Everything You've Ever Needed To Know About Health Systems

New to the wonderful world of health systems? Then this post is for you! Whether you're a wonk that needs to brush up, a student, a health care practitioner or just an interested and engaged citizen – this primer is full of everything you've ever needed to know about health systems and how they function around the world.

This post is designed to always be a work in progress. Think there's a topic we haven't covered that explains something key about health systems? Let us know and add your own section by getting in touch!

The World Health Organization (WHO) defines health systems as comprised of six ‘building blocks’

WHO / Via emro.who.int

While it’s hard to separate these building blocks out, it’s been a helpful way to think about the different areas that may need attention in order to improve health systems. It’s sort of a visual checklist of what to think about when improving health systems.

The six building blocks are: service delivery, health workforce, health information, medical products, vaccines and technologies, health financing, and leadership and governance.

[Contributed by Jeff Knezovich, Future Health Systems, with input from Kate Tulenko, CapacityPlus]

But the ‘building blocks’ approach has its critics

Savigny D, Adam T: Systems Thinking for Health Systems Strengthening. Edited by de Savigny D, Adam T. Geneva, Alliance for Health Policy and Systems Research; WHO; 2009. / Via who.int

While separating out the building blocks gives useful focal points for health systems strengthening, some have argued that this gives the incorrect impression that one can just look at one block at a time — that somehow they are disconnected.

But it’s clear that they are not — health systems strengthening requires an integrated approach that adopts true systems thinking. It’s no good having more vaccines available, for example, if there aren’t enough doctors and nurses to administer them.

Others have argued that these six building blocks are too disconnected from the people that use health systems, and that there needs to be a focus on putting people back into health systems.

Not only are people the engines powering health systems, setting priorities and innovations, but social hierarchies — including gender, class, race along with other social determinants — affect how health systems function and for whom.

Improved health of people and reduced health-related poverty are the ultimate goals of a health system.

[Contributed by Jeff Knezovich, with inputs from Asha George, both Future Health Systems and Kate Tulenko, CapacityPlus]

Right, so now we know what health systems are — but why are they important?

youtube.com

Didn’t watch the video? Let me recap — the video explains what all is involved in vaccinating children. First, we need the science to determine whether a vaccine is effective at solving a particular problem. We’ve got lots of this type of science in health, we know what sorts of technologies seem to work.

But having an effective technology isn’t enough if it can’t get to the people who need it, or if they can’t afford it, or if it’s broken along the way — that’s where health systems (and health systems strengthening) come in.

As the video explains, there is vaccine production in a variety of countries. These vaccines need to be purchased and then distributed to the countries where they are needed. Once they arrive in country, there need to be further distribution mechanisms — often while kept in cold storage. Let’s say that they arrive at a local clinic, in addition to keeping cold they then have to be administered by a trained health care provider of some sort with the proper materials, including alcohol wipes, needles, syringes, and plasters or bandaids.

Overall something as ‘simple’ as administering a vaccine is actually rather complicated, and effective health systems are necessary to ensure each step.

[Contributed by Jeff Knezovich, Future Health Systems, with inputs from Kate Tulenko, CapacityPlus.]

Who pays for health care services?

FHS Uganda Photovoice / Via futurehealthsystems.org

Research and development, medicines, diagnostics, staff, training, and the health facilities and their operating costs — these are all things that must be paid for by someone.

Health services can be paid for in a number of ways, including direct government revenues, income taxes, sales taxes, sin taxes (i.e. taxes on alcohol, tobacco, gambling, and junk food), health insurance payments, and users fees paid at the time of service.

In the US there are many private health insurance providers, but people who don’t have insurance must pay for services ‘out of pocket’. High out of pocket expenditures is typical in many LMICs. For example in Bangladesh, according to its most recent health accounts, roughly 64% of the total health expenditure (THE) of the country in 2007 came from out-of-pocket payments. This can be disastrous for poor people.

Beyond that, user fees and out-of-pocket expenditures can be particularly concerning from a gender and poverty point of view. Women are likely to have less income or less control over income. As a result, they often need to negotiate with other household members to secure cash. User fees therefore disproportionately affect women not just because they are less able to pay, but also because they typically need more preventive and routine services due to maternal and child health needs.

In Uganda, while voucher schemes increased women’s access to health care, it did not address why they didn’t have cash in the first place. Men have more control over income and can spend it in ways that neglect maternal health. But not all men are the same: younger men were more likely to feel comfortable with changing gender roles than older men.

