1. Health
Beyond Hospitals
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine
Faculty of Medicine Ramathibodi Hospital
Mahidol University
May 14, 2014

2. Introduction
2003 Doctor of Medicine (1st-Class Honors), Ramathibodi
2009 M.S. (Health Informatics), University of Minnesota
2011 Ph.D. (Health Informatics), University of Minnesota
Currently
• Lecturer, Department of Community Medicine
• Deputy Executive Director for Informatics
Chakri Naruebodindra Medical Institute
Contacts
nawanan.the@mahidol.ac.th
SlideShare.net/Nawanan
www.tc.umn.edu/~theer002
2

3. Outline
• “Health” & Its Determinants
• Health Systems & Healthcare Systems
• Functions & Components
• Characteristics of a Desirable Health System
• Models of Healthcare Systems
• Thailand’s Context
• Major Issues in Health Care
3

4. “Health” &
Its Determinants
4

5. Class Discussion:
What Is Health?
5

6. Health
• Health vs. Illness and Disease
• Medical Model:
Health = Absence of Illness or Disease
• So what’s the problem with this model?
6

7. Problems with the Medical Model
• Emphasis on treatment of illness/disease
• Promotion and Prevention deemphasized
• Not true sense of the word “Health” but
rather just “Lack of ill health”
• So what’s a better model of health?
Shi & Singh (2004)
7

8. The WHO Model & Definition
• “Health is a state of complete physical,
mental and social well-being and not
merely the absence of disease or infirmity.”
WHO Constitution (1948)
• Also known as biopsychosocial model of
health
8

9. Holistic Health
• The well-being of every aspect of what
makes a person whole and complete
Shi & Singh (2004)
Holistic
Health
Physical
Mental
Social
Spiritual
9

10. 10
The Epidemiology Triangle
10
Host
EnvironmentAgent
Disease

11. 11
Determinants of Health
11
Individual
Adapted from Leerapan B. Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
Environment
Health
Healthcare
Systems
Biological
- Genetics
Psychologic
al (KAP)
- Knowledge
- Attitudes
- Practice
(Behaviors/
Lifestyles)
- Physical
- Chemical
- Biological
- Social, cultural,
economic, political,
technological

12. 12
Natural History of Disease
Adapted from Centers for Disease Control and Prevention. Principles of epidemiology, 2nd ed. Atlanta: U.S. Department of
Health and Human Services; 1992 (Cited in http://www.cdc.gov/osels/scientific_edu/ss1978/lesson1/Section9.html)
Healthy
Health
Promotion
Disease
Prevention
Early Detection Prompt Treatment Rehabilitation/
Limitation of
Disability
Primary Prevention
(Preventing Disease)
Secondary Prevention
(Preventing Disability or Death)
Tertiary Prevention
(Preventing More
Disability or Death)
Stage of
Susceptibility
Stage of Subclinical
Disease
Stage of
Clinical Disease
Stage of Recovery,
Disability or Death
Exposure
Pathologic
Changes
Onset of
Symptoms
Usual Time
of Diagnosis

13. 13
Health Promotion Strategies:
Ottawa Charter
13
WHO (1986)

14. 14
Social Determinants of Health
• The circumstances in which people are
born, grow up, live, work and age, and the
systems put in place to deal with illness.
These circumstances are in turn shaped by
a wider set of forces: economics, social
policies, and politics.
14
WHO (2008)

15. 15
Social Determinants of Health
15
WHO (2008)

16. Health Systems &
Healthcare Systems
16

17. Health Systems
• A health system consists of all
organizations, people and actions whose
primary intent is to promote, restore or
maintain health.
• Includes efforts to influence determinants of
health as well as more direct health-
improving activities.
• More than the pyramid of publicly owned
facilities that deliver personal health
services. WHO (2007)
17

