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A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health .

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health .

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  • 1. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health SystemFunctions And Structure "HS Building Blocks" Dr. Ahmed-Refat A.G Refat Taibah University - Nov. 2012 1
  • 2. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Contents Definition of Health System Health System Goals Attributes of a Good Health System Health System Functions Problems with Health System Health System Challenges ( Global Facts) Six Health System Building Blocks of Health System Ten Essential Public Health Functions 2
  • 3. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Definition ofHealth System!! 3
  • 4. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) What is a Health System? A “system” is an arrangement of parts and their interconnections that come together for a purpose .A health system, like any other system, is a set of inter-connected parts that have to function together to be effective . 4
  • 5. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)A health system has many parts. In addition to patients, families, and communities, Ministries of Health, health providers, healthservices organizations, pharmaceutical companies, health financing bodies, and other organizations play important roles. The interconnections of the health system can be viewed as thefunctions and roles played by these parts. These functions include oversight (e.g., policymaking, regulation), health service provision (e.g., preventive services, clinical services, health promotion),financing, and managing resources (e.g., pharmaceuticals, medical equipment, information). 5
  • 6. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) A Health System can defined as : “the combination of resources, organization, financing and management that culminate in the delivery of health services to the population.” “all activities whose primary purpose is to promote, restore, and maintainhealth.” ( WHO 2000). In recent years, the definition of “purpose” has beenfurther extended to include the prevention of household poverty due toillness. "A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health. 6
  • 7. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health (WHO 2007) . This includes efforts to influence determinants of health as well as more direct health-improving activities.Health System is much broader than the public health service deliverysystem that is often the focus of public health officials.It includes the full range of stakeholders in a health sector, for example,private for-profit and not-for-profit service providers, health insuranceorganizations, public safety legislation, community outreach workers,patients, and consumers, as well as mothers caring for sick children. 7
  • 8. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) WHO (2007) also defined health system strengthening, as:…improving [the] six health system building blocks and managing theirinteractions in ways that achieve more equitable and sustainedimprovements across health services and health outcomes.A health system is therefore more than the pyramid of publicly ownedfacilities that deliver personal health services. It includes, for example, amother caring for a sick child at home; private providers; behaviourchange programmes; vector-control campaigns; health insuranceorganizations; occupational health and safety legislation. 8
  • 9. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) It 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 A health system needs staff, funds, information, supplies, transport,communications and overall guidance and direction. And it needs toprovide services that are responsive and financially fair, while treatingpeople decently.The ultimate responsibility for the overall performance of a countrys healthsystem lies with government, but good stewardship by regions andindividual health institutions is also vital. 9
  • 10. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health System GoalsHealth systems have multiple goals. The World health report 2000 definedoverall health system outcomes or goals as: improving health and healthequity, in ways that are responsive, financially fair, and make the best, ormost efficient, use of available resources.There are also important intermediate goals: the route from inputs tohealth outcomes is through achieving greater access to and coverage foreffective health interventions, without compromising efforts to ensureprovider quality and safety. 11
  • 11. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Good Health SystemA good health system delivers quality services to all people, when andwhere they need them.The exact configuration of services varies from country to country, but inall cases requires a forceful financing mechanism; a well-trained andadequately paid workforce; reliable information on which to basedecisions and policies; well maintained facilities and logistics to deliverquality medicines and technologies. 11
  • 12. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) HS FunctionThe World Health Report 2000 (WHO 2000) identifies the four keyfunctions of the health system:(1) stewardship (often referred to as governance or oversight),(2) financing,(3) human and physical resources,and (4) organization and management of service delivery. 12
  • 13. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 13
