Lecture - The life and experience of a health system: considering political economy

1. The life and experience
of a health system:
considering political
economy
ICHS 1
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introduction to Complex Health
Systems

2. Outline
• What is a health system?
• What influences how health systems
develop & perform?

3. Key social goal…
Improve health by
average level of population
health
health inequities
Health systems
“All organizations, people and action whose
primary intent is to promote, restore or maintain
health”
WHO, 2007 http://www.who.int/healthsystems/strategy/en/

4. Health system boundaries
Personal health care
Health care/services
Intersectoral health action
Other factors: national and global influences
Source: Modified from WHO World Health Report, 2000
HEALTH

5. Organisational
Hierarchy
National Health system
National context
Global context
AN OPEN SYSTEM

6. International influences on
African health systems
Period Approach Context/Values base
1970s Whole system
focus/comprehensive PHC
Basic needs development, social
justice
1980s Focus on
interventions/selective PHC
Economic crisis & conservative
economic policies/efficiency
1990s Health system reform –
financing & organisation
Structural adjustment/efficiency,
competition
1990s-
2000s
Focus on ‘big killers’ AIDS crisis response/medical
responses
2000s Health system strengthening Response to the implementation gap
& concern for MDGs
Van Olmen et al. 2012

7. Changing over time
The UK:
• 1800s mutual aid societies &
medical relief for the indigent;
with private care for rich
• 1911 Health Insurance Act:
mandated basic medical
benefits for poorer employed
• 1948 NHS: public, universal
health service: coverage
extended, benefits expanded,
hospitals nationalized
• 1990s Internal markets to
encourage competition
> Growing OOPs, Growing %
pop with private health
insurance

8. The Nigerian experience
See
https://www.youtube.com/watch?v=V-
cXDl20i5k&feature=youtu.be

9. What is political economy?
Inter-relationships between political processes,
economic systems and health/health systems
Political
System
Health
Economic
System
Aggregate level
or by race,
class, gender,
place
Health Systems

10. Political System and Processes
(political and socio-economic rights, decisionmaking practices)
Acceptance of discrimination
Definition of public need
Attitude towards privatisation
Determination of public policy
Level of unionisation Accountability of public administration
Income and wealth levels and distribution
Food intake
Access to health-promoting inputs
Access to cost-effective and quality health care
Access to other services
Spatial development
Macro-economic Policy
Interest rates
Access to credit
Exchange rate
Import & export tariffs
Domestic subsidies & taxes
Public expenditure level
Labour Policy
Access to employment
Minimum wages
Hours of work
Employment benefits
Public sector pay determination
Land Distribution and
Housing Policy
Access to land and housing
Distribution of land and housing
Public Provisioning Policy
Provision and financing of:
Education
Social welfare
Health care
Water & sanitation
Quality of environment
Disposable income
Own food production
Health-seeking behaviour
Household health investment
Intrahousehold allocation of time and resources
Individual and Household Health and Welfare
SOCIO-POLITICO-
ECONOMIC-
HEALTH
INTERACTIONS
Household
factors

11. Health system Type 1:
private
Type 2:
pluralistic
Type 3: NHI Type 4: NHS Type 5:
socialized
health service
Political &
ideological
values
HC an item of
personal
consumption
HC primarily
consumer
good
HC as
insured,
guaranteed
service
HC as state
supported
service
HC as right &
state-provided
pub service
Position of the
physicians
Solo
entrepreneur
Solo
entrepreneur
& member
practitioner
group
Private solo or
group practice
&/or employed
by hospitals
Private solo
or group
practice &/or
employed by
hospitals
State
employee
Ownership of
facilities
private Private, NFP
& Public
NFP & public Mostly public Entirely public
Source of
financing
Private OOP Mix OOP &
public
Primarily
single payer
public
Public Public
Administration &
regulation
Market Market, some
Govt
Govt Govt Govt
Prototype Most countries
till 19th&20th C
USA
Peru
France
Canada
Korea
UK Soviet Union
Cuba
Birn et al. 2009, adapted from Rodwin 1984 & Field 1978

12. Economic
level
Entrepreneurial
& dismissive
Welfare
oriented
Universal &
comprehensiv
e
Socialist &
Centrally
planned
Affluent &
industrialised
USA Canada
Germany
Netherlands
Japan
Norway
UK
Former Soviet
Union
Former Czech
Developing &
transitional
Thailand
Philippines
South Africa
Brazil
Egypt
Malaysia
Mexico
Costa Rica Cuba
Very poor Bangladesh
Nepal
Honduras
Botswana
Tajikistan
Sri Lanka China
Vietnam
Resource rich Nigeria Libya
Gabon
Venezuela
Kuwait (except
guest workers)
Roemer’s 1991 Typology updated by Birn et al. 2009

13. Conclusions:
1. The political ideologies of governing parties affect some
indicators of population health
2. Political parties with egalitarian ideologies tend to implement
redistributive policies
3. Policies aimed at reducing social inequalities do impact positively
on IMR and, to lesser extent, on LEB
Navarro et al. Lancet 2006
OECD countries 1950-2000

14. Using gapminder
http://www.gapminder.org/

15. Copyright
Funding
You are free:
To Share – to copy, distribute and transmit the work
To Remix – to adapt the work
Under the following conditions:
Attribution You must attribute the work in the manner
specified by the author or licensor (but not in any way that
suggests that they endorse you or your use of the work).
Non-commercial You may not use this work for commercial
purposes.
Share Alike If you alter, transform, or build upon this work,
you may distribute the resulting work but only under the same
or similar license to this one.
Other conditions
For any reuse or distribution, you must make clear to
others the license terms of this work.
Nothing in this license impairs or restricts the authors’
moral rights.
Nothing in this license impairs or restricts the rights of
authors whose work is referenced in this document.
Cited works used in this document must be cited following
usual academic conventions.
Citation of this work must follow normal academic
conventions. Suggested citation:
Introduction to Complex Health Systems, Presentation
1. Copyright CHEPSAA (Consortium for Health Policy &
Systems Analysis in Africa) 2014, www.hpsa-africa.org
www.slideshare.net/hpsa_africa
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.

16. 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