18. Health Systems
• Includes
• A mother caring for a sick child at home
• Private providers
• Behavior change program
• Vector-control campaigns
• Health insurance organizations
• Occupational health and safety legislation.
• Inter-sectoral action by health staff, for
example, encouraging the ministry of education
to promote female education, a well known
determinant of better health. WHO (2007)
18

19. Health Care
• Health care: Activities and services
performed to improve a person’s health and
well-being, through prevention and
treatment of illness.
• Similar terms
• Healthcare services
• Healthcare delivery
Adapted from Shi & Singh (2004)
19

20. 20
Healthcare Systems
• An organization that delivers healthcare
• In general, healthcare systems
• promote good health in populations
• balance levels of actual care provided
with the expectations of the population
they serve
• Narrower definition than WHO’s “Health
Systems”
20
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

21. 21
Healthcare Systems
• Different models of healthcare systems
• Purely public (care conducted by the state)
• Purely private (care conducted by independent,
privately funded organizations)
• Often a mixed model
• In countries with state run healthcare
system, a private system may coexist in
parallel or offer services not available under
the public system
21
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

22. 22
Healthcare Systems
• Privately owned, commercial organizations
may also act as healthcare systems
• These organizations may serve a single area
or multiple geographic locations
• Private healthcare systems may be:
• Not-for-profit organizations (governed by
principle of non-distribution) or
• For profit organizations (distribute surplus
funds to shareholders or owners)
22
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

23. 23
Healthcare Systems
• Healthcare systems can be measured
using benchmarks
• One framework for assessment:
•Patient assessed value
•Performance on clinical interventions
•Efficiency
23
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

24. 24
Public Health
24
“is the science and art of preventing disease, prolonging life
and promoting health through the organized efforts and
informed choices of society, organizations, public and
private, communities and individuals.“
(Winslow, C.E.A. 1920)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).

25. What is Public Health?
• Private Health
• Clinicians, Health
Practitioners
• Treat Individual Health
Problems
• Action usually taken after
illness/injury occurs
• Public Health
• Agencies
• Treat/Maintain Health of
Populations
• Actions include
Education, Policy,
Research, Monitoring
25
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 7a).

26. Multiple Layers of “Health Systems”:
A Health Systems Research Perspective
26
Hoffman et al. (2012)

27. 27
10 Great Public Health Achievements –
US, 1900-1999
• Vaccination
• Motor-vehicle safety
• Safe workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard
27
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).

28. 28
How Has Public Health Improved
Healthcare?
• Improvements in understanding disease
• Epidemiology is considered the basic science of public
health and is
• a quantitative basic science
• a method of causal reasoning based on developing
and testing hypotheses pertaining to occurrence and
prevention of morbidity and mortality
• a tool for public health action to promote and protect
the public’s health
28
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).

29. 29
• An example of epidemiology at work:
• In 1854: epidemic of cholera in London, England
• Cholera is a bacterial disease
• Lack of sanitation and overcrowding led to the spread
of disease
• Dr. John Snow linked the spread of disease to a
contaminated public water pump
• Snow’s hypothesis: cholera was spread by
contaminated water
29
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
How Has Public Health Improved
Healthcare?

30. 30
• Improvements in data collection
• Original methods of data collection were crude
• progressive improvement in methodology led to the use
of sophisticated scientific methods to collect data
• cohort studies
• randomized controlled trials
30
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
How Has Public Health Improved
Healthcare?

31. 31
• Improvements in data analysis (use of tools such as
multivariate analysis and meta-analysis)
• Improvement in disease surveillance
• Example: the Real-Time Outbreak and Disease
Surveillance (RODS) Laboratory at the University of
Pittsburgh, Department of Biomedical Informatics
31
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
How Has Public Health Improved
Healthcare?

32. 32
• Improvement in training
• Establishment of many schools of public health in the
early 20th century
• Professional degrees such as Master of Public Health
(M.P.H.)
• Improvements in infrastructure
• Federal
• State
• Local health departments
32
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1b).
How Has Public Health Improved
Healthcare?

