Lectures

1. Comparative Healthcare
Systems
Lecture 3
Erick Ndenga

2. Today’s Road Map
 What is a healthcare system? How do they develop?
 Comparing Healthcare Systems
 Comparative Cost
 Comparative Service and Access
 Comparative Quality and Outcomes
Some key data to provide a quantitative overview and analysis
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3. Definitions of a Healthcare System
 The combination of healthcare institutions, supporting
human resources, financing mechanisms,
organizational structures that link institutions,
information systems, and resources and management
structures that collectively culminate in the delivery of
healthcare services to patients – Lassey, Lassey and
Jinks
Healthcare systems permeate society and represent a large part
of the economy: We ain’t just talking hospitals, nurses and doctors
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4. Operational Environment and
Healthcare
 All healthcare systems function in a physical, economic, historical
and cultural environment
 General physical environment and climate
 Socio-economic factors: income levels and distribution, education and
knowledge of hygiene
 History and historical values - a sense of “solidarity” or individualism
 Political and cultural ideals expressing norms and values
 Cultural, Family and Individual factors: personality, genetic make-up, life
style, diet, use of tobacco, alcohol use, exercise, mental health, etc.
Healthcare Systems are born from their environment and history
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5. Conceptual Framework
Health system goal: improving health and health equity, in
ways that are responsive, financially fair, and make the best,
or most efficient use of available resources.
Health system objectives: definition of objectives being
sought:
Improve access, and quality of services;
Achieve better coverage of services.
Health system building blocks: seven investment areas:
Investment in the building blocks aims to improve
coverage of services through attaining desired access to
interventions, without compromising quality and safety.
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6. Healthcare Systems and their Origins
 Britain: solidarity and WWII
 Tradition of hospitals funded by altruistic individuals or workhouses (1834) funded by local
taxes, then compulsory trade union or fraternal societies coverage (prepaid health plans);
slow evolution to government funded (Downton Abbey) first locally
 Burden of care for wartime casualties led to the creation of a national system made law by
National Health Service Act in 1948
 France: egalitarianism and liberalism (free market)
 Medical profession built charters and standards of care 1927
 Nation health insurance laws of 1928/1945/1967 built on local tradition of local sickness
funds, established by guilds and professional organizations
 French system continues a mix of private and public system.
 USA: individualism and the need attract workers
 Large hospitals, largely funded by charity; Private HC company 1848
 Private insurance(“the Blues”) becomes prevalent in the 1930’s and 40’s
 Need to attract workers during WWII led to employee sponsored plans and they became tax
deductible if employee sponsors
 Efforts at a universal insurance have been defeated on numerous occasions
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7. 7
BUILDING BLOCKS GOALS / OUTCOMES
Responsiveness to
legitimate needs
Social, and financial risk
protection
Improved health
(level and equity)
Access
Coverage
Quality
Safety
SERVICE DELIVERY
LEADERSHIP / GOVERNANCE
HEALTH WORKFORCE
INFORMATION
MEDICAL PRODUCTS,
VACCINES & TECHNOLOGIES
FINANCING
Improved efficiency
Source: World Health Organisation. Everybody’s Business: Strengthening Health Systems to Improve Health
Outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
Health System Building Blocks / Components

8. Healthcare systems: inputs and outputs
Inputs
• Culture: norms and
values, political
attitudes
• Environment and
climate
• Patients: education,
socio-economic level,
diet, disease
prevalence and acuity,
age
• Transportation
• Religion
Healthcare
System
• Hospitals, clinics
and other
institutions
• Doctors, nurses,
etc.
• Financing,
Insurance
• Education of
healthcare
workers
• Technology
• Laws pertinent to
the delivery and
payment of care
Outputs
• Quality/
Outcomes
• Service/
Access
• Cost
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Our comparison between systems will focus first on Outputs

9. Expected Outcomes of a Well
functioning Pillars
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A good health financing system:
Raises adequate funds for health, in ways that
ensure people can use needed services, and are
protected from financial catastrophes or
impoverishment associated with having to pay
for them;
Provides incentives for providers and users to be
efficient;
Includes policies that support sustainable
options/social protection, use of information,
sound financial management/ dialogue.

