely managed by public sector like other low income countries in Africa. Part of the reason for having public sector in the main role is after gaining independence Tanzania prohibited the provision of for profit health services. The health care system of Tanzania is consists of several levels. At the lowest level, there are village health posts. They are staffed by two community members who are trained to focus on disease prevention and health promotion. Dispensaries are the second level of health care that serve 6000 to 10,000 people and are staffed by clinical officer, nurse midwife, maternal and child health aide, nurse assistant and laboratory assistant. Secondary care starts at the level of health centers which are staffed by physicians, pharmaceutical technicians, medical clerk and all other facilities that dispensaries have. These health centers serve approximately 50,000 people. At the district level it was expected to have a public hospital however, when public hospitals are not possible, government helps in financing NGOs that operate hospitals. Above district level hospital there are regional hospitals that serve similar functions with some added specialty.
Tanzania has four tertiary level hospitals that provide the highest level of services available in the country. The basic health care that is provided in primary health care is free in Tanzania.
27
| Indicator | Year 2010 |
| Life expectancy | 58 |
| Infant mortality rate | 50/1000 live birth |
| Under 5 mortality | 76/1000 live birth |
| Crude birth rate | 41/1000 live birth |
| Maternal mortality ratio | 460 |
| Total expenditure on health as % of GDP | 6% |
| Private expenditure on health (as % of total expenditure on health) | 32.7% |
| Government expenditure on health (as % of total expenditure on health) | 67.3% |
Tanzania, Cont.
(no audio)
28
Key Health Sector Issues
In general, health systems in high-income countries perform better than those in low- and middle-income countries.
Health systems of a small group of middle-income countries (Costa Rica and Morocco) rate higher in the WHO ranking than countries with higher income.
All systems struggle with a variety of challenges and constraints.
According to WHO health criteria, some health system performs better than others. In general, high income countries perform better than do other health systems in low and middle income countries. However, in this platform a small group of middle and low income countries such as Costa Rica and Morocco rate higher in WHO ranking than a number of countries with high income countries. A variety of challenges and constrains all health system suffer in relation to health outcomes. Among them are the issues of changing epidemiologic and demographic patterns, governance of the health sector, having an appropriate number and disposition of healthcare personnel, the financing of health care and the role of private sector in the overall health system.
29
Overall Health System Performance Ranking, Selected Countries
These are some examples of overall health system performance rankings.
30
Health system performance rankings
A full list is available at:
http:// www.who.int/healthinfo/paper30.pdf
The lowest: The highest:
The worst health system systems ranking is Sierra Leone, based on overall efficiency as determined by the WHO. The highest health systems ranking is France.
31
Concerns
Reduce cardiovascular disease burden related to tobacco
Strengthen health systems
Adopt models of care that sustain more frequent contacts with patients
DEMOGRAPHIC AND EPIDEMIOLOGIC CHANGES
Issues
People are living longer so societies will face a greater burden of non-communicable diseases
Cost of treating non-communicable conditions is high
Poor countries face burden of communicable diseases, non- communicable disease and injuries simultaneously
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS
In high income countries people are living longer, so is true for low income countries as life expectancies have increased for these countries. As people are moving to high life expectancy, the epidemiological changes are occurring from communicable to non-communicable diseases. The burden for treating non communicable disease is high. As low income countries are still dealing with the burden of infectious disease, the added burden of chronic disease and injury put these countries in significant economic constrain.
For low income countries they need to find out the cost effective ways to fight the battle of chronic and infectious disease. For example, a number of chronic disease (e.g. cardiovascular disease) burdens could be reduced by reducing the consumption of tobacco. Evidence suggests that policies such as high price of cigarette could reduce consumption of tobacco smoking and thereby could reduce disease burden. Low income countries also need to take measures to ensure the safety of roads by better engineering, safer cars, and more traffic enforcement.
32
Issues
Problems of governance in many low- and middle-income countries
Penalize poor people in particular because they have less choice and power
Governments unable to enforce health sector rules and regulations
Weak management of human resources
Poorly built facilities
Substantial corruption
Concerns
National anticorruption programs
Reform procurement systems
Increase audits of the health system
Improve transparency
Oversight by communities
Contract out services
Key Health Sector Issues & addressing key concerns - Stewardship
In high income countries, the health care sector is operated in more transparent and open way. They tend to have clear rules and regulation and tighter law enforcement which results in very little corruption in health sector. In the low and middle income countries however, the government is weak across all strata which leads to corruption affecting health care sector of the countries as well. Poor people are penalized more and they do not have means of affordability to seek health care in private sector. Going to a private sector for health care brings financial catastrophe for poor people. The management of the health care system is also weak; often recruit people by connection rather than on merit. The issue of bribery is so rampant that the people who are recruited though the use of bribery, often absent from their job. As a result the end receiver of health care suffers most. In many places health care personnel charge money to the patient for the service which is meant to be free.
It is more challenging in countries where corruption is huge issue to improve the health governance. However, there are a number of countries that adopted certain measures which help decrease the corruption. For example, in Poland, national anticorruption program with strong political backlashing help achieve reduced corruption. Countries like Chili and Argentina reformed procurement systems and made them more open. Increased number of audits in health system with penalties in case of adverse findings helped Madagascar to reduce its corruption.