  • 14. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)In a 2005 World Health Assembly resolution, WHO member statescommitted to develop their health systems to ensure that all people haveaccess to health services without being subject to financial hardshippaying for them – a goal defined as universal health coverage (WHO2010).http://www.who.int/features/factfiles/universal_health_coverage/facts/en/index.html 14
  • 15. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health System Building BlocksTo achieve their goals, all health systems have to carry out some basicfunctions, regardless of how they are organized: they have to provideservices; develop health workers and other key resources; mobilize andallocate finances, and ensure health system leadership and governance(also known as stewardship, which is about oversight and guidance ofthe whole system). For the purpose of clearly articulating what WHO will do to helpstrengthen health systems, the functions identified in the World healthreport 2000 have been broken down into a set of six essential ‘buildingblocks’. All are needed to improve outcomes. This is WHO’s healthsystem framework. 15
  • 16. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health System functions/ building bloc ks:1. Leadership and governance2. Health financing3. Service delivery4. Human resources for health5. Medical products, vaccines and technologies6. Health information systemsThis WHO enumeration and definition of the building blocks has beenadopted widely, and now provides a common terminology for discussingkey health system functions. 16
  • 17. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)The six build ing block s of a he alth system a re:1- Good health services are those which deliver effective, safe, qualitypersonal and non-personal health interventions to those who needthem, when and where needed, with minimum waste of resources.2- A well-performing health workforce is one which works in waysthat are responsive, fair and efficient to achieve the best healthoutcomes possible, given available resources and circumstances. I.e.There are sufficient numbers and mix of staff, fairly distributed; they arecompetent, responsive and productive. 17
  • 18. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)3- A well-functioning health information system is one that ensuresthe production, analysis, dissemination and use of reliable and timelyinformation on health determinants, health systems performance andhealth status.4- A well-functioning health system ensures equitable access toessential medical products, vaccines and technologies of assuredquality, safety, efficacy and cost-effectiveness, and their scientificallysound and cost-effective use. 18
  • 19. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)5- A good health financing system raises adequate funds for health,in ways that ensure people can use needed services, and are protectedfrom financial catastrophe or impoverishment associated with having topay for them.6- Leadership and governance involves ensuring strategic policyframeworks exist and are combined with effective oversight, coalitionbuilding, the provision of appropriate regulations and incentives,attention to system-design, and accountability 19
  • 20. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 21
  • 21. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 21
  • 22. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 22
  • 23. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Building Blocks Interaction 23
  • 24. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health System Actors1. Public SectorThe public sector, also called the government sector, is a complex group ofactors that includes ministries of health (MOHs), line ministries, and publicservants.Public health funding comes from a variety of sources such as taxes, socialsecurity payments, and donors . 24
  • 25. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) The public sector has 11 Essential Public Health Functions (EPHF) as defined by a WHO study in 41 countries- EPHF 1 - Monitoring, evaluation, and analysis of health status- EPHF 2 - Surveillance, research, and control of the risks and threats to public health- EPHF 3 - Health promotion- EPHF 4 - Social participation in health- EPHF 5 - Development of policies and institutional capacity for public health planning and management 25
  • 26. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)- EPHF 6 - Strengthening of public health regulation and enforcement capacity-EPHF 7 - Evaluation and promotion of equitable access to necessary health services- EPHF 8 - Human resources development and training in public healthEPHF 9 - Quality assurance in personal and population-based health servicesEPHF 10 - Research in public health- EPHF 11 - Reduction of the impact of emergencies and disasters on health 26
  • 27. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)Challenges Facing public health SectorPublic health sectors face many challenges in carrying out their essentialfunctions. Some are internal, such as lack of financing, insufficient managementskills, and corruption. Others are environmental, such as changing epidemiologicand demographic trends and emerging diseases, new medical technology,globalization, and health reform . 27
