The document provides an overview of a course on health service systems and health systems. It discusses several topics that will be covered in the course, including major issues in organizing health services, assessing population health status, analyzing healthcare access and costs. The course will also examine sociopolitical, economic, and ethical issues facing public health systems. Students will learn about different components of health systems through mini-lectures, discussions, and by analyzing case studies.

1. Introduction to Health Systems &
Health Services Systems
Borwornsom Leerapan, MD PhD
MGMG 548: Health Service Systems and Health Systems
CMMU, Mahidol University
May 18, 2014
Pix source: ra.mahidol.ac.th

2. Course Description
MGMG 548
• Major issues in the organization of a health services system
• The role of values in the development of health care policy
• Methods for assessing the health status of populations
• Analysis of need for, access to and use of services; current supply
and distribution of health resources
• Analysis of health care costs and expenditures
• Sociopolitical, economic, and moral/ethical issues confronting the
public health and medical care system
• Trends in service provision, human resources, financing and health
services organization, and implications for the public’s health.
Source Prattana Punnakitikashem. PhD; Pix source: online.wsj.com

4. Format
F/U
Pix source: online.wsj.com
Mini-lecture
Discussion
Q&A
Wrap
up
To-do
list

5. Course Website

6. Course Calendar
Week Date Topic
1 May 18, 2014 Overview of health & health services
Systems
2 May 25, 2014 Systems thinking & the building blocks of
health systems
3 June 1, 2014 Healthcare quality
4 June 8, 2014 Healthcare efficiency
5 June 15, 2014 Health equity
6 June 22, 2014 Social determinants of health
7 June 29, 2014 Mid-term exam

7. Course Calendar
Week Date Topic
8 July 6, 2014 Ambulatory care and primary healthcare
9 July 13, 2014 Chronic care
10 July 20, 2014 Long-term care
11 July 27, 2014 Emergency care
12 August 3, 2014 Palliative care
13 August 10, 2014 Care for certain diseases and populations:
travel clinic
14 August 17, 2014 Student presentations of final papers

8. Learning Materials
Required reading:
• Selected readings available via the course website.
• In addition, there is a recommended textbook for this course.
– The Institute of Medicine (2001). Crossing the quality chasm: a new
health system for the 21st century. Committee on Quality Health Care
in America, Institute of Medicine. Washington, D.C.: National Academy
Press.
Source: nap.edu

9. Learning Materials
Optional textbook/resource:
• Garwande, A. (2002). Complications: a surgeon's notes on an imperfect
science. New York, NY: Picador Press.
• Roberts, M. J., Hsiao, W., Berman, P., & Reich, M. R. (2004). Getting health
reform right: a guide to improving performance and equity. New York,
USA: Oxford University Press.
• Aday, L. A., Begley, C. E., Lairson, D. R., & Balkrishnan, R. (2013).
Evaluating the healthcare system: effectiveness, efficiency, and equity.
Chicago, IL: Health Administration Press.
• Wibulpolprasert, S., Sirilak, S., Ekachampaka, P., & Wattanamano, N. (2011).
Thailand health profile 2008-2010. Bangkok; The War Veterans
Organization of Thailand Press.

10. Up and Down the Ladder of Abstraction
Abstract:
• Concepts
• Theories
• Principles
• Strategies
Concrete:
• Case studies
• Data, Evidence
• Analysis, Synthesis
• Presentations

11. Outline for Today
1. Pre-test
2. Concepts of health and health determinants
3. Health systems vs. Health services systems
4. Desirable characteristics of health services systems
5. Case study and discussion
– Healthcare managers vs. policy/systems analysts.
Pix source: online.wsj.com

12. Pretest
(in-class exam, no grade)
Pix source: online.wsj.com

13. Considering the provided VDO presentation, please give
your best answers to these two following questions:
1. What “health systems issues” are dominated in the
provided VDO presentation? (Please describe.)
2. As a (future) administrators in your healthcare
organizations, what could you do to address such
issues? (Elaborate more on what, why, and how.)
(30 min)
Pre-test Exam

14. Concepts of Health
& Health Determinants
Pix source: online.wsj.com

15. “Heath”
WHO definition of Health:
“Health is a state of complete
physical, mental and social well-being
and not merely the absence of
disease or infirmity.”
Source: reamble to the Constitution of the World Health Organization as adopted by the International Health
Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official
Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

16. “Heath”
Thailand’s Definition of Health:
Source: Statute on National Health System B.E. 2552 (2009)

17. Health & Health Determinants
Figure source: Thailand Health Profile 2012

18. Health Systems
& Health Services Systems
Pix source: online.wsj.com

19. “System”
“CIPO” Model
Source: Scheerens and Bosker 1997; Pix source: system humanrevod.wordpress.com

20. “Health System”
Source: who’s World Health Report (2000)

