Health

Systems

By
Hana Taha
WHO defines health systems as:

• 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.
Health system
• Is more than the pyramid of publicly owned facilities that deliver
personal health services. It includes, for example:
✓ a mother caring for a sick child at home;
✓private providers;
✓behavior change programs;
✓vector-control campaigns;
✓health insurance organizations;
✓occupational health and safety legislation.
✓It includes inter-sectoral collaboration to improve health
Functions and objectives of a health system

Functions the system performs Objectives of the system

Stewardship
(oversight)
Responsiveness to
people’s expectations

Creating resources Delivering

(investment and services Health
training) (provision)

Fair (financial)
contribution

Financing
(collecting, pooling
and purchasing)
Source: WHO, 2016
What then makes a health system good?
Common elements of a good health system
include: ‘a robust financing mechanism; a well-
trained and adequately paid workforce; reliable
information on which to base decisions and
policies; well-maintained facilities and logistics to
deliver quality medicines and technologies’ (WHO
2013 ).
The Performance of Health Systems
To assess performance of health systems, we must measure it against
the objectives and intended results of a health system.

The Objectives for health systems are:

1. Improving the health of the populations they serve: measured by life
expectancy, maternal mortality, and infant mortality in addition to its
distribution across the population.
 The Performance of Health Systems
2. Responding to peoples’ expectations:
The Performance of Health Systems
3. Providing financial protection against the costs of ill health: - Health
care costs are unpredictable and may be catastrophic thus Universal
coverage protects from the financial burden of healthcare costs.
However, many barriers of health insurance plans such as co-payment
and ceiling may prevent patients from using them. Payment should be
progressive (related to ability to pay).
4. Equity and fairness in the distribution of the above three objectives
(across population subgroups).
• horizontal equity means similar treatment of people with similar
needs;
• vertical equity means different treatment of people with different
needs.
Financing of healthcare
Financing is one of the central functions of a health system and it encompasses:

• Revenue collection Revenue collection refers to the process of raising money from
different sources. The ‘primary sources’ of funding can include taxpayers, businesses
and external funders such as donors.

• Pooling: Refers to accumulating the revenue to spread risks across population.

• Resource allocation and purchasing Resource allocation and purchasing refers to how
those pooled funds are then channeled to pay for service provision.
Without Risk Pooling
Let’s say we have 10 people. 1 person becomes ill during the year.

What happens if This 1 person will bear

this person is the full risk of paying for
low-income? his or her care ?
With Risk Pooling
When someone falls ill…

Everyone pools their resources together before anyone falls ill

The care is paid

for from the
pool of money
Why is health care so costly?
• Use of expensive new diagnostic tests and treatments
• Increased costs of healthcare services
• Marketing of new drugs, devices, and procedures
• Overuse of specialists
• High administrative costs
• Doctor fees
• Malpractice costs
• Defensive medicine
• Aging of the population
Efficiency in Healthcare
• Technical efficiency: where a given output is produced
with the least inputs (i.e. minimizing wastage).This is
also known as operational efficiency;
• Economic efficiency: where a given output is
produced at least cost. Also known as productive
efficiency;
• Allocative efficiency: where the pattern of output
matches the pattern of demand.
Cost-effectiveness in healthcare
• Cost-effectiveness analysis is often used in the field of health care,
where it may be inappropriate to monetize health effect.
• Cost-effectiveness analysis (CEA) is a way to examine both the costs and
health outcomes of one or more interventions. It compares an
intervention to another intervention or with the baseline by estimating
how much it costs to gain a unit of a health outcome, like QALYs gained
or DALYs prevented.
• The most commonly used outcome measures are DALYs and QALYs.
• Cost–benefit analysis assigns a monetary value to the measure of
effect.
 Who pays for health care?
• The following are the main payers:
• a) Government programs
• b) Private health insurance plans (some through employers)
• c) The person's own funds (out-of-pocket).
✓Because health expenditures of individuals on health are
unpredictable, prepayment systems (a & b above) with universal
coverage protect from extreme poverty due to health care
expenditures.
✓Prepayment based on ability to pay allows for cross-subsidy from the
rich to the poor and from the healthy to the sick.
✓Health systems financed by the government provide the greatest
potential for pooling risk.
Health care financing models
 National Health Services systems (Beveridge model)