  • 28. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 2. Private SectorReliance on government health services alone is often insufficient in achievingimprovements in health status indicators such as child mortality or the preventionof HIV/AIDS. The private sector is a key source of health services, and itscoverage is rapidly expanding. In many developing countries, there is highutilization of the private sector for essential health services, (IFC 2007).Therefore, including the private health sector in the HSA provides a morecomplete and accurate understanding of a country’s health sector. 28
  • 29. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) The private health sector is typically described as comprising “all providers who exist outside of the public sector, whether their aim is charitable or commercial, and whose aim is to treat illness or prevent disease” The private health sector comprises both forprofit, commercial entities andthe not-for-profit organizations like nongovernmental organizations (NGOs) andfaith-based organizations (FBOs) that engage in health care. 29
  • 30. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)There are also a variety of private providers. 1-Formally trained and licensed private providers include doctors, nurses, midwives, and paramedical staff such as clinical officers and physician assistants.  Private pharmacists and drug sellers are often the first-line providers in the formal health sector that serves people in poor and remote communities.2-The informal health sector consists of traditional healers, traditional birthattendants (TBAs), indigenous systems medical providers (ISMPs), and marketdrug sellers. 31
  • 31. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)The informal sector is a significant, although not well documented, source ofhealth care, particularly for rural and poor populations.A substantial number of public sector health practitioners in developing countriesalso work for private clients during evenings and weekends. These providersconstitute animportant component that spans the public and private sector, and their rolecould be an important consideration when assessing service delivery and humanresources. 31
  • 32. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 3. Communities and PatientsWith their focus on the supply side of health care (service provision), the sixbuilding blocks do not always capture the importance of the demand side, whichcomprises communities and patients.The World Health Report 2000 (WHO 2000) recognized the importance of peopleas financiers of care, as citizens with a role in health governance, as careproviders, and as consumers. 32
  • 33. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Problems with health systemsProblems with health systems are not confined to poor countries. Some richcountries have large populations without access to care because of inequitablearrangements for social protection. Others are struggling with escalating costsbecause of inefficient use of resources.Health outcomes are unacceptably low across much of the developing world, andthe persistence of deep inequities in health status is a problem from which no 33
  • 34. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)country in the world is exempt. At the centre of this human crisis is a failure ofhealth systems .Failing or inadequate health systems are one of the main obstacles to scaling-upinterventions to make achievement of internationally agreed goals such as theMDGs a realistic prospect. 34
  • 35. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health system challenges: a few facts and figures• Globally, health is a US$3.5 trillion industry, or equal to 8% of the worldsGDP.• Large health inequalities persist: even within rich countries such as USA andAustralia, life expectancy still varies across the population by over 20 years.• Recent essential medicines surveys in 39 mainly low- and low-middle-incomecountries found that, while there was wide variation, average availability was20% in the public sector, and 56% in the private sector.• Each year, 100 million people are impoverished as a result of healthspending. 35
  • 36. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health system challenges: a few facts and figures• Extreme shortages of health workers exist in 57 countries; 36 of these are inAfrica.• In over 60 countries, less than a quarter of deaths are recorded by vitalregistration systems.• An estimated 50% of medical equipment in developing countries is not used,either because of a lack of spare parts or maintenance, or because healthworkers do not know how to use it.• Private providers are used by poor as well as rich people. For example, inBangladesh, around ¾ of health service contacts are with non-public providers. 36
  • 37. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Health system challenges: a few facts and figures• In 2000, less than 1% of publications on Medline were on health services andsystems research.• Globally, about 20% of all health aid goes to support governments overallprogrammes (i.e. is given as general budget or sector support), while anestimated 50% of health aid is off budget.• There has been a rapid increase in global health partnerships. More than 80now exist, of which WHO houses over 30. 37
  • 38. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 38
  • 39. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) 10 Essential Public Health Services http://www.cdc.gov/nphpsp/essentialservices.htmlThe Essential Public Health Services provide the fundamental framework ofthe public health activities that should be undertaken in all communities.The Core Public Health Functions Steering Committee developed the framework for the Essential Services in 1994. This steering committee includedrepresentatives from US Public Health Service agencies and other major public health organizations. 39