33. Functions & Components
of Health Systems
33

34. 34
Functions of Healthcare Systems
34
Healthcare
Service
Delivery
Health
Insurance
Adapted from Shi & Singh (2004) by Theera‐Ampornpunt
Healthcare
Payment
Healthcare
Financing
Access
Funding
Funding
Claims & Reimbursements
Governance,
Policy &
Administration

35. 35
Components of Health Systems
35
Cited in: Hoffman et al. (2012)

36. 36
Components of Health Systems
36
WHO (2009)

37. 37
Healthcare Delivery
37
• Healthcare is delivered in different places
Inpatient facilities
• Hospitals
• Institutions for treating sick or injured people
• Historically places for shelter, almshouses
• Different types of hospitals
• General medical and surgical hospitals
• Specialty hospitals (orthopedic, pediatrics, women’s
services, psychiatric, neurological, infectious disease)
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

38. 38
Healthcare Delivery
• Hospitals may be publicly or privately owned
• Patients can be admitted to a hospital through
• Emergency room
• An internal outpatient clinic
• Directly admitted from an external physician’s office
• Depends on local practices
38
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

39. 39
Healthcare Delivery
• Nursing and residential care facilities
• Can be short term facilities or long term
facilities
• Long term care classified by level of care
• Nursing homes gradually shifted from being
part of the welfare system to being a part of
the healthcare system
39
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

40. 40
Healthcare Delivery
Outpatient facilities
• Hospitals in some countries provide
ambulatory care through internal outpatient
clinics
• Physicians offices (also known as private
clinics)
• Primary care offices
• Specialty care offices
• Single specialty or multispecialty offices
40
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

41. 41
Healthcare Delivery
• Dental offices
• General dentists or specialists
• Medical and diagnostic laboratories
• Pharmacies
• Internal pharmacies of hospitals
• Private pharmacies
• Community health centers
• Other ambulatory health services
41
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

42. U.S. Healthcare Industry
Industry segment Employment Establishments
Total 100.0 100.0
Ambulatory healthcare services 42.6 87.3
Offices of physicians 17.0 36.0
Home healthcare services 7.2 3.7
Offices of dentists 6.2 20.4
Offices of other health practitioners 4.7 19.6
Outpatient care centers 4.0 3.6
Other ambulatory healthcare services 1.8 1.4
Medical and diagnostic laboratories 1.6 2.4
Hospitals 34.6 1.3
General medical and surgical hospitals 32.5 1.0
Other specialty hospitals 1.4 0.2
Psychiatric and substance abuse hospitals 0.7 0.1
Nursing and residential care facilities 22.8 11.4
Community care facilities for the elderly 5.2 3.5
Residential mental health facilities 4.1 4.0
Other residential care facilities 1.3 1.1
1.1 Table: Percent distribution of employment and establishments in health services by detailed industry sector, 2008.
42
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1a).

43. Characteristics of a
Desirable Health System
43

44. 44
WHO Framework
44
WHO (2009)

45. 45
EQESAR Framework
• E - Equity
• Q - Quality
• E - Efficiency
• SA - Social Accountability
• R - Relevancy
45
Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

46. 46
Equity
• Equal services for equal needs
• Unequal services for unequal needs
• Accessibility
• Physical
• Psychological
• Financial
• Information
46
Leerapan B. Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

47. Quality
• Safety
• Timeliness
• Effectiveness
• Patient-centeredness
Adapted from IOM (2001)

48. 48
Efficiency
• Cost-effectiveness
• Output or outcome versus cost
• Technical/operational efficiency
• Allocative efficiency
48
Adapted from Leerapan B. Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

49. 49
Social Accountability
• Good governance
• Adequate oversight and monitoring
• Transparency
49
Adapted from Leerapan B. Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