21. “Health System”
• “The Six Building Blocks” and their interconnections
Pix source: WHO’s framework for action. (2007)

22. “Health System”
Pix source: WHO’s framework for action. (2007)

23. Social Determinants of Health
• Health is not merely the absence of disease or infirmity.
• Health promotion and disease prevention
• Health promotion strategies have to go beyond health services
sector.
Pix source: greenpeace.org; twirlit.com; who.int/bulletin; cha-amcity.go.th

25. Stakeholders in Thai Health System
Pix source: www.nationalhealth.or.th

26. Desirable Characteristics of
Health Services Systems
Pix source: online.wsj.com

27. Goals of Health Services System
Source: Modified from WHO (2000) and Marc J Roberts et al. (2003)
Health

28. Desirable Health Services System
• A great health services system should be:
1. Equitable
2. Efficient
3. Safe
4. Timely
5. Effective
6. Patient-centered
Source: Adapted from IOM (2001)
Quality
“STEEEP”

29. 1. Equitable Health Services
• Equity:
– Equality of opportunity to access to healthcare
services, regardless of race, gender, age, religion,
geographic location, socioeconomic status
– “Equal services for equal needs, and unequal
services for unequal needs”
Pix source: www.stephenharrington-online.com

30. What is Your Theory of Justice?
• How would you fairly cut this cake into two
pieces for each of the twins?
Pix source: hp-lexicon.org/wizards; helenicproducts.com

31. Theory of Justice
• John Rawls: “Justice as Fairness”
– Fair decisions should be made
from “the original position”
where no one knows what
burdens or benefits he or she
might receive once “the veil of
ignorance” is lifted.
Source: John Rawls. The Theory of Justice (1971, 2001): Pix source: irwinbartlet.wordpress.com

32. Equity vs. Equality
• Equity means equality of opportunity (“justice as fairness”).
• Equality is not always justice.
Pix source: twicsy.com/i/TwC76c
Equality Equity

33. Equitable Health Services
• It is very difficult to measure “health equity”.
• Equitable health services could be used as its proxy
measures, particularly measures of the “accessibility
to health services”:
– Physical accessibility
– Psychological accessibility
– Financial accessibility
– Information accessibility
Source: WHO/Europe (2007)

34. 2. Efficient Health Services
• Efficiency:
– Efficient health services means a system that utilize
health resources (drugs, human resources, budgets)
in a cost-effective fashion, with utility maximization
and waste reduction.
Source: Modified from IOM (2001)

35. Efficiency of Thai Healthcare?
“31.2% of diabetes patients and 50.3% of
hypertension patients are not diagnosed.
Only 28.5% and 20.9% of cases have been
diagnosed, treated and brought under control.”
Figure source: Kanchanachitra .et al. (2010)

36. Technical vs. Allocative Efficiency
• Two approaches to improve efficiency:
1. Technical efficiency
2. Allocative efficiency

37. 3. Quality Health Services
• Quality:
– “Quality is in the eye of the beholder.”
– Nonetheless, all health services should be “safe,
timely, effective, patient-centered”.
Source: Adapted from IOM (2001)

38. Quality as Safety
• Safety:
– By design, a system that prevents medical error and
avoid iatrogenic injuries.
Source: Modified from IOM (2001); Pix source: thieme-connect.de/ejournals; tumblr.com

39. Quality as Safety
(Disclaimer: Obviously, this is partly my self-advertisement!)
Source: amazon.com, matichonbook.com

40. Quality as Timeliness
• Timeliness:
– Reducing waiting time of both health providers and
consumers, which sometimes lead to injuries and
harms.
Source: Modified from IOM (2001);
Pix source: toonpool.com/cartoons.jpg

41. Quality as Effectiveness
• Effectiveness:
– Delivery of evidence-based
health services to all people who
likely will benefit from such
services (“avoid underuse”) and
provide no services that have no
evidence of benefits or that
could be harmful (“avoid
overuse and misuse”).
Source: Modified from IOM (2001); Pix source: www.rch.org.au/clinicalguide

42. Quality as Patient-Centeredness
• Patient-centeredness:
– A system that respects the patient’s rights.
– Be responsive to personal beliefs ่ and value of individuals.
– Open an opportunity for patients (and families) and
clinicians to make mutual decisions on their health
interventions
– Not a disease-centered system
– Not a provider-centered system
Source: Modified from IOM (2001); Pix source: blog.skylight.com/patient-centric

43. Adult Learning
Ø Learning about health systems: “Experience, not explanation.”
Picture source: commonsenseatheism.com; variety.thaiza.com
EXPERIENCE

44. What Level of Our Learning?
Wisdom • Why
Knowledge • How
Information • What, Who, When, Where
Data • Number, Text, Picture, Sound, etc.

45. Q& A
Discussions
Pix source: online.wsj.com