what is a health system?
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What is a health system?
ICHS 2
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introduction to Complex Health Systems
Outline• Definition of health system
• Conceptual frameworks that help think about health systems as basis for action
Key social goal…
Improve health by
average level of population health
health inequities
Health systems
“All organizations, people and action whose primary intent is to promote, restore or maintain health”
WHO, 2007 http://www.who.int/healthsystems/strategy/en/
Health System
Health• Beyond sickness
– mental & physical health– social wellbeing
• Beyond the individual– all agents promoting
health & wellbeing– domestic/national AND
international factors impacting on health and HS agents
A system is
any collection of related parts
that interact
in an organized way
for a purpose
STARTING POINTS: WHAT ARE THE BASIC BUILDING BLOCKS?
Moving beyond basic categorisations
Health Care Financing
Health Care Delivery
Public Private
Public UK
Private US
WHO, 2007
7
WHO Building Blocks
Strengths NB• All health systems
have multiple goals
• Thinking ‘health systems’ requires consideration of horizontal management & support functions, and resources, as well as services & programmes
Weaknesses• No sense of the
interactions among blocks
• No explicit recognition of the people & relationships within & across blocks, or what drives them
• Citizens/users are absent
Van Olmen et al. 2012
van Olmen et al. 2012
Strengths• More indication of
relationships among blocks – importance given to
leadership & governance, service delivery
• Population part of the system
• Influence of context and values recognised
Weaknesses• Limited sense of the
people within the system
• Influence of values & principles still quite hidden
ACKNOWLEDGING ACTORS AND RELATIONSHIPS
COLLECTIVE MEDIATOR
HEALTH CARE PROVIDERS
ORGANISATION
POPULATION
ORGANISATION
RESOURCE GENERATORS
OTHER SECTORS
Basis for eligibility
Degree of control
Degree of control
Degree of control
Taxes, Demands for services
Services with health effects
Subsidies, Information, Ideologies
Potential personnel, money, data
Schemes for interpreting human experience
Human resources, Payment mechanisms, Scientific information, Technology
Formal health services
Community participation
Frenk, 1994
Competition for responsibilities and resources
Frenk model
Strengths• More sense of range of
actors in the system e.g. providers as well as population recognised
• Nature of relationships among organisations and people made clear, and shown to be quite varied
• Goes beyond health services!
Weaknesses• Simplicity AND
complexity
consumers providers
purchasers
government/
professional bodytaxes/insurance
premium
s
insurance
payments
health services
paym
ent
clai
ms
regulation
regulationregulation
WHO 1993
WHO Financing Framework
Strengths• Zooms in on particular
actors & relationships• Considers what drives
relationships• Basis for generating
ideas for action
Weaknesses• One particular lens
being used to see health system: economics lens– sees only certain actors– assumes particular
behaviours and relationships
16
Accountability
Brinkerhoff & Bossert 2013
Brinkerhoff & Bossert model
Strengths• Zooms in on particular
actors & relationships• Considers broadly
what drives relationships
• Basis for generating ideas for action
Weaknesses• One particular lens
being used to see health system: accountability lens– sees only certain actors
RECOGNISING SYSTEM COMPLEXITY
Basic health system framework
INPUTS & PROCESSES
Governance
Finances
Human resources
Medicines, technologies & infrastructure
Information
OUTPUTS
Service delivery
• efficiency• access• availability• affordability• acceptability• quality• safety
OUTCOMES
Increased • effective coverage• responsiveness
IMPACTS
Improved • survival• nutrition• equity
Reduced• morbidity• impoverishment
due to health expenditures
• OTHER DETERMINANTS OF HEALTH • (Economic, Social, Political, Environmental)
Modified from: WHO Everybody’s business, 2007 & Health Metrics Network Framework, 2008
But is
this
sim
ple li
near logic
the w
ay th
ings
really
work?
Characteristics of all complex systems
And ….