10. 10
A well-performing health workforce is one that:
Works in ways that are responsive, fair and
efficient to achieve the best health outcomes
possible, given available resources and
circumstances (i.e. there are sufficient staff, fairly
distributed, they are competent, responsive and
productive);
Needs norms/standards that govern production of
sufficient staff and ensure fair distribution (HRH
must be competent, responsive and productive);
HRH observatories are essential for facilitating
HRH management.
Expected Health Outcomes of Well Functioning
Pillars (Cont’d)

11. 11
A well-functioning health information system is
one that:
Ensures the production, analysis, dissemination
and use of reliable and timely information on
health determinants, health system performance
and health status;
Has standardised and integrated systems and
tools;
Enables linkages – local, national, regional and
global.
Expected Health Outcomes of Well Functioning
Pillars (Cont’d)

12. 12
A well-functioning health system ensures equitable
access to essential medical products and
technologies of assured quality, safety, efficacy and
cost-effectiveness, and their scientific soundness and
cost-effective use.
The medical products include medicine, reagents,
etc.;
Technologies include health infrastructure (e.g. X-
ray, lab, vaccines, etc.);
Norms/standards and policy options on products
and technologies are needed;
Procurement processes, monitoring, innovation
and patenting of new products are essential.
Expected Health Outcomes of Well Functioning
Pillars (Cont’d)

13. 13
.5
A good health financing system:
Raises adequate funds for health, in ways that
ensure people can use needed services, and are
protected from financial catastrophes or
impoverishment associated with having to pay for
them;
Provides incentives for providers and users to be
efficient;
Includes policies that support sustainable
options/social protection, use of information,
sound financial management/ dialogue.
Expected Health Outcomes of Well Functioning
Pillars (Cont’d)

14. Frameworks for Measuring
 WHO framework for health systems performance
assessment
 the World Bank control knobs framework
 the WHO building blocks framework
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15. Comparing Healthcare Systems
Cost
Outcomes
and Quality
Service
and Access
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VALUE

16. 16
Building Block Variables for Consideration
Service
Delivery
• Supervision activities – (technical, integrated, emergency);
• Outreach activities;
• Strategies to ensure patient safety;
• Efforts to ensure quality of services;
• Creation of demand for health services (community demand creation);
• Research in service delivery approaches.
Health
Workforce
• Definition of norms and standards for investment in health workforce;
• Regular planning and review of use of applicable health workforce;
• Recruitment and deployment of required health workforce;
• Strategies to motivate existing workforce;
• Monitoring, and review of health workforce distribution and motivation.
Health
Information
• Mechanisms to access, and use relevant facility based information;
• Mechanisms to access, and use relevant population based
information;
• Mechanisms to access, and use relevant surveillance information.
Variables for Consideration for Health System
Building Blocks

17. Building Block Variables for Consideration
Medical
Products,
Vaccines,
Technologies
• Definition of norms, and standards for medical products;
• Definition of comprehensive procurement, and
distribution plans;
• Quantities of medical products required:
- Medicines (essential, and public health) and related
supplies required,
- Vaccines and related supplies required,
- Medical and hospital equipment and related
supplies required,
- Physical infrastructure required,
- Transport (medical, and utility) required,
- ICT supplies and equipment required.
• Maintenance of medical products;
• Monitoring, and review of medical products
procurement, distribution and functionality.
Variables for Consideration for Health System
Building Blocks (Cont’d)

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Building Block Variables for Consideration
Health
Financing
• Definition of resource mobilisation strategy;
• Support to health financing management system;
• Monitoring, and review of health financing status.
Leadership and
Governance
• Definition of overall knowledge management
approach;
• Support to planning process at national, and sub
national levels;
• Performance monitoring process at national, and sub
national levels;
• Coordination and partnership arrangements;
• Strengthening of regulatory framework.
Variables for Consideration for Health System
Building Blocks (Cont’d)

19. Why Measure Performance
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