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HC International Comparative Analysis of Health Systems (uitgebreid)
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Lectures ICAHSLecture 1 – Introduction to – comparative- analyses of HS (5-1-2015)
What constitutes a HS?
- Providers/suppliers, patients/consumers, financing
- Infrastructure The available buildings, accessibility, roads towards them… the roads
are not their responsibility, without roads no access. Also, information is an important
concept of infrastructure. Not just ICT, but the whole processing of data infrastructure
etc.
- Subsystem of a country to promote public health, organization of institutions, people
and resources to meet the needs of the targeted population.
o Public health is the health of the whole population. The health system also
includes the doctor-patient relationship. Public health is indeed focused on the
public health, but public health is also different from clinical things like the
doctor-patient relationship.
What should it do, what should it deliver?
- Accessible, available, acceptable and affordable care. It should deliver quality care,
equity, efficiency, stewardship, financing, and resource generation.
- What do we mean with accessible? Include everyone, not discriminate (perhaps it
should actually between the sick and not so sick or between the rich and poor). What
other services do we have? Medicine, pharmacies, mental health, GPs, nurses,
elderly care, midwives, dentists, Botox, also for the disables ( rehabilitation centres,
physiotherapists), psychologists, people that advice you on nutrition.
- Safety belts also part of the HS?
We cannot really grasp a HS. We can conceptually grasp it in a way. It is rather complex. We
have to be on terms with that. All those things do matter in HS. Do not be reductionist in your
thinking, skip the details; we should have holistic views, because all those things are related.
We make choices whether our dentists or physiotherapist, the GP, stop smoking therapies
are in our packages. Traditional care in the HS? How do we define it, what is it? We can even
say a lot of the work psychologists do is also part of traditional care. Why not? We have
biomedical care giving and a lot of other care giving. What is that? Not research based or not
evidence based. That also counts for the work psychologists or therapists do. Does it work?
Yes of course, there is a lot of benefit in all kinds of traditional care. It is at least part of in a
way or relevant for the HS.
We have to try to narrow it down (in the assignments, work on pharmaceuticals, maternal
care, traditional care).
- Thus, what should a HS do? It should provide care. More explicit? Keep people
healthy, make them healthy, and protect them from impoverishing effects of illness.
They should foremost do that; provide health (whether it is treating/curing or
preventing matter). When they are already disabled, we at least make the disability
last harmful, or when they are already dying we provide palliative care. Health is the
foremost goal of the HS. Are there other goals? The WHO also distinguishes care
financial risk protection. So that both HS provide revenue, but at the same time not in
a way that people, because of the health care expenditure, may fall into catastrophic
health expenditure; that they have to pay too much to keep them healthy, that they
cannot pay for other primary needs like education, food, nutrition.
o Also in the NL, we were the best or second best of financial risk protection in
EU, and now we moved to being average, because or own risk is increasing.
People do not seek care, because it will cost them money. It can be good
because people do not seek unnecessary care. However, it can also be bad
because people will not search care soon enough.
,If we talk about the health system there are two things we need to discuss:
- What is health? Health is not merely the absence of disease, but a state of complete
mental, physical and social well-being (WHO). What is that? Example of Kate who
could not go up the stairs because of her knew. It also has to do with your own
personal perception, perhaps also the group perception. If health is the overarching
goal of the HS and if we think about what is health and we look at the definition of
WHO, that means that the definition is rather broad. Physical well-being well okay, but
mental well-being, what does that mean? For example, feeling happy. What makes or
keeps you happy? My friends. If your mental well-being also deals with such things as
friends and it fall under health, then the HS is responsible for providing you with
friends. This is part in a way of the HS, also intersectoral collaboration. The question
is, we do frame health as quality of life nowadays. You have to have quality of life.
That is our ultimate goal. For instance, the “rollator”, the walker. It may hugely
improve your quality of life when you cannot walk, but is it the responsibility of the HS
or not? It depends on your restriction of life without it. We have to challenge
ourselves. For example, antibiotics are part of the HS. Further, what is part of the HS
and what not? To what are we all entitled? Our innovations over the last year, even
more so than our greying/aging society, even more so the costs of technologies etc.
are making HS unsustainable. We can do more, but it is also more costly. To do it
universally would be problematic.
