Health system
What is a health system?
A health system consists of all the organizations, institutions, resources and people whose primary
purpose is to improve health. it includes the full range of players engaged in the provision and
financing of health services; public, non-profit, for-profit private sectors, international and
bilateral donors, foundations, and voluntary organizations.
A health system is, therefore, more than the pyramid of publicly owned facilities that deliver
personal health services.
The health system delivers preventive, promotive, curative and rehabilitative interventions
through a combination by both State and non-State actors (commercial/ profit making hospitals).
A health system needs staff, funds, information, supplies, transport, communications and overall
guidance and direction to function. Strengthening health systems thus means addressing key
constraints in each of these areas.
The actions of the health system should be responsive and financially fair, while treating people,
respectably.
Health care activities
It includes “all the activities whose primary purpose is to promote, restore or maintain health”. This includes
direct health improvement activities as well as efforts to influence determinants of health.
It include the institutions, people and resources involved in delivering health care to individuals for example;
● a mother caring for a sick child at home
● a child receiving rehabilitation services within the school setting
● an individual access vocational rehabilitation services within the workplace
● private providers
● behavior change programmes
● vector-control campaigns
● health insurance organizations
● occupational health and safety legislation which includes inter-sectoral action by health staff
for example, encouraging the ministry of education to promote female education, a well-known
determinant of better health.
Goal of the health system
Three major goals given in WHO report:
1 Improved health indicators (levels and equity)
Measures such as life expectancy, mortality rates, indicators for people living healthier life. We
are not only interested in the overall levels of these indicators but also their distribution is well
to avoid the situation of health inequality between different population groups.
2. Responsive to non-medical expectations
When people interact with the health system they should be treated timely manner and with
respect as well, by respecting people's dignity, autonomy and confidentiality.
3. Fair (financial) contribution
This involves the accomplishment of two related objectives; (i) to raise sufficient funds and (ii)
to provide financial risk protection to the population.
Responsive to non-medical expectations
The aim is to enhance the responsiveness of the health system to the legitimate expectations of
the population regarding the non-health improving dimensions.
➢ Respect for the dignity of the person: includes aspects of the interaction with providers
such as courtesy and sensitivity to potentially embarrassing moments.
➢ Respect for the autonomy: of the individual to make choices about his/her own health.
Individuals, when competent, should have the right to choose what interventions they do
and do not receive.
➢ Respect for confidentiality. In interacting with the health system, individuals should have
the right to preserve the confidentiality of their personal health information. If respected,
people are more likely to give complete and true medical history and other information to
healthcare providers
Responsive to non-medical expectations continued….
➢ Prompt attention to health needs: Individuals may also value prompt attention may be
it reduces fear and concerns that come while waiting for diagnosis or treatment
➢ Basic amenities. The basic amenities of health services such as clean waiting rooms
or adequate beds and food in hospitals are aspects of care that are often highly valued
by the population
➢ Access to social support networks for individuals receiving care
➢ Choice of institution and individual providing care: Individuals may want to select
who provides them with healthcare
Aims
they aim to:
● promote and improve health for individuals and groups
● avert dangers to health
● protect people against financial disasters as consequences of ill health
● provide equitable access to health care
● enable people to participate in decisions affecting their health
Functions of health systems
1. Creating Resources: inputs that required to built health systems (construction and maintenance
of health facilities, production and distribution of medicines; production, distribution and
maintenance of instruments and equipment)
2. Delivering services: combining the resources in delivering services. Make sure the efficient and
equitable service deliver (health promotion, prevention of diseases and injuries, primary care,
specialist medicine, hospital services, services for specific groups, self-help).
3. Financing the health care: how one pools resources and also important issue of purchasing the
services efficiently. (mobilization of funds, allocation of finances)
4. Stewardship: the overall management to oversight to the health system. It is extremely
important role to the state.
Functions of health care system continued….
Management of a National Health System (health policy and strategy development and it's
implementation by action plans, information, coordination with other sectors, regulation
of activities and utilization of health manpower, physical resources and environmental
health services).