• Named after William Beveridge

• Health care is provided and financed by the government through tax payments.
• Many hospitals and clinics are owned and run by the government.
• There are also private hospitals and doctors who collect their fees from the
government.
• Low costs per capita, because the government controls what doctors can do
and what they can charge.
• Beveridge model: Great Britain, Spain, most of Scandinavia , New Zealand.
Hong Kong and Cuba which represents the extreme application of the
Beveridge approach; it is probably the world’s purest example of total
government control.
Social Insurance systems (Bismark model)
• Named after Chancellor Otto von Bismarck and it was found in
Germany
• This model has an insurance system. The insurers are called
“sickness funds”
• Multi-payer model ; Germany has about 240 different sickness funds
• Financed jointly by employers and employees through payroll
deduction.
• Cover everybody, and not for profit.
• Doctors and hospitals tend to be private in Bismarck countries.
• Tight regulation gives government much of the cost-control.
• The Bismarck model is found in Germany, of course, and France,
Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in
Latin America.
The National Health Insurance Model
• Has elements of both Beveridge and Bismarck.
• Uses private-sector providers, but payment comes from a government
• The government runs an insurance program that every legal resident pays into.
• No need for marketing, no financial motive to deny claims and no profit.
• Cost effective and administratively simple.
• The single payer ( the government) has considerable market power to
negotiate for lower prices and control costs by limiting the medical services
they will pay for.
• Patients waiting to be treated is one of the cons.
• The classic NHI system is found in Australia, Canada, but some newly
industrialized countries — Taiwan and South Korea, for example — have also
adopted the NHI model.
Mixed Health systems
• Most of the Low and Middle Income (LMIC) Countries governments
are too disorganized or too poor to provide universal healthcare.
• Health care in a majority of LMIC is delivered by a mixed health system.
• It is a health system in which out-of-pocket payments and market provision of
services predominate as a way of financing and providing health services.
• Publicly-financed government health delivery coexists with privately-financed
market delivery.
• Insufficient state funding for health and weak governance
• A regulatory environment that enables the private sector to deliver health
services without an appropriate regulatory framework
• This triad of determinants acts together to compromise the quality of public
services and defeat the equity objective
Universal
Health
Coverage
 Health as a human right
“There can be no real growth without healthy populations.
No sustainable development without tackling disease and malnutrition.
No international security without assisting crisis-ridden countries.
And no hope for the spread of freedom, democracy and human dignity
unless we treat health as a basic human right.
Our networked world means that we are only as strong as our weakest
link”

GRO HARLEM BRUNDTLAND

First woman Prime Minister of Norway; former Director-General of WHO. From a speech
delivered at the World Leaders Forum: Global Health Security at Columbia University in
New York, on 24 September 2019.
The gap between the Global North and the Global South
• In 1980, the Brandt Line was
developed as a way of
visualizing the world that
highlights the disparities and
inequalities in development
and wealth between the
prosperous North and the
poorer Global South. Lees, N. (2021). The Brandt Line after forty years: The more North–
South relations change, the more they stay the same? Review of
International Studies, 47(1), 85-106. doi:10.1017/S026021052000039X
Is the Brandt Line still valid ?

• The evidence from the literature suggests that the Brandt Line is
largely intact after forty-four years of its dissemination

• Although the economic power has risen, still the North–South divide
is lingering.

• Despite the significant development gains globally that pulled

millions of people out of absolute poverty, still the gap between the
world’s richest and poorest countries is widening.
Universal Health Coverage (UHC)

“Universal health coverage is the single most powerful

concept that public health has to offer”

- Dr. Margaret Chan, the 7th Director General of the World Health Organization

(WHO), addressing to the 65th World Health Assembly, May 2012

 What is UHC?
The idea of universal health coverage is based on the WHO
constitution of 1948 declaring health as a fundamental human
right and on the Health for All agenda set by the Alma Ata
Declaration in 1978.
UHC means that “All individuals and communities have the right to
receive the health services they need without suffering financial
hardships”
UHC includes the full spectrum of essential, quality health services,
from health promotion to prevention, treatment, rehabilitation,
and palliative care across the life course.
 The main pillars of UHC
- Equity in access: everyone who needs health services
should get them, not only those who can pay for them.
- Sufficient quality: health services should be good
enough to improve the health of those receiving
services.
- No undue financial risk: The cost of using health
services should not put people at risk of financial harm.
 Direct relation between health and wealth

People in the • Health is a fundamental

Global south with
no financial risk human right and it is also the
protection
foundation of economic
exacerbating When they become prosperity and security.
financial hardships ill
• UHC is a triple win: It improves

They either seek

people’s health, reduces
treatment they will have People unable to
financial hardships , or
don’t use health services pay out-of-pocket poverty, and fuels economic
and remain ill and for health services
unable to work growth.
 Global commitment towards UHC
• In 2010, the WHO released a call for all countries to move towards UHC.