  • 40. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)The Essential Services provide a working definition of public health and a guiding framework for the responsibilities of local public health systems.1. Monitor health status to identify and solve community health problems.2. Diagnose and investigate health problems and health hazards in the community.3. Inform, educate, and empower people about health issues.4. Mobilize community partnerships and action to identify and solve health problems. 41
  • 41. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)5. Develop policies and plans that support individual and community health efforts.6. Enforce laws and regulations that protect health and ensure safety.7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.8. Assure competent public and personal health care workforce.9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.10. Research for new insights and innovative solutions to health problems. 41
  • 42. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #1 Monitor Health Status to Identify Health Problems Assessment of statewide health status and its determinants, including the identification of health threats and the determination of health service needs. Analysis of the health of specific groups that are at higher risk for health threats than the general population. Identification of community assets and resources, which support the state public health system (SPHS) in promoting health and improving quality of life. Interpretation and communication of health information to diverse audiences in different sectors. Collaboration in integrating and managing public health related information systems. 42
  • 43. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #2 Diagnose and Investigate Health Problems and Health HazardsThis service includes:• Epidemiologic investigation of disease outbreaks and patterns of infectiousand chronic diseases, injuries, and other adverse health conditions.• Population-based screening, case finding, investigation, and the scientificanalysis of health problems.• Rapid screening, high volume testing, and active infectious diseaseepidemiologic investigations. 43
  • 44. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #3 Inform, Educate, and Empower People about Health IssuesThis service includes: • Health information, health education, and health promotion activities designed to reduce health risk and promote better health. • Health communication plans and activities such as media advocacy and social marketing.• Accessible health information and educational resources.• Health education and promotion program partnerships with schools, faithcommunities, work sites, personal care providers, and others to implement andreinforce health promotion programs and messages. 44
  • 45. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #4 Mobilize Partnerships to Identify and Solve Health ProblemsThis service includes:• The organization and leadership to convene, facilitate, and collaborate withstatewide partners (including those not typically considered to be health-related)to identify public health priorities and create effective solutions to solve state andlocal health problems.• The building of a statewide partnership to collaborate in the performance ofpublic health functions and essential services in an effort to utilize the full rangeof available human and material resources to improve the state’s health status.• Assistance to partners and communities to organize and undertake actions toimprove the health of the state’s communities. 45
  • 46. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #5 Develop Policies and Plans that Support Individual and Statewide Health EffortsThis service includes:• Systematic health planning that relies on appropriate data, develops andtracks measurable health objectives, and establishes strategies and actions toguide community health improvement at the state and local levels.• Development of legislation, codes, rules, regulations, ordinances, and otherpolicies to enable performance of the Essential Public Health Services,supporting individual, community, and state health efforts.• The process of dialogue, advocacy and debate among groups affected by theproposed health plans and policies prior to adoption of such plans or policies. 46
  • 47. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #6 Enforce Laws and Regulations that Protect Health and Ensure Safety• The review, evaluation, and revision of laws (laws refers to all laws,regulations, statutes, ordinances, and codes) designed to protect health andensure safety to assure that they reflect current scientific knowledge and bestpractices for achieving compliance.• Education of persons and entities in the regulated environment and personsand entities that enforce laws designed to protect health and ensure safety.• Enforcement activities of public health concern, including, but not limited to,enforcement of clean air and potable water standards; regulation of health carefacilities; safety inspections of workplaces; review of new drug, biological, andmedical device applications; activities occurring during emergency safety seatusage, and childhood immunizations. …etc.. 47
