The life and experience

of a health system:

considering political

economy

ICHS 1

www.hpsa-africa.org

@hpsa_africa

www.slideshare.net/hpsa_africa

Introduction to Complex Health

Systems

Outline

• What is a health system?

• What influences how health systems

develop & perform?

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 boundaries

Personal health care

Health care/services

Intersectoral health action

Other factors: national and global influences

Source: Modified from WHO World Health Report, 2000

HEALTH

Organisational Hierarchy

National Health system

National context

Global contextAN OPEN SYSTEM

International influences on

African health systemsPeriod Approach Context/Values base

1970s Whole system

focus/comprehensive PHC

Basic needs development, social

justice

1980s Focus on

interventions/selective PHC

Economic crisis & conservative

economic policies/efficiency

1990s Health system reform –

financing & organisation

Structural adjustment/efficiency,

competition

1990s-

2000s

Focus on ‘big killers’ AIDS crisis response/medical

responses

2000s Health system strengthening Response to the implementation gap

& concern for MDGs

Van Olmen et al. 2012

Changing over timeThe UK:

• 1800s mutual aid societies &

medical relief for the indigent;

with private care for rich

• 1911 Health Insurance Act:

mandated basic medical

benefits for poorer employed

• 1948 NHS: public, universal

health service: coverage

extended, benefits expanded,

hospitals nationalized

• 1990s Internal markets to

encourage competition

> Growing OOPs, Growing %

pop with private health

insurance

The Nigerian experience

See

https://www.youtube.com/watch?v=V-

cXDl20i5k&feature=youtu.be

What is political economy?Inter-relationships between political processes,

economic systems and health/health systems

Political

System

Health

Economic

System

Aggregate level

or by race,

class, gender,

placeHealth Systems

Political System and Processes(political and socio-economic rights, decisionmaking practices)

Acceptance of discrimination

Definition of public need

Attitude towards privatisation

Determination of public policy

Level of unionisation Accountability of public administration

Income and wealth levels and distribution

Food intake

Access to health-promoting inputs

Access to cost-effective and quality health care

Access to other services

Spatial development

Macro-economic PolicyInterest rates

Access to credit

Exchange rate

Import & export tariffs

Domestic subsidies & taxes

Public expenditure level

Labour PolicyAccess to employment

Minimum wages

Hours of work

Employment benefits

Public sector pay determination

Land Distribution and

Housing PolicyAccess to land and housing

Distribution of land and housing

Public Provisioning PolicyProvision and financing of:

Education

Social welfare

Health careWater & sanitation

Quality of environment

Disposable income

Own food production

Health-seeking behaviour

Household health investment

Intrahousehold allocation of time and resources

Individual and Household Health and Welfare

SOCIO-POLITICO-

ECONOMIC-

HEALTH

INTERACTIONS

Household

factors

Health system Type 1:

private

Type 2:

pluralistic

Type 3: NHI Type 4: NHS Type 5:

socialized

health service

Political &

ideological

values

HC an item of

personal

consumption

HC primarily

consumer

good

HC as

insured,

guaranteed

service

HC as state

supported

service

HC as right &

state-provided

pub service

Position of the

physicians

Solo

entrepreneur

Solo

entrepreneur

& member

practitioner

group

Private solo or

group practice

&/or employed

by hospitals

Private solo

or group

practice &/or

employed by

hospitals

State

employee

Ownership of

facilities

private Private, NFP

& Public

NFP & public Mostly public Entirely public

Source of

financing

Private OOP Mix OOP &

public

Primarily

single payer

public

Public Public

Administration &

regulation

Market Market, some

Govt

Govt Govt Govt

Prototype Most countries

till 19th&20th C

USA

Peru

France

Canada

Korea

UK Soviet Union

Cuba

Birn et al. 2009, adapted from Rodwin 1984 & Field 1978

Economic

level

Entrepreneurial

& dismissive

Welfare

oriented

Universal &

comprehensiv

e

Socialist &

Centrally

planned

Affluent &

industrialised

USA Canada

Germany

Netherlands

Japan

Norway

UK

Former Soviet

Union

Former Czech

Developing &

transitional

Thailand

Philippines

South Africa

Brazil

Egypt

Malaysia

Mexico

Costa Rica Cuba

Very poor Bangladesh

Nepal

Honduras

Botswana

Tajikistan

Sri Lanka China

Vietnam

Resource rich Nigeria Libya

Gabon

Venezuela

Kuwait (except

guest workers)

Roemer’s 1991 Typology updated by Birn et al. 2009

Conclusions:

1. The political ideologies of governing parties affect some

indicators of population health

2. Political parties with egalitarian ideologies tend to implement

redistributive policies

3. Policies aimed at reducing social inequalities do impact positively

on IMR and, to lesser extent, on LEB

Navarro et al. Lancet 2006

OECD countries 1950-2000

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Introduction to Complex Health Systems, Presentation

1. 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