Education and training of health manpower (skill development, inservice training)
Research and development (health research, technology development, quality control)
Relations between functions and objectives of a health system
These functions should work together effectively and worked well in an efficient and equitable
way. This is how one improves the health system and delivers outcomes of improved health
indicators with fair financial contribution and also system responsive to the people's needs.
Inter related services
A set of interrelated services, processes and capacities that include:
1. Direct service delivery to the population
2. Supporting services that make service delivery possible
3. Health workforce and their development
4. Physical infrastructure needed to deliver the health services
5. Financing arrangements-might include health insurance, direct payments by
patients, public funding, international aid
6. System of regulation and licensing that protects the public from unsafe products,
ineffective medicines or treatments
7. Overall stewardship function for the health system:
• Setting policy • Planning and allocating
resources
• Monitoring performance
WHO Health Systems Framework
The WHO published the health systems framework in 2007 to help people understand what a health
system is and how to strengthen it.
To measure the health system's performance the framework includes:
Six building blocks that describe the essential components of health system
Four process elements
Four outcomes
Process elements
Access
Coverage
Equity
Safety
Important intermediate goals:
The route from inputs to health outcomes is through achieving greater access to and coverage for
effective health interventions, without compromising efforts to ensure provider quality and
safety.
1. Service delivery
“good health services are those which deliver effective, safe, and good quality care to those who
need it, when needed, with minimum wastage of resources”.
Services are provided as close as possible; may be delivered in the home, the community, the
workplace or in health facilities.
This building block concerned with how inputs and services are organized and managed, to
ensure access, quality, safety and continuity of care across health conditions, across different
locations and over time.
There should be the continuity of care across the services. e.g. taking a primary health contact
then refers to more specialised care and then may be continuing the rehabilitative care.
1. Service delivery continued….
Attention is needed to generate demand for services by understanding the user’s perspective,
raising public knowledge and reducing barriers to care like cultural, social, financial or gender
barriers.
The government also been concerns about overall management of the providers network. It is
supervised properly whether people doing their jobs they meant to do.
Making sure the whole infrastructure is organised properly and distributed well so that everyone
can benefit from health services that they need. The registry system is working so that medicine
are available in health centers and health workers are paid on time.
Effective provision requires trained staff, working with the right medicines and equipment and
with adequate financing.
2. Health workforce
It is vital for effectively running its system. It very important to scale up availability of qualified health
workers if they are inadequate and improve their distribution, so that health workers are not just
working in urban areas catering to the elite but reaching populations across the countries.
It is the most important element in the health system because it is most costly. Typically, government is
spending more than 50 % of their health expenditure on human resources.
Appropriate skill mix of different profession the doctors, nurses, midwives and ancillary staff is also
important. The countries who want to improve their performance should look to shift tasks that can be
done by lower paid workers and free up specialists for the services they are trained to do.
To Ensure workers are working efficiently and safely, they should be trained adequately; before they
are enrolled for job as well as inservice training.
Whole health workforce requires extensive management of health labour market. Governments to be
involved in the recruitment of the health workers, retaining them and making sure that they are working
in places where they benefit populations.
3. Health information systems
Another very important area is efficient health information systems. The generation and strategic use
of information is an internal part of stewardship function. Practically, it is impossible to run an
efficient health system, if you don't know what is going on.
Countries need to generate population data about health status and health needs of the population for
effective planning of the services.
Aslo, required facility wise data tracking where people are being treated and where these services are
having an impact.
There are number of ways to generate this information through census, surveys, civil registration,
public health surveillance system, medical records and health systems performance records.
The system should have capacity to synthesise information and use it effectively to improve the
performance of the health system.
4. Access to essential medical products and technologies
Health care is heavily dependent on access to affordable essential medicines, vaccines, diagnostics and
health technologies of assured quality, which are used in a scientifically sound and cost-effective way.
Economically, medical products are the second largest component of most health budgets (after
salaries).
