Health Systems 2009 20Aug A

8/3/2019 Health Systems 2009 20Aug A

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Health Systems & HealthPolicy: About the Course

P.R. Sodani, PhD, MPHProfessor &Course Coordinator, Health Systems and Health PolicyPGDHM & PGPHMInstitute of Health Management Research

Jaipur


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About the Course

This course is a core course andfundamental in the context of healthcare environment.

This course is designed to help thestudents understand the existinghealth care delivery system andrelated issues in India.


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Course Objectives

Understand the concept of health systems andobjectives of health systems

Describe the concept and principles of primary

health care approach Describe health care delivery system of India

Understand functioning of public health system

Describe issues and challenges in health care

services delivery


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Course Objectives

Understand National Health Policy, Population Policyand Policy linked Schemes/Programs and Issues

Describe issues and challenges in health careservices delivery

Describe implementation framework of NRHM

Understand the financing of health in India

Understand health sector reforms in India


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Teaching Methods

Lectures

Discussions

Assignments Industry Interface


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Readings

Suggested readings for the course iscompiled in the Module.

The reading material is compiled from

various sources such Ministry of Health & Family Welfare

WHO and World Bank material

Policy documents/approach paper Reference books

Research papers publishsed


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Contents

Health Systems Basic Concepts

Health Planning in India

Primary Health Care Approach

Health Care Delivery System in India National Health Policy

National Population Policy

National Rural Health Mission

Financing Health Care in India

Health Sector Reforms


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Methods of Grading andEvaluation

1 Mid-term Examination

Written and closed book

30%

2 Final ExaminationWritten and closed book

70%

Total 100


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Health Systems:An Overview

P.R. Sodani, PhD, MPH

Professor

Health Systems, Health Economics and Financing

Institute of Health Management Research

Jaipur


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Session Plan

What is a health system?

Why health systems matter?

What are the objectives of healthsystems?


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Health systems have contributed

enormously to better health andinfluenced the lives and well-being ofbillions of men, women and childrenaround the world. Their role has

become increasingly important.


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Enormous gaps remain, however,between the potential of healthsystems and their actualperformance. There is far too muchvariations in outcomes amongcountries which seems to have the

same resources.


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What do we mean by

Health System?


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What is a health system?

A health system consists of all

organizations, people and actionswhoseprimary intentis to promote,restore or maintain health.


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Formal health services, including the

professional delivery of personalmedical attention, are clearly withinthese boundaries.


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Actions by traditional healers, and all

use of medication, whetherprescribed by a provider or not.


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Public health activities such as health

promotion and disease prevention,and other health enhancinginterventions like road andenvironmental safety improvement,

are also part of the system.


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Beyond the boundaries of thisdefinition are those activities whoseprimary purpose is something other

than health education, for example even if these activities have asecondary, health-enhancing benefit.Hence, the general education system

is outside the boundaries, butspecifically health-related education isincluded.


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Nearly all the information availableabout health systems refers only tothe provision of and investment in,health services: that is, the healthcare system, including preventive,curative and palliative interventions,

whether directed to individuals or topopulations.


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In most countries, these health careservices account for the great bulk ofemployment, expenditure and activity.


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Nonetheless, efforts are needed toquantify and assess these activitieswhich matters a lot for health systemand to estimate their relative costand effectiveness (consequences incontributing to the goals of the

system.


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To take one example, in the United Statesbetween 1966 and 1979 the introduction ofa variety of safety features in automobiledesign (laminated windshields, collapsiblesteering columns, interior padding, lap andshoulder belts, side marker lights, headrestraints, leak resistant fuel systems,stronger bumpers, increased side door

strength and better brakes) helped reducethe vehicle accident fatality rate per miletravelled by 40%.


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Only three of these innovations added morethan $10 to the price of a car and in totalthey accounted for only 2% of the average

price increase during 19751979.

From 1975 to 1998, seat belts saved anestimated 112 000 lives in the United

States and total traffic fatalities continuedto fall.


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The potential health gains were evengreater: in 1998 alone, 9000 peopledied because they did not use theirbelts.

The potential savings are very large:

road traffic accidents in low andmiddle income countries.


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Health systems today represent one of the largestsectors in the world economy.