[Contributed by Asha George and Jeff Knezovich, Future Health Systems]

Who provides health care services?

Meenakshi Gautham, K M Shyamprasad, Rajesh Singh, Anshi Zachariah, Rajkumari Singh, and Gerald Bloom Informal rural healthcare providers in North and South India Health Policy Plan. (2014) 29 (suppl 1): i20-i29 doi:10.1093 / Via heapol.oxfordjournals.org

Most health systems are mixes of public and private service providers. Private service providers can include non-for-profit organisations and charities as well as for-profit providers. Sometimes the distinction between these services can be difficult to make. It is not atypical in many East Asian countries, for example, to have a single clinic or provider that sees clients both on a public and on a private basis.

The private, for-profit sector can be further divided into qualified providers and informal providers of modern medicine. Informal providers might be pharmacists and chemists acting beyond their scope of work, or might just be someone who has apprenticed with a doctor or chemist and then set up their own shop. The informal providers tend not to be discussed when looking at overall health systems. But in many places, like Guntur district in Andhra Pradesh, India (pictured above), these informal workers provide most of the care.

Most attention on informal providers has focused on those selling modern 'Western' medical (allopathic) treatments. If one were to include traditional birth attendants and home carers, the count of informal providers would be even higher, their gender profile and concerns somewhat different.

In terms of the public sector, the frontlines of many government health services are overwhelmingly female. They are often poorly paid, supported or supervised and yet expected to save lives. This is particularly a concern with some cadres of community health workers..

When it comes to governing health systems, overwhelmingly, men are still in decision making roles, whether in terms of management or policy. Female voices in health committees or health planning processes, while mandated in a few instances, remains isolated and largely unheard.

[Contributed by Jeff Knezovich and Asha George, Future Health Systems]

So which country has the best health system?

The Commonwealth Fund / Via commonwealthfund.org

OK, that's a bit of a tough question and gets right to the heart of a number of elements of what makes a good health system beyond the building blocks. The Commonwealth Fund released a report in June 2014 that compared a number of health systems, mainly across OECD (wealthy) countries. They looked at quality of care -- things like how effective and coordinated the care was. They also examined access in terms of cost and wait times. They looked at how efficient the overall system was, and how equitable the system was (i.e. can everyone actually get care no matter how much money they have or where they are geographically in that country).

We recommend reading the whole report — but, SPOILER ALERT, the United Kingdom comes out quite well across a number of the indicators. The United States? Not so much.

Obviously this isn't an exhaustive look at all health systems around the world though, so I wouldn't get too carried away in proclaiming that the UK has the best health system.

It should be particularly noted that although the care in the UK was deemed appropriate, the outcome of the care — i.e. how healthy people actually were — was toward the bottom of the pack. A measure that looked at the healthiness of people overall would look quite different from measuring how well health system services work or can be accessed.

The broader social determinants of health influences who gets sick in the first place and once sick, how well they are able to recover and with what consequences.

[Contributed by Jeff Knezovich, Future Health Systems, with inputs from Kate Tulenko, CapacityPlus]

What about countries whose health system has been devastated by war or conflict?

Economist/Graphic Detail / Via economist.com

By their very nature wars are a cause of death and poor health. Those who survive can be left disabled or psychologically traumatised, which has serious implications for health systems.

Unfortunately post-conflict countries face other problems too.

Often, clinics and hospitals have been destroyed, doctors and nurses have fled the country, people have been displaced, systems for buying and distributing medicine and other health supplies have been disrupted and citizen’s trust in governments and leaders has been weakened. Additionally, the economies of post-conflict countries are often shattered - leaving them poorly equipped to properly fund health care.

Re-building health systems in these countries, assuming they do not slip back into conflict, as is often the case, is necessary to provide health services on an equitable basis, and it might also provide a ‘window of opportunity’ to do things differently and better – to put in place new processes and systems…

For example mainstreaming gender considerations into the way that health systems are structured and operate is important. ReBUILD Consortium researchers in Northern Uganda argue that humanitarian health system reconstruction often focuses on the development of infrastructure. The assumption is that once the facilities exist, anyone should be able to access health care equally and equitably. But this ignores the multiple challenges and costs women, men, girls and boys have to negotiate when required medicines are not available or when they are referred for costly investigations.