Key components of a functioning system are:
● National policies with standards, guidelines and regulations that support this policy
● National lists of essential medical products, national diagnostic and treatment protocols, and
standardized equipment per levels of care
● A supply and distribution system to ensure universal access to essential medical products and
health technologies through public and private channels, with focus on the poor and
disadvantaged
● A national medical products availability and price monitoring system looking at procurement,
supply and storage, and distribution systems that minimize leakage and other waste
● A national programme to promote rational prescribing
● Reliable manufacturing practices when they exist in-country and quality assessment of products
● Support for rational use of medicines, commodities and equipment, through guidelines and strategies to
assure adherence, reduce resistance, maximize patient safety and training
5. Financing
“function of a health system concerned with the mobilization, accumulation and allocation of money
to cover the health needs of the people”
The purpose of health financing is to make funding available, low-income and many middle-income
countries, revenue collection derives from a mix of domestic and external sources.
To set the right financial incentives to providers, to ensure that all individuals have access to effective
public health and personal health care.
Funds should be allocated in a way that allows people to use the needed services without the risk of
severe financial hardship (often called financial catastrophe or impoverishment).
Financial risk protection:
Financial risk protection is concerned with safeguarding people against the financial hardship
associated with paying for health services.
Two commonly applied concepts capture the lack of financial risk protection.
The first, catastrophic health expenditure, occurs when a household's out-of-pocket payments are so
high relative to its available resources that the household forgoes the consumption of other necessary
goods and services.
The second concept, impoverishment, occurs when out-of-pocket payments push households below or
further below the poverty line, a threshold under which even the most basic standard of living is not
ensured.
5. Financing continued….
The financing system is often divided conceptually into two functions; revenue collection and fund pooling.
A domestic financing policy grapple with the question of how to raise funds equitably, which usually implies
a degree of progressivity (where the rich contribute a higher proportion of their income than the poor).
Even funds, sometime do not provide financial risk protection, as people pay when they are sick and do not
pay when they are healthy. In case of lack of solidarity, some sick people incur financial hardships and may
even be pushed below the poverty line.
It also needs to consider how to ensure access to needed services while protecting people against the more
severe financial consequences of paying for care.
Protection can be achieved if there is some form of prepayment and the subsequent pooling of the collected
revenues, i.e. people pay into a pool when they are healthy and can draw on these funds when they are sick.
Pooled funds can be derived from tax or health insurance contributions and in most countries they come
from a mix of sources.
6. Leadership / governance / stewardship
It is important that state needs to get into running of the health systems. Firstly, because health
should be the national priority. For all countries, welfare of people is very important. People should
live long healthy live and don't suffer financial hardship in accessing services.
Secondly, free markets in health services do not deliver equitable health systems. Providers of
supplies of health services have a lot more information than the users of the services. In this type of
situation it is very easy for people to be exploited by the healthcare providers.
This is going to be the major reason that state needs to be heavily involved in the stewardship of the
healthcare system. The state has a key role in setting the rules of the game; running the health
systems, monitoring the performance of providers of services and improvement in accountability
towards the population how are paying for the services.
Role of the public and private health systems: state has a major role in stewardship whereas private
systems can contribute in resource generation/ manufacturing the inputs.
Limitations of the WHO framework
The building blocks alone do not constitute the system, any more than a pile of bricks
constitutes a functioning building.
It is the multiple relationships and interactions among the blocks; how one affects and
influence the others, and is in turn affected by them, that convert these blocks into a
system.
A health system may be understood through the arrangements and interaction of its parts,
how they enable the system to achieve the purpose for which it was designed.
The role of people is missing in the structure as they the key player.
The dynamic architecture and interconnectedness of the health system
building blocks
The health system building blocks are sub-
systems of the health system that function
and therefore must be understood together in
a dynamic architecture of interactions and
synergies.
People are placed at the centre of the system as mediators and
beneficiaries as well they are actors to driving the system itself.
This includes their participation as individuals, civil society
organizations and stakeholder networks and also a key actors
influencing each of the building blocks.
Placing people and their institutions in the centre of this framework
emphasizes WHO’s renewed commitment to the principles and values
of primary health care; fairness, social justice, participation and inter-
sectoral collaboration.
The Health System Dynamics Framework
The Health System Dynamics
Framework: The introduction of
an analytical model for health
system analysis and its application
to two case-studies
J van Olmen 2010
Ref
MONITORING THE BUILDING BLOCKS OF HEALTH SYSTEMS: A HANDBOOK
OF INDICATORS AND THEIR MEASUREMENT STRATEGIES (WHO)