33
Issues
Poorest countries do not have enough healthcare personnel to operate a system effectively
Quality of training, knowledge, and skills is deficient
Lack of incentives to perform jobs properly
Staff not well distributed to poor and rural areas
Brain Drain-health care personnel move to other high income countries
Concerns
More shared global responsibility for resources
More explicit strategies for workforce development focusing on coverage, motivation and competence
Train lower level personnel to carry out functions usually reserved of higher-level staff
Financial incentives
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS - HUMAN RESOURCE ISSUES
Poorest countries face human resource issue from every aspect. They do not have enough physician, nurse, lab technician, for some countries where they have staff that are well trained they are tend to cluster around urban areas so rural areas are deprived of health care. Public sector salaried staff earn comparatively very less than private sectors. On top of all these issue, there is another issue which is brain drain, qualified health care personnel move to other high income countries.
To face the issue of human resources, it has been suggested to have shared global responsibility for resource allocation. Support for education and training is much needed to reduce the event of brain drain. Countries should focus on for more explicit work environment, motivation, competence, and to provide better financial incentives for healthcare personnel.
34
Issues
Health services should be safe, effective, patient-centered, timely, efficient, and equitable
Evidence suggest that low-, middle-, and high-income countries have problems with quality
Many countries have weak systems of monitoring performance
Concerns
Carry out assessments of quality gaps
Better professional oversight, supervision, and continuing training
Use of clear guidelines, protocols, and algorithms
Link payments with performance when contracting out services
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS - QUALITY OF CARE
Low ,middle and high income countries all suffer from important problems in quality of health. Quality varies across health system. In USA studies have shown that out of 306 hospital region only in 8, physicians comply with evidence based guidelines for at least 80% of the patient. In Papua New Guinea, a country endemic for malaria, only 24% of health care workers could successfully recognize the symptoms of malaria. Many low income countries do not have strong, structured monitoring system in health care to measure the performance status of health services.
Low quality health care could be detrimental as it is a waste of money and resources and could harm people’s health. Health system should carry out assessment to find out the gaps in the quality of care and then should be supervised by better professionals and with the use of clear, protocols and guidelines. For service contract with NGOs payment for performance method should be followed to ensure better quality.
35
Issues
All systems have to ration services in some way
Significant lack of public sector resources in low- and middle-income countries
Many low-income countries do not provide the health sector with the public funds needed to ensure an appropriate basic package of services is provided
Concerns
Shift resources from other areas of the economy
Shift expenditure within health sector to a selected group of low-cost, highly effective investments
Improve efficiency
Monitor investments more carefully
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS - THE FINANCING OF HEALTH SYSTEM
The issue of finance varies by the economic condition of countries. High income countries face the issue of financing the health care cost of aging populations and the use of new drugs and technologies. Low and middle income countries do not spend effectively the limited financial resources they have. It is also a fact that low income countries lack the fund needed to provide to health sector for providing basic health care package.
WHO estimated that in low income countries between 20-40% of expenditure on health is wasted. Given the fact that low income countries have very limited resources such waste could be effectively used for better outcome in health. Since there is high return in health investment, countries should make every effort to properly allocate money in health sectors even if that means shifting resources from other sector. Prioritizing areas that have the potential for maximum health outcome with effective management is vital for financial resource allocation.
36
Issues
Capacity of people to pay for health services is a barrier to access
Catastrophic costs impoverish people in many settings
Providing all people with an insured package of services is a key goal
Concerns
Raise additional revenue
Improve efficiency of health sector expenditure
Reduce dependence on out-of-pocket expenditures
Enhance equity
Provide basic primary care package
Subsidize selected hospital services
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS - FINANCIAL PROTECTION AND PROVISION OF UNIVERSAL COVERAGE
In high income countries even if people are unable to pay their bills, they might not face catastrophic events because they have social insurance scheme. In poor countries however people need to make the choice between health care and living. Studies in India have shown that expenditure on health push people fall below poverty line. Families need to sell their asset to pay the bills.
According to WHO countries need to take measures to reduce the burden of disease and to achieve universal coverage of a basic package of health care. This could be achievable by raising additional revenue, improving efficacy in health sector expenditure, reducing dependency out of pocket expenditure, and enhancing quality. It seems like universal health coverage option may not be a real one at this moment for low income and middle income countries but a number of countries for instance Brazil, Mexico, Rwanda and Thailand have made progress in providing universal health coverage.
37
Issues
Lack of coverage of basic health services in areas where poor, rural and minority people live
Service coverage that varies with income and education levels
Unequal access to relatively expensive services
Concerns
Use data from national surveys to identify gaps in health status
Specifically target health resources to the places most in need
KEY HEALTH SECTOR ISSUES & ADDRESSING KEY CONCERNS - ACCESS AND EQUITY
The provision of health service varies by sex, income, age, education. In low and middle income countries disparities exist for the people who live in rural area. People in such region do not have access to better treatment and expensive services. Service coverage also varies with income and education level for example urban dwellers have better access to vaccination programs than rural dwellers.
38
Addressing Key Health Sector Concerns
Delivering Primary Health Care:
Focus services on the main burdens of disease.
Strengthen the health system to deliver services effectively and efficiently.
Deliver services as close to where people live as possible.
To enhance the health care of low income countries it is necessary that the concerns and issue we have talked about not remain in the discussion level rather a comprehensive action plan is very much needed. There is consensus that a number a measures need to be taken to achieve better health. First, there should be a focus on services on the main burdens of disease. Second, strengthen the health system to deliver services effectively and efficiently and deliver services as close to where people live as possible.
39
Source: Data used with permission from Tollman S, Doherty J, Mulligan J-A. General primary care. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC and New York: The World Bank and Oxford University Press;
2006: 1193-1209.
This table suggests what the “basic health care package” or primary health care package should contain.
40