Global spending on health care was about $2985

billion (thousand million) in 1997, or almost 8% ofworld gross domestic product (GDP)

The International Labour Organisation estimates thatthere were about 35 million health workers worldwide

a decade ago, while employment in health servicesnow is likely to be substantially higher.


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These figures reflect how what was forthousands of years a basic, privaterelationship in which one person with an

illness was looked after by family membersor religious caregivers, or sometimes paid aprofessional healer to treat him or her has expanded over the past two centuries

into the complex network of activities thatnow comprise a health system.


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More than simple growth, thecreation of modern health systemshas involved increasing differentiationand specialization of skills andactivities.


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It has also involved an immense shiftin the economic burden of ill-health.Until recently, most of that burden

took the form of lost productivity, aspeople died young or became andremained too sick to work at full

strength.


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The cost of health care accounted for only asmall part of the economic loss, becausesuch care was relatively cheap and largely

ineffective.

Productivity losses are still substantial,especially in the poorest countries, but

success in prolonging life and reducingdisability has meant that more and more ofthe burden is borne by health systems.


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This includes the cost of pharmaceuticalproducts for controlling diabetes,hypertension, and heart disease, for

example that allow people to stayactive and productive.


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The resources devoted to healthsystems are very unequallydistributed, and not at all in

proportion to the distribution ofhealth problems.


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Low and middle income countriesaccount for only 18% of world incomeand 11% of global health spending

($250 billion or 4% of GDP in thosecountries).

Yet 84% of the worlds population livein these countries, and they bear93% of the worlds disease burden.


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These countries face many difficultchallenges in meeting the healthneeds of their populations, mobilizing

sufficient financing in an equitableand affordable manner, and securingvalue for scarce resources.


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What do health systems do?

For rich and poor alike, health needs todayare very different from those of 100 oreven 50 years ago.

There are growing expectations of access tohealth care in some form and growingdemands for measures to protect the sick

and their families, against the financialcosts of ill-health.


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People also now turn to healthsystems for help with a much widervariety of problems than before not

just for the relief of pain andtreatment of physical limitations andemotional disorders but for advice on

diet, child-rearing and sexualbehaviour that they used to seekfrom other sources.


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Patients and populations

Providers

Consumers of nonprescription medications and

Recipients of health-related information Recipients of advice

Contributors for paying for health system


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It matters very much how the systemtreats peoples health needs and howit raises revenues from them,

including how much protection itoffers them from financial risk.


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But it also matters how it responds totheir expectations. In particular, peoplehave a right to expect that the health

system will treat them with individualdignity. So far as possible, their needsshould be promptly attended to, withoutlong delays in waiting for diagnosis and

treatment not only for better healthoutcomes but also to respect the value ofpeoples time.


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Patients also often expectconfidentiality, and to be involved inchoices about their own health,

including where and from whom theyreceive care. They should not alwaysbe expected passively to receive

services determined by the provideralone.


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In summary, we may say that healthsystems have a responsibility not justto improve peoples health but to

protect them against the financialcost of illness and to treat them withdignity.


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Objectives of Health Systems

Health systems thus have threefundamental objectives:

Improving the health of the population

Responding to peoples expectations

Providing financial protection against the

costs of ill-health


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Because better health is the mostimportant objective of a healthsystem and because health status is

worse in poor populations, one mightassume that for a low-incomecountry, improving health is all

matters.


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Concern for non-health outcomes ofthe health system for fairly sharingthe burden of paying for health so

that no one is exposed to greatfinancial risks and attending topeoples expectations about how they

are to be treated, would then beluxuries.


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But, this is not true. This view is takenmistaken for several reasons.

Poor people need financial protection as

much as or more than the well off sinceeven small absolute risks may havecatastrophic consequences for them.

And the poor are just as entitled to

respectful treatment as the rich, even ifless can be done for them materially.


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Moreover, pursuing the objectives ofresponsiveness and financial protectiondoes not necessarily take substantialresources away from activities to improvehealth.

Much improvement in how a health systemperforms with respect to these

responsibilities may often be had at little orno cost.


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So, all three objectives matter in everycountry, independently of how rich or poorit is or how its health system is organized.

Better ways of achieving these objectives,are similarly relevant for all countries andhealth systems, although the specific

implications for policy will vary according toincome level and the cultural andorganizational features of the system.