What is health? We do not have an answer. At least, as a group, whether it is a family
or a municipality or country or the world, we think about what is it then; otherwise we
are talking about noting or different things.
- What is system? How health is organized. Most of us will have a quite functional
approach how we organize something to make a certain goal (health) happen. A
system has a behavior. There are so many elements, actors (even technology being
an actor on its own), rules (explicit or not/informal like you are all silent when I talk).
Similar to an ecosystem is the product of all the interactions that are happening. The
HS is not the product of a grand design. The HS consists of a lot of people with
different ideas, in one way they are part of the HS for example as a doctor, but also
part of a golf club or political party, they do all sorts of things. A system, when you
think of the/a system, is the product always of a lot of interactions between different
elements. Those elements exist because they were probably successful in the past,
we keep or improve them. They have developed, constantly, and we keep them still.
We have this feeling that it is all there, but we also try to manipulate constantly
through politics. It develops through time, product of time reproduced by our
interactions. We have to work with it. As a researcher you have to conceptualize, to
make a simple representation of how it is, but it is not simple.
Why do we want to compare it?
Because far most we think health is important. Often people in the NL describe being healthy
as most important, even more than being happy. We want to improve.
As we know, across countries, at similar level of income and educational attainment, there is
a wide variation in health outcomes (Worldbank). So, we differ. There is room for
improvement.
“The way health systems are designed, managed and financed affects people’s lives and
livelihoods. The difference between a well-performing health system and one that is failing
can be measured in death, disability, impoverishment, humiliation and despair.” (Dr Gro
Brundtland)
Two definitions of HS:
1. “All the activities whose primary purpose is to promote, restore, improve or maintain
health, protect people against impoverishing effects of illness, and ensure that those
, who need care are treated with dignity and respect.” (World health report, WHO,
2000) GOAL
2. “A combination of resources, organization, financing and management that cumulates
in the delivery of health services to the population.” (Roemer, 1991) DESCRIPTIVE
The second one describes the elements more and first describes the goal (it should do
something). Do you think the goal of the HS is part of the system or is the goal the things that
the system produces (external)? A goal is only there because of the system, and it is part of
the system because the goal is the one thing valued by the system. Health is not a goal we
should per se have, health is only a goal because we value it. The ones in the system give
value to it. We give meaning to it and that is why we aim for it. That is why the system itself
creates its goals. For example with friends or family (small system) you also create values.
This is more the functional part (what
you see at symposia or conferences,
you can even see it as an intervention
which have certain inputs (sick
people, financial, material, HR) and
outputs (health, high quality,
efficiency, and quality). What you
often see that what happens in
between remains in the black box. It is
very hard to say what something leads to another. Not on an individual level (give AB, see
effect), but on HS level causality is hard to determine. We try to have some ideas about the
causal relationships. There are so many things happening in this black box, that causality is
hard to determine.
TWO VIDEOS
Analysis is an imperative first step: whether we analyze in-outputs or the actual process.
Examples on differences:
- Expenditure per capita
o USA 8.000 USD
o Eritrea 16 USD
- Number of doctors
o Greece 65/10.000
o Liberia 0,1/10.000
- CIA 2010 life expectancy
o Monaco 90 years
o Zw 32 years Main reason why it is below 60 is because of HIV/AIDS
It is like comparing apples to oranges. The one HS is not the other. We have to understand
that they are different. Within this difference, we should try to compare it.
Divers context in which HS function: There are differences in geography, financing, traditional
healing, technology, insurance mechanisms, etc.
We talked about what is health? Quality of life.
- Disease is being the objective thing, the biomedical approach.
- Illness is the subjective approach. I feel ill. This is different than having a disease.
When you have a disease you often feel ill, but you can also feel ill without a specific
cause.
- Sickness Social perception. Someone with ADHD, is this person sick? Is a gay
person sick? All things that in the past have socially been labeled sick.
We have different things on what is health.
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