50. 50
Relevancy
• Relevant to issues/problems in the context
of interest
• Context-dependent
50
Adapted from Leerapan B. Department of Community Medicine,
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand

51. Models of Healthcare
Systems
51

52. 52
Models of Healthcare Systems
52
Model Financing Provider
Ownership
Example of
Countries
Employer-based
(market-based)
private insurance
Multipayer,
voluntary
Private United States
National health
insurance
Single-payer
(general taxes)
Public/Private Canada
National health
system
Single-pyaer
(general taxes)
Public United Kingdom
Socialized health
insurance
Employer-
employee,
mandatory
Private Germany
Hybrid Multiple models Public/Private Thailand
Adapted from Shi & Singh (2004)

53. Thailand’s Context
53

54. 54
Thailand’s Health Systems: Public
• กระทรวงสาธารณสุข
• สํานักงานรัฐมนตรี
• สํานักงานปลัดกระทรวงสาธารณสุข (สป.)
• สํานักงานคณะกรรมการอาหารและยา (อย.)
• กรมการแพทย์
• กรมควบคุมโรค
• กรมพัฒนาการแพทย์แผนไทยและการแพทย์ทางเลือก
• กรมวิทยาศาสตร์การแพทย์
• กรมสนับสนุนบริการสุขภาพ
• กรมสุขภาพจิต
• กรมอนามัย
54

55. Thailand’s Health Systems: Public
ราชการบริหารส่วนกลางใน สป.
• สํานักบริหารกลาง
• ศูนย์เทคโนโลยีสารสนเทศและการ
สื่อสาร
• สถาบันพระบรมราชชนก
• สํานักการพยาบาล
• สํานักตรวจและประเมินผล
• สํานักนโยบายและยุทธศาสตร์ (สนย.)
• สํานักบริหารการสาธารณสุข (สบรส.)
ราชการบริหารส่วนภูมิภาคใน สป.
• สํานักงานสาธารณสุขจังหวัด (สสจ.)
• สํานักงานสาธารณสุขอําเภอ (สสอ.)
• โรงพยาบาลส่งเสริมสุขภาพตําบล
(รพ.สต.)
55

56. 56
Thailand’s Health Systems: Public
• สถาบันวิจัยระบบสาธารณสุข (สวรส.)
• สํานักงานกองทุนสนับสนุนการสร้างเสริมสุขภาพ (สสส.)
• สํานักงานหลักประกันสุขภาพแห่งชาติ (สปสช.)
• สํานักงานคณะกรรมการสุขภาพแห่งชาติ (สช.)
• สถาบันรับรองคุณภาพสถานพยาบาล (สรพ.)
• องค์การเภสัชกรรม
• โรงพยาบาลบ้านแพ้ว (องค์การมหาชน)
• โรงพยาบาลของรัฐนอกสังกัดกระทรวงสาธารณสุข
56

57. Thailand’s Health Systems: Public
สภาวิชาชีพ
• แพทยสภา
• ทันตแพทยสภา
• สภาการพยาบาล
• สภาเภสัชกรรม
• สภาเทคนิคการแพทย์
• สภากายภาพบําบัด
• สภาการแพทย์แผนไทย
• สภาการสาธารณสุขชุมชน
คณะกรรมการการประกอบโรคศิลปะ
• สาขาเทคโนโลยีหัวใจและทรวงอก
• สาขาการแก้ไขความผิดปกติของการ
สื่อความหมาย
• สาขากายอุปกรณ์
• สาขาการแพทย์แผนจีน
• สาขากิจกรรมบําบัด
• สาขารังสีเทคนิค
• สาขาจิตวิทยาคลินิก
57