The ‘window of opportunity’ may not occur in the immediate aftermath of conflict, as is illustrated in the case of human resource policies in Sierra Leone, where a convergence of the right the political situation, availability of funding and donor support and the sense of need for radical change led to policy change.

Fragility after conflict might leave countries vulnerable to health crises – like we have seen with Ebola in Sierra Leone, Liberia, and Guinea.

There is a need to support the longer-term construction of resilient and responsive health systems in post-conflict countries as well as provide short-term emergency support.

[Contributed by Kate Hawkins, ReBUILD Consortium.]

You keep banging on about social determinants of health? What are they, and how do they relate to health systems?

Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies; 1991. / Via heapol.oxfordjournals.org

As this graphic shows, health outcomes aren't just influenced by existing health systems. The overall environment might influence a person's health. And we don't just mean the physical environment (though that can certainly be a factor). Everything from where someone works, to their access to clean water, to the types of food they have available and influence their health outcomes. Social bonds can also influence health, which is the concept behind the idea that obesity is 'socially contagious'. On an individual level, there are a number of risk factors that might determine a person's level of health.

The above chart is clear: health systems only play a small part of all of the social determinants of health. That might be one reason why the United Kingdom's health system can rate highly and yet have lower-than-expected health outcomes at the population level.

Of course, these same factors can influence access to health services. If someone is living in a rural area and is a subsistence farmer, they might not have the money nor the time to travel to the nearest health clinic.

[Contributed by Jeff Knezovich, Future Health Systems]

And what about the people involved in the health system?

Karen LeBan. How Social Capital in Community Systems Strengthens Health Systems: People, Structures, Processes / Via coregroup.org

They matter.

Let’s not forget the people who make health systems dynamic and complex: the clients, caregivers, community members and leaders, frontline health workers, doctors, nurses, midwives, health managers and policy makers. Each of these actors influences how health is accessed and has a direct link with the results that are achieved as a result of their interactions. Existing health systems frameworks focus primarily on the supply side.

However, the relationship between individuals and the health system has a large role to play in how health outcomes are reached, as communities often reflect values, and in low and middle-income countries, these values often focus on group customs and practices.

Therefore, there is a need to think about the quality of relationships between health system actors and communities in the zone of interaction, where the two come together. These relationships depend on community members and end users being treated with dignity and respect, with good quality services being provided, and the meaningful engagement of both community and health systems actors so they are able to work together while building social capital through norms of reciprocity and trustworthiness, thereby bringing diverse people together for a common cause.

[Contributed by : Minal Rahimtoola, Pathfinder International]

Can health systems be 'governed', 'managed' or even just improved?

Via ihris.org

'Governance' is a fancy word and isn’t always well understood. In fact, the Oxford English Dictionary defines governance with a tautology: 'the action or manner of governing.'

The Roundtable Conference on Governance for Health in Low and Middle Income Countries defined governance most simply as 'a collective process of making decisions for organizations or health systems.'

One good summary of what governance of health systems can be is summarised in the chart above. The Uganda Medical and Dental Practitioners Council (UMDPC) had a problem. They are responsible for relicensing all the physicians and dentists in Uganda. Yet with no enforcement system and little funding, fewer than 100 physicians and dentists renewed their licenses every year.

In addition, quacks masquerading as physicians (see section above on health service providers) were setting up practices and even charging patients in government hospitals. Seeking a solution, UMDPC partnered with the several development projects supported by the US Agency for International Development (USAID), including the Uganda Capacity Project, the Capacity Project and CapacityPlus. Together they designed a free, open code database of physicians and dentists that enabled patients and their families and community members to use their mobile phones to text in the name of a physician or dentist and find out if they were registered.

This simple act of good governance — making physician and dentist registration data available to the public — resulted in an over 14 fold increase in the number of physicians and dentists registered per year and resulted in a ‘triple win':

It was a win for patients and communities because they could ensure the health worker they were seeing was a legitimate health worker.

it was a win for the physicians and dentists because they no longer had to compete against quacks and could prove their legitimacy.

And it was a win for UMDPC and the government which now had better data to plan the training and posting of health workers.

In addition, UMDPC’s net revenues more than quintupled and allowed them to provide better service to their members and buy a new building. Now that’s good governance!

[Contributed by Kate Tulenko, CapacityPlus, with input by Jeff Knezovich, Future Health Systems]