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Functions of Health Systems

Functions of the health system are asfollows:

Financing

Management of non-financial resources

Delivery of services

Stewardship (oversight)


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Responsibilities for the first three setsof functions financing, managementof inputs and service delivery are

shared between private and publicsector.


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Financing

Revenue generation

Risk pooling

Allocation of resources

purchasing


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Management of non-financial inputs

Human resources

Knowledge and software

Pharmaceuticals

Consumables

Medical equipment

Buildings Supplies


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Service delivery

Public health services

Clinical services

Outpatients services

Inpatients services

Diagnostic services

Therapeutic services Rehabilitative services


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Oversight

Oversight function is largely aresponsibility of the State.

The concept of oversight goes beyondthe conventional idea of regulation setting and enforcing rules to otherfunctions such as developing policy

and providing strategic direction tothe health system.


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examples

Policy setting

Regulation and setting standards

Providing incentives

Developing partnerships

Providing information and advocacy

Monitoring and evaluation


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The financial costs of strengtheningoversight are small and the benefitsare considerable.

Oversight activities are a prerequisiteto improving quality, equity and beingable to use health insurance or

strategic purchasing of healthservices.


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Oversight roles are the developmentof partnerships or networks amonghealth service providers and

financiers and the strategic use ofincentives to promote the publicpolicy objectives.


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Acquiring and disseminatinginformation about performance,quality or pricing is another oversight

function.

Using information through monitoringand evaluation for programme

strengthening


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The distinctions between some ofthese functions may be somewhatarbitrary because the functions are

often closely related. Example - Peoples demand healthy

deliveries, which creates markets formore particular services such as fetal

ultrasound testing, and productsperhaps new drugs.


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Oversight function influence each ofthe other actors and functions. Themanagement of inputs is tied to the

types of services delivered; how theyare paid for affects their quality,quantity and distribution.


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Outcomes of Health System

The health system has three types ofoutcomes:

Health status

Financial status

Consumer responsiveness


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Health status

Measures of health status:

Mortality

Nutrition

Fertility

Illness

Disability


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Financial protection

The financial protection is a measure of thefinancial loss due to illness, which includedirect costs of health care and indirect costsof health care.

The concern is not about how costs affectaccess but also the risk of loss of incomeand assets.

Financial protection is particularly important

to the poor as the costs of ill health pushpeople into poverty and deepen the levelsof poverty.


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Consumer responsiveness

The consumer responsiveness of thehealth system is measured by howsatisfied the public is with various

aspects of health services. It also includes consideration of

whether health services treat peoplewith respect and whether they are

provided with protection againstmalpractice and explotiation.


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Here, again the poor are just asconcerned with dignity and with beingtreated respectfully by the health

system as are those who arewealthier and more powerful.


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Intermediate objectives

How can Indias health system meetits fundamental objectives in anequitable, effective, accountable and

affordable manner?

This question raises a second order ofobjectives relevant for the health

system.


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This level of intermediate objectivesmay include the followingparameters:

Equity

Quality

Costs

Consumer choices

Provider autonomy


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Equity

Some minimum of health care shouldbe accessible to all citizens inaccordance with their needs, at least

in services publicly financed.


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Quality

Health services should provide theoptimum combination of goodoutcomes good health, financial

protection, and consumersatisfaction, with costs minimized fora given level of output.


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Another way of stating this is thatquality of health services should beoptimized which can be considered in

terms of technical quality of services(how well the interventions providedwork), managerial quality (how welloutputs are maximized given the

level of inputs), and perception ofquality (how well patients aresatisfied with services).


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Costs

At macro level, the healthexpenditure should consume anappropriate proportion of GDP. At

micro level, the patients should befinancially protected.


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Consumer choice

The clients should have a sufficient ofproviders in both public sector andprivate sector for their treatment and

services.


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Provider autonomy

Doctors and health providers shouldhave the maximum freedomcompatible with the attainment of the

other health system objectives.


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The overall levels of health systemsoutcomes are important but thedistribution of the results among

different geographic areas andpopulations, and particularly forvarious vulnerable groups such as

poor, scheduled castes, scheduledtribes, women and young.


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Assignment 1

1. Define health systems and what are the majorobjective of health system?

2. Describe the Health System of India including itsactors, functions and outcomes.

3. Analyze systems outcomes health status; financialstatus, and consumer responsiveness based on

evidence gathered from secondary data sources.


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Thanks

Health Systems 2009 20Aug A

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