What is a health system?

ICHS 2

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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….

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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