Lecture - Key issues in health system development

1. Key issues in health
system development
ICHS 3
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Introduction to Complex Health
Systems

2. Outline
1. Dimensions of health system
performance
2. Understanding the Thai experience

3. STARTING POINTS: HEALTH
SYSTEM PERFORMANCE

4. WHO, 2007
4

5. Washington, among others [9–11]. organization. This framework is informed by extensive
Fig. 1. Framework for health systems performance measures.
Kruk and Freedman, 2008
Improved
health
Social &
financial
risk
protection

6. Access & coverage
Donabedian: “proof of
access is in use of service,
not presence of a facility”
Degree of fit between
between the health
system and the
population it serves
A vailability
A cceptability
A ffordability

7. From availability to effective
coverage
for whom
service
available
can use
service
who are
willing to use
services
who use
service
who receive
‘effective’
care
People:
Shrinking proportion >>>

8. Responsiveness
how people are treated and the
environment in which they are treated
when seeking health care
a particular focus on inequitable
treatment associated with social status
www.who.int/responsiveness/en

9. Health care responsiveness (percentage of respondents who responded either
“good” or “very good”) comparisons across countries
Outpatient experiences Inpatient experiences
S
Africa
Brazil Israel Euro* S
Africa
Brazil Israel Euro*
Time 58 65 69 72 66 69 77 81
Dignity 71 93 92 90 74 90 90 89
Communication 69 81 87 87 67 76 87 82
Autonomy 60 70 80 83 61 66 79 72
Confidentiality 74 90 88 89 73 80 83 82
Quality of basic
amenities
68 80 90 91 70 80 60 87
Support 68 70 91 92
Summary 67 80 83 87 68 76 81 83
*European countries included were: Austria, Belgium, Denmark, Finland, France,
Germany, Greece, Ireland, Italy, Luxemburg, Netherlands, Portugal, Sweden, and United
Kingdom
World Health Survey data, 2003 (Pelzer, 2009 BMC Health Services
Research)
2352 participants (1116 men and 1236 women)

10. What is a health system’s
broader societal value?
The knowledge of a safety net for times of
vulnerability
‘Public value’
• producing things of value to groups of citizens
• operating in fair, efficient & accountable ways

11. THE THAI EXPERIENCE

12. Health performance
• Achieved MDGs
early 2000s
• Over 40 years:
– LEB gone up, IMR
gone down, MMR
gone down, strong
annual reduction in
ChMR over 20yrs
• Reduction in IMR
and ChMR
inequalities
Value for money:
Relatively low IMR for
relatively low per capita
health expenditure
(compared to other
countries)

13. Health care performance
• Cause specific mortality
decreases for
intervention-addressable
conditions (PyCare,
MCH, pub health), except
for peri-natal care
• High coverage with many
interventions critical for
child survival
• ‘Satisfactory’ essential
obstetric care (no policy
on unsafe abortions)
• Equity in utilisation
• Low out of pocket
payments with low levels
of catastrophic health
expenditure

14. Factors explaining
experience
Health care performance gains over time
due to
Sustained action to address access barriers
over time

15. Sustained action to address access barriers over time:
Balabanova et al. 2011

16. Source: de Savigny and Adam (2009)
What building blocks were
addressed?

17. What building blocks were addressed?

18. Tackling access barriers
Hardware:
• Physical availability:
– provincial > district hospitals (phased imp)
– human resources:
• Bonding to rural areas for doctors and
nurses, plus
• Expansion of nurse training & intro of less
qualified cadres with career paths by MOPH
(not MoEd)
(some provincial EDLs)
• Financial risk protection
– Piecemeal & gradual extension to 70% of
population by 2001
– Universal coverage 2002
– Increased government spending over time
Software:
• ‘Pro-rural’ values
• Dedicated and
committed health
professionals
across the system
• Social recognition
of health
professionals

19. Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
Health system

20. Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
1) Decision-making
processes that have
ensured consistent
vision and persistent
development
towards goals
How and
why?
1. Values-based and
charismatic political
leadership
2. Elite and interest
groups support
3. Competent, values-
based and
distributed technical
leadership
4. Generation and use
of evidence in
decision-making
5. Decentralised
authority
6. Flexible
implementation
7. Communication and
feedback, learning
through doing
Pro-poor, pro-
rural ideologyHealth system

21. Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
2) HC features:
1. public sector
strengthened
2. integrated
service
provision
3. limited reliance
on external
resources
How and
why?
Pro-poor ideology; Use of
evidence; Economic context
Health system

22. Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
3) Community
factors:
1. community
awareness &
acceptance
of health
programmes
2. public trust &
confidence in
DHS
3. public status
of health
professionals
How and
why?
Socio-cultural values;
positive experiences
Health system

23. Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
1) Decision-making
processes that have
ensured consistent
vision and persistent
development
towards goals
How and
why?
2) HS features:
1. public sector
strengthened
2. integrated
service
provision
3. limited reliance
on external
resources
1. Values-based and
charismatic political
leadership
2. Elite and interest
groups support
3. Competent, values-
based and
distributed technical
leadership
4. Generation and use
of evidence in
decision-making
5. Decentralised
authority
6. Flexible
implementation
7. Communication and
feedback, learning
through doing
3) Community
factors:
1. community
awareness &
acceptance
of health
programmes
2. public trust &
confidence in
DHS
3. public status
of health
professionals
How and
why?
Socio-cultural values;
positive experiences
Pro-poor, pro-
rural ideology
How and
why?
Pro-poor ideology; Use of
evidence; Economic context
Health system

24. Note
• SYSTEM development matters!
– Action went beyond specific interventions,
services or programmes
– Intersectoral actions
• New challenges to be addressed

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Introduction to Complex Health Systems, Presentation
3. Copyright CHEPSAA (Consortium for Health Policy &
Systems Analysis in Africa) 2014, www.hpsa-africa.org
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This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.
265482). The views expressed are not necessarily those of the EC.

26. The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre for Health Policy
University of Ghana
School of Public Health, Department of
Health Policy, Planning and Management
University of Leeds
Nuffield Centre for International Health and
Development
University of Nigeria Enugu
Health Policy Research Group & the
Department of Health Administration and
Management
London School of Hygiene and
Tropical Medicine
Health Economics and Systems Analysis
Group, Depart of Global Health & Dev.
Great Lakes University of Kisumu
Tropical Institute of Community Health and
Development
Karolinska Institutet
Health Systems and Policy Group,
Department of Public Health Sciences
University of Cape Town
Health Policy and Systems Programme,
Health Economics Unit
Swiss Tropical and Public Health
Institute
Health Systems Research Group
University of the Western Cape
School of Public Health