Global health Issue

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Global Health 101 By Richard Skolnik

Chapter Five: An Introduction to Health Systems

What is a Health System?

Health system – component parts: • 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”

How are Health Services Organized?

Categorizing Health Services Some 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

How are Health Services Organized?

Categorizing Health Services • Most low-income countries have fragmented

health systems that include both public and private providers

• Many middle-income countries have a system organized around a national insurance scheme

• Almost all high-income countries have a national health insurance system

How are Health Services Organized?

Levels of Care • Primary - first point of contact • Secondary - provided by some specialist

physicians and general hospitals • Tertiary - provided by an array of specialist

physicians and specialized hospitals Many low- and middle-income countries have

these levels organized by geographic area

Primary Health Care

Declaration of Alma-Ata • Speaks of health as a human right • Outlines content of primary health care as care

that is essential and socially acceptable • “Primary health care” as a movement and

central tenet of global health

Themes Leading to Alma Ata 1. Changing theories of health & development:

shift away from Gross National Product (GNP) as measure of development towards recognition of the need of social development

2. Concerns about poverty & population control 3. Increasing reliance upon alternative

approaches to medical care model 4. Success of community health workers (CHWs)

& associated emphasis on community participation

5. Revival of interest in public health; tackling causes of ill health rather than symptoms

ALMA ATA DECLARATION

‘The main goal of Governments and World Health Organization in the coming decades should be the attainment by all people of the world by the year 2000, a level of health that would permit them to lead a socially and economically productive life’

PRIMARY HEALTH CARE

PHC is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation

and at a cost that the community and the country can afford… It forms an integral part of the country's health system, of which it is the central function and the main

focus, and of the overall social and economic development of the community

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

Table 5.4: Total Health Expenditure as a Percentage of GDP and Private Expenditure on Health as a

Percentage of Total Expenditure of Health, Selected Countries, 2003

Source: Data from WHO. Global Health Observatory. Health expenditure ratios. Available at: http://apps.who.int/ghodata/. Accessed December 28, 2010.

Table 5.4: Total Health Expenditure as a Percentage of GDP and Private Expenditure on Health as a

Percentage of Total Expenditure of Health, Selected Countries, 2003 (cont.)

Source: Data from WHO. Global Health Observatory. Health expenditure ratios. Available at: http://apps.who.int/ghodata/. Accessed December 28, 2010.

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

Selected Examples of Health Services

High-Income Countries 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

Selected Examples of Health Systems

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

Selected Examples of Health Systems

Middle-Income Countries Brazil • 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

Selected Examples of Health Systems

Low-Income Countries India • Tiered public sector network including health

subcenters, 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

Selected Examples of Health Systems

Low-Income Countries • 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

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 rate higher in the WHO ranking than countries with higher incomes

• All systems struggle with a variety of challenges and constraints

Table 5.5: Overall Health System Performance Ranking, Selected Countries

Key Health Sector Issues

Demographic and Epidemiologic Change • People are living longer so societies will face a

greater burden of noncommunicable diseases • Cost of treating noncommunicable conditions

is high • Poor countries face burden of communicable

disease, noncommunicable disease, and injuries simultaneously

Key Health Sector Issues

Stewardship • 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

Key Health Sector Issues

Human Resource 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

Key Health Sector Issues

Quality of Care • 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

Key Health Sector Issues

The Financing of Health Systems • 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

Key Health Sector Issues

Financial Protection and Provision of Universal Coverage

• 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

Key Health Sector Issues

Access and Equity • 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