• The 2030 Agenda for Sustainable Development Goals (SDGs) that was
adopted in 2015 by all United Nations Member States, included under
SDG 3.8.1: to achieve universal health coverage by 2030, including
financial risk protection, access to quality essential health-care services
and access to safe, effective, quality and affordable essential medicines
and vaccines for all.
How to assess the progress towards UHC ?
Evidence based actions for UHC reforms success
Political commitment towards equity and effective stewardship by the
government synergized by engaging the private sector.
Investing in a strong, resilient, efficient and well-run health system
that meets priority health needs through a people-centered integrated
approach
Collaboration of all the stakeholders in knowledge sharing and
engaging the community for the public good.
Priority setting using systematic processes based on evidence and
stakeholders’ agreement before setting the range of the potential
health services.
Using steppingstones in progressing towards UHC by using a bottom-
up approach, starting with the poor and progressing step by step.
Evidence based actions for UHC reforms success

Quality of services and accountability should be integral to UHC program

design.
A focus on primary care gatekeeping and referral mechanisms
contributes to a more sustainable, accessible, and equitable health
system, attaining better health outcomes at lower cost.
A sustainable system for financing health services, effective financial
management, monitoring, and oversight are essential for the success of
UHC.
Using novel financing mechanisms for revenue generation, risk pooling,
procurement, contracting and purchasing.
Establishing a culture of evidence-based policy making built on research
and information technology.
 No one-size-fits-all recipe

There is no “best practice” model capable of accommodating any country at any stage
of development.
The best path to cover people is through corresponding to the needs of the
population within the socioeconomic fundamentals of the country.
The quality of UHC programs often improves during the implementation process as
they mature.
Learning is an essential element for all the countries transitioning towards UHC. UHC
skills are progressive capacities that are built during the implementation.
Addressing the social determinants of health through a comprehensive PHC care
approach is essential.
 Ethics and governance are central in the path to
universal health coverage
• UHC is a powerful expression of fairness, solidarity and recognition of health as a human
right.
• To achieve Universal Health Coverage for all by 2030, countries must recognize the role of
Stewardship in ensuring that health care systems are strong and provide quality care to
everyone.
• Whether in providing justification for UHC, identifying the interests at stake in health
system reform, or providing guidance in building more robust health systems, ethics and
governance both play a central role.
Discussion topic: Cuba health system
• Video to watch: THE CUBAN DOSE: Insights into Cuba’s
legendary healthcare system
https://youtu.be/0i7z0S4Ve8c
Article to read:
• Health Equity, Cuban Style. AMA J Ethics. 2021;23(3):E258-
264. doi: 10.1001/amajethics.2021.258.
https://journalofethics.ama-assn.org/article/health-equity-
cuban-style/2021-03
Cuba health system example
• Universal
• Free
• Accessible
• Everyone has the right to health protection and
care .
 Cuba healthcare system
• Health care is a right, available to all equally and free of charge.
• Health care is the responsibility of the state.
• Preventive and curative services are integrated.
• The public participates in the health system’s development and functioning.
• Strong comprehensive primary health care that addresses the social determinants of
health
• Health care activities are integrated with economic and social development.
• Global health cooperation is a fundamental obligation of the health system and its
professionals.
Cuba healthcare system
• Promote health through positive changes in the population’s
knowledge, sanitary habits, and lifestyle.

• Prevent the emergence of diseases and damage to the population’s

health.

• Guarantee early diagnosis, outpatient services, and hospitalization, as

well as timely, continuous, and comprehensive medical care in the
community.
 Cuba healthcare system
• Develop community-based rehabilitation for physically or
psychologically disabled persons.

• Achieve improvements in neighborhood environmental clean up and in

home hygiene.

• Achieve improvements in social relations and integration of

neighborhood families.

• Develop studies that respond to the health needs of the population.

 Take home message

Ethics matters:
Governance ethical commitment towards the public good and to health as a
basic human right

Priorities matter
Governance political commitment, a higher (or lower) share that
government devotes to health can make a big difference
Context and Policy matters
There is more to it than just spending levels; how you organize your health
system is important