  • 48. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #7Link People to Needed Personal Health Services and Assure the Provision of Health Care When Otherwise Unavailable  Assessment of access to and availability of quality personal health services for the state’s population.  Assurances that access is available in a coordinated system of quality care which includes outreach services to link populations to preventive and curative care, medical services, case management, enabling social and mental health services, culturally and linguistically appropriate services, and health care quality review programs.  Partnership with public, private, and voluntary sectors to provide populations with a coordinated system of health care.  Development of a continuous improvement process to assure the equitable distribution of resources for those in greatest need. 48
  • 49. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #8 Assure a Competent Public and Personal Health Care Workforce• Education, training, development, and assessment of health professionals--including partners, volunteers and other lay community health workers--to meetstatewide needs for public and personal health services.• Efficient processes for credentialing technical and professional healthpersonnel.• Adoption of continuous quality improvement and life-long learning programs.• Partnerships with professional workforce development programs to assurerelevant learning experiences for all participants.• Continuing education in management, cultural competence, and leadershipdevelopment programs. 49
  • 50. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #9 Evaluate Effectiveness, Accessibility, and Quality of Personal and Population-Based Health ServicesThis service includes:• Evaluation and critical review of health programs, based on analyses ofhealth status and service utilization data, are conducted to determine programeffectiveness and to provide information necessary for allocating resources andreshaping programs for improved efficiency, effectiveness, and quality.• Assessment of and quality improvement in the State Public Health System’sperformance and capacity. 51
  • 51. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Essential Service #10 Research for New Insights and Innovative Solutions to Health ProblemsThis service includes:• A full continuum of research ranging from field-based efforts to fosterimprovements in public health practice to formal scientific research.• Linkage with research institutions and other institutions of higher learning.• Internal capacity to mount timely epidemiologic and economic analyses andconduct needed health services research. 51
  • 52. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Public Health Agency of Canada: Six Essential Activities Of Public health1. Health protection: This includes ensuring that water, air and food are safe, maintaining the regulatory framework for the control of infectious disease and protection from environmental threats, as well as advising on food and drug safety regulations.2. Health surveillance: The ongoing, systematic use of routinely collected health data for the purpose of tracking and forecasting health events or health determinants. It includes i. The collection and storage of relevant data ii. The integration, analysis, and interpretation of these data 52
  • 53. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) iii. The production of tracking and forecasting products with the interpreted data iv. Publication and dissemination of those products v. Provision of expertise to those developing or contributing to surveillance systems, including risk surveillance. vi. The information produced by surveillance is used in planning services and prevention programmes.3. Disease and injury prevention: The investigation, contact tracing, and development of preventive and control measures to reduce the risk of infectious disease emergence and outbreaks as well as the promotion of safe, healthy lifestyles to reduce preventable illness and injuries.4. Population health assessment: Understanding the health of communities or specific populations, as well as the factors that underlie good health or pose potential risks, to produce better policies and services. 53
  • 54. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012)5. Health promotion: Preventing disease, encouraging safe behaviours, and improving health through public policy, community-based interventions, active public participation, and advocacy or action on environmental and socio-economic determinants of health.6. Emergency preparedness and response: Planning for natural disasters (e.g., floods, earthquakes, fires, dangerous infectious disease) and man- made disasters (e.g., those involving explosives, chemicals, radioactive substances, or biological threats and social disruption). 54
  • 55. Health System Functions And Structure "HS Building Blocks" Dr. Ahmed-Refat AG Refat (Nov. 2012) Cited ReferencesWHO Health System Web Pages http://www.who.int/healthsystems/en/http://www. who.int/healthsystems/topics/en/WHO- 2012 : World Health Reporthttp://www. who.int/healthinfo/EN_W HS2012_Full.pdfThe World health report 2000 : health system s : improving performancehttp://www.who.int/whr/2000/en/whr00_en.pdfWHO- Health System Performancehttp://www. who.int/health-systems-performance/Monitoring the building blocks of health system s: a handbook of indicators and their measurement strategies. © World Health Organization 2010http://www. who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdfTHE HEALTH S YSTEM ASS ESSMENT APPROACH: A HOW-TO MANUALVersion 2.0 September 2012http://www.healthsystem s2020.org/ content/re source/detail/528/USAI D- Health system 2020http://www.healthsystems2020.org/ 55