58. 58
Thailand’s Health Systems: Public
• กระทรวงศึกษาธิการ
• กระทรวงแรงงาน
• สํานักงานประกันสังคม (สปส.)
• กรมสวัสดิการและคุ้มครองแรงงาน (occupational health & safety)
• กระทรวงการคลัง
• กรมบัญชีกลาง (สิทธิข้าราชการ)
• กระทรวงการพัฒนาสังคมและความมั่นคงของมนุษย์
• กรมพัฒนาสังคมและสวัสดิการ
• สํานักงานส่งเสริมสวัสดิภาพและพิทักษ์เด็ก เยาวชน ผู้ด้อยโอกาส คนพิการ และผู้สูงอายุ
• สํานักงานส่งเสริมและพัฒนาคุณภาพชีวิตคนพิการแห่งชาติ
58

59. 59
Thailand’s Health Systems: Public
• กระทรวงเกษตรและสหกรณ์
• กรมปศุสัตว์ (Zoonosis & control of outbreaks)
• กระทรวงทรัพยากรธรรมชาติและสิ่งแวดล้อม
• กรมควบคุมมลพิษ (Environmental health)
• กระทรวงคมนาคม (เช่น เรื่องอุบัติเหตุจราจร)
• กระทรวงการต่างประเทศ (เช่น นโยบายสุขภาพระหว่างประเทศ)
• กระทรวงยุติธรรม (เช่น การฟื้นฟูสมรรถภาพผู้ติดยาเสพติด)
• สํานักงานคณะกรรมการคุ้มครองผู้บริโภค (สคบ.)
59

60. 60
Thailand’s Health Systems: Private
• For-profit hospitals
• Non-profit hospitals
• Private clinics
• Pharmacies
• Private laboratories
• NGOs
• Media
• etc.
60

61. 61
Thailand’s Hospitals (2010)
61
Hospital Category Number of
Hospitals
Percentage of All
Hospitals
District hospitals (MOPH) 737 56.4%
General hospitals (MOPH) 68 5.2%
Regional hospitals (MOPH) 26 2.0%
Other hospitals under
MOPH*
50 3.8%
Other public hospitals
outside MOPH†
111 8.5%
Private hospitals 315 24.1%
Total 1307 100.0%
*Including general and specialty hospitals under other departments within the Ministry of Public Health.
†Including university hospitals, military hospitals, autonomous public hospitals, prison hospitals, hospitals of state
enterprises, and public hospitals under local governments.
MOPH = Ministry of Public Health
Source: Bureau of Policy and Strategy, Ministry of Public Health (November 2010).

62. Major Issues in
Health Care
62

63. 63
Major Issues in Health Care
• Public Policy & Healthcare Reform
• Universal Health Coverage
• Cost Containment
• Quality & Patient Safety
• Innovative Models of Healthcare Delivery &
Financing
63

64. 64
Major Issues in Health Care
• Evidence-Based Practice
• Increased Expectations & Patient Volumes
• Prevention vs. Treatment
• Rise of Aging Population & Chronic Diseases
• Legal Issues (e.g. Malpractice)
• Patient engagement
• Workforce: Shortages, maldistributions &
evolving competency requirements
• Technological Advances 64

65. 65
Major Issues in Health Care
• Globalization
• Educated, engaged patients
• Lifestyle changes
• Challenges in control of disease outbreaks
• Emerging field of “Global Health”
65

66. Paradigm Shifts in Medicine
66
• Physician-centric to patient-centric care
• Individual to team-based care
• Paper-based to electronic-based
management of medical records
• Provider-kept to personal health records
Adapted from materials developed by Oregon Health & Science University, funded by the Office of the
National Coordinator for Health Information Technology, U.S. Department of Health and Human
Services (Health IT Workforce Curriculum v.3.0/Spring 2012, Component 1/Unit 1c).

67. 67
Summary
• Health  Health care
• There are “Health” issues beyond hospitals
• There are key players of “Health” beyond
hospitals
• Clinicians should learn to play collaborative
roles with others within and outside hospitals
for health of individuals and population.
67

68. References
• Centers for Disease Control and Prevention (CDC). Ten great public health
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