Introduction to Health Systems

Today I want to talk about health systems and in particular, the role of health systems in delivering universal health coverage which you’ve heard about in another lecture[1]. So what is a health system? According to the World Health Organization, a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.

This includes efforts to influence determinants of health as well as more direct health improving activities. So you can see this is really quite a broad definition. And the health system is certainly much bigger than really just talking about public health units and hospitals. And in fact, if one thinks about the entire health system, it also includes the private health sector providers, both in terms of commercial, for-profit providers, but also non-government organization providers of services. But it also includes people caring for sick relatives at home. Another big area of course is in preventive healthcare and things like vector control programs to control mosquitoes for example. Behavior change programs would also be in the health system, encouraging people to lead healthier lifestyle by reducing the amount of fat intake and tobacco and taking more physical exercise. The health system also includes occupational health and safety legislation. Those are all activities that one would typically associate with the health sector, but also in really thinking about the much broader health system, it also includes intersectoral action to promote interventions that improve health. For example, the education of girls is very important for improving health status. Encouraging legislation to reduce tobacco, alcohol and sugar consumption and road safety measures. These are all what we’d call part of the broader health system. So that’s what a health system is. Now what should a health system be trying to do? Now here the World Health Organization have been extremely helpful and back in 2000, produced a memorable World Health report all about health systems and improving the performance of health systems.

In this document, they stated that there are three major goals for, for a health system. Firstly, to improve health indicators. Measures such as life expectancy, mortality rates, but also associated with people leading healthier lives. Here we’re not only interested in the overall levels of these indicators, but their distribution as well, to avoid the situation of there being big health inequalities between different population groups. Another goal for the health system is that it should be responsive to people’s non-medical expectations. That when people interact with the health system they’re treated courteously and in a timely manner and with respect as well. And the third major area is that the health system should be fair, particularly in terms of the financial contributions that people make towards financing the health system. So we’ve described what a health system is trying to achieve, now how does it go about trying to do that? And again the World Health report provided good structure in terms of describing four key functions of a health system. Firstly, in creating the resources that are required to run the health system, the inputs that go into the health system. Here one can think of things like medicines and health workers and computers, the basic inputs that go into the system. The next major area of course is in combining those inputs in delivering services. And this whole issue of how does one deliver efficient and equitable services? This will be the topic of the next lecture. The third major function concerns the financing of the health system. Again, we’ll discuss this in another lecture, but here one should consider the functions of how one raises the finances for the health system, how one pools resources, and then also the very important issue of purchasing services efficiently. And the final major function concerns stewardship. The overall management and oversight of the health system, where it’s an extremely important role for the state. Now when these functions combine effectively together and work well in an efficient and equitable way, this is how one improves the health system and delivers those outcomes that one’s looking for of improved health indicator figures, better fair financial contributions and also a system that is responsive to people’s needs. I’d like to just dwell briefly on this very important issue of stewardship and why it’s so important that the state gets involved in the running of the health sector. Now why should this be the case? Well firstly because health should be a national priority, all countries everywhere, people, it’s very important for them and the welfare of their families that they lead long, healthy lives and don’t suffer financial hardship in accessing services. So health really should be a national priority that good governments are concerned about. Secondly, it’s clear that free markets in health services don’t deliver equitable health systems. And really this is to do a lot with what they call market failures in the way that health systems worked. And the, the providers and suppliers of health services have a lot more information than the users of services. And in this type of situation, it’s very easy for people to be exploited by unscrupulous healthcare providers. And really this is one of the major reasons that it’s very important for the state to be heavily involved in the stewardship of the, of the health system. So the state really should be involved in setting the rules of the game of running the health system. And also in monitoring the performance of providers of services and improving accountability to the population who are paying for them. Now one area that has attracted quite a lot of controversy over the years is the role of the public and private sectors in, in a health system. And here, Professor Julio Frenk at the Harvard School of Public Health has provided a very useful description of the different roles of the public and private sectors, looking at those functions I was describing before. So thinking of that overall stewardship and accountability function, clearly that lies predominantly within the public sector, to set the rules and regulations to the system, with only perhaps a very small role for the private sector there. Likewise, it’s becoming increasingly clear that to achieve universal health coverage in an equitable health system, one needs to predominantly be looking at a publicly financed system. However, looking at the issue and function of service provision, it’s slightly less clear. And indeed, many countries the, the majority of health service providers are actually in the private sector, contracted, using public financing. So here there tends to be more of a mix of public and private providers. But when one looks at that final function or resource generation, manufacturing the inputs that go into the health sector, here the tendency is more for the private sector to produce the medicines and the computers and the basic inputs that go into the system. Now another area that’s attracted quite a lot of controversy over recent years is how one measures health service performance. And countries are very keen to match, to identify how their health sector is performing against others. Now how does one do this? How do you measure performance? Well clearly the indicators you should be trying to use are those around those objectives we were talking about of improved health status, better financial protection, and a more responsive system. And again, we don’t want just to be looking at absolute levels of those measures, but how they’re distributed across society. Now the World Health report in 2000 did this and ranked health systems across the world and created an index and therefore created a lead table. This was quite a controversial exercise and in that, at that time it was the French system that was deemed to be the best performing. Other organizations have been doing this as well. Most notably the Commonwealth Funds that assesses the performance, particularly of high income countries looking at measures of quality of care, access to health services, the efficiency of the system, equity and also those all-important health indicators. And in the most recent study that the Commonwealth Fund done, they showed that the British National Health Service scored the highest, was ranked the highest performing sector. Of course the system that is predominantly publicly financed and interestingly, the United States, of the eleven countries surveyed was actually bottom of the lead table, largely due to problems with inequitable access to services. Now what was striking is that the United States’ health system spend more than twice what a number of other OECD countries are doing, are spending. So it’s interesting therefore that necessarily spending more money on a health system doesn’t always improve performance. And therefore governments can learn about improving efficiency and doing more with the money that they have available. Thank you.

[1] http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTHSD/0,,contentMDK:22523961~menuPK:6485077~pagePK:148956~piPK:216618~theSitePK:376793~isCURL:Y,00.html

---

---