• nest sub-systems within them
• but are part of larger systems
Self-organising & Constantly
changing
Source Of Funds
Procurement Agent/Body
Point of 1st warehousing
Point of 2nd warehousing
MEDICAL STORE
PRIMARY HEALTH CARE FACILITYDISTRICT STORE
ZONAL MEDICAL STORE
ESSENTIAL MEDICINES
ARVs MALARIA TB OIARVs Ped
REAGENT Blood safety(+ HIV test)
VACCINES CONDOMS CONTRACEPTIVESMEDICALSUPPLIES
REGIONAL/DISTRICT
VACCINE STORE
HEALTH FACILITY
GOVERNMENT
MULTILATERAL DONOR
BILATERAL DONOR
NGO/PRIVATE
AXIOSTEC &CC
TCRS IMA CUAMMHOSPITAL COLUMBIA HOSPITAL
TEC &CC
T
HEALTH FACILITY
HEALTH FACILITY HOSPITALTEC &CC
T
ZONAL BLOOD SAFETY CENTRE
Point of Distribution
GOVERNMENT
WBGLOBAL
FUND
SIDA
PEPFAR
USAID
UNICEF
WHO
ABBOTT
CSSC
COLUMBIA
PFIZER
JICA
CLINTON
UNITAID
CIDA
CDC
GAVI
CUAMM
HAVARD
NORAD
HOSPITAL
TEC&
CCT
CLINTON
HAVARD
MEDICALSTORE
CRS
SCMS
EGPAF
MOH& SW
AXIOS
UNICEF
JICA
CDC
COLUMBIA
ABBOTT
GAVI
CUAMM
CROWNAGENTS
USAID
TMAP
AXIOS
PATIENT
Tightly linked Medicines & Technologies building block – Tanzania 2007
SUPERVISOR PROVIDERS PATIENTS
FEEDBACK LOOPS SATISFACTION?ACCEPTABILITY?SENSE OF CARE?
Health system interventions have unpredictable paths of
implementation
Health system
Intervention
Recognising complexity
Health systems are dynamic & interconnected systems at whose heart are people
Source: de Savigny and Adam (2009)
‘It is the multiple relationships and interactions among the building blocks ... that convert these blocks into a system’
How stakeholder perspectives can vary
A health system is ….
Source: de Savigny and Adam (2009)
Figure 1. Health policy and systems: alternative perspectives.
Sheikh K, Gilson L, Agyepong IA, Hanson K, et al. (2011) Building the Field of Health Policy and Systems Research: Framing the Questions. PLoS Med 8(8): e1001073. doi:10.1371/journal.pmed.1001073http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001073
29
Hardware:
Tangible software:
Intangible software:capabilities to commit and engage; adapt & self-renew; balance diversity and coherence
Organ-isational hierarchy
HR estab-
lishment
Technology
Finance
Management knowledge
and skills
Formal manageme
nt processes
Values &norms
Informal rules
Relation-ships
Comm-unicatio
n
Understanding organisations
adapted from Aragon, 2010
All these ‘conceptual frameworks’ provide the basis for
• understanding • investigating • strengthening
health systems (or facets of them)
• and so, for working within them!(and researching them!)
CAVEAT – NO EASY ANSWERS TO HOW TO IMPROVE A HEALTH SYSTEM!
POLITICS AND VALUES MATTER….
Copyright
Funding
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Citation of this work must follow normal academic conventions. Suggested citation:
Introduction to Complex Health Systems, Presentation 2. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa
This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.
The CHEPSAA partners
University of Dar Es SalaamInstitute of Development Studies
University of the WitwatersrandCentre for Health Policy
University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management
University of LeedsNuffield Centre for International Health and Development
University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management
London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.
Great Lakes University of KisumuTropical Institute of Community Health and Development
Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences
University of Cape TownHealth Policy and Systems Programme, Health Economics Unit
Swiss Tropical and Public Health InstituteHealth Systems Research Group
University of the Western CapeSchool of Public Health
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