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Case 1Problem statement: What is the role of the analytical model within health systems and
how to apply it?
Learning goals:
1. What are the elements of the analytic model and describe them separately
(general)
Durán A, Kutzin J, Martin-Moreno JM, Travis P. (2012) Understanding health systems:
scope, functions and objectives.
The definition of a health system, therefore, includes:
• health services (personal and population based) and the activities to enable their delivery
provided by finance, resource generation and stewardship functions;
• stewardship, which includes activities seeking to influence the positive health impact of
other sectors – even though the primary purpose of those sectors is not to improve health.
We distinguish (i) health services as the ‘machinery’ related to the delivery of personal and
population-based interventions from (ii) other activities addressing the broad determinants of
health, and (iii) health systems as defined above but incorporating some context-specific
notion of mandate as well as primary intent.
,Health system goals:
• improving the health status of the population: the average level of health and equity in the
distribution of health;
• improving both the average level and the distribution of system responsiveness when
individuals come into contact with the health system: respect for persons (ensuring patient
dignity, confidentiality and autonomy) and client (service-user) orientation (prompt attention,
basic amenities and choice); responsiveness: plan direction setting and implementation of the
rules. You can measure in emergencies reactions or reduced waiting times etc. responsiveness
of system is important to contribute to social welfare.
• improving fairness in financial contributions, incorporating both avoidance of
impoverishment as a consequence of ‘catastrophic’ health payments and equitable distribution
of the burden of funding the system.
Health system functions (interconnected): population view!!!
- providing (personal and population) services: purposeful production of services is
at the core of all health systems. Services permeate the set of institutions, people and
resources intended (mandated) to improve health. Poor coordination between those
involved leads to waste and inefficiency. The service production function
encompasses decisions on what services should be produced, where such production
should take place and how they should be managed. Services need to be accessible,
affordable and acceptable.
- financing: dealing with the sources, accumulation and allocation of funds used for the
health system (revenue collection); pooling (dividing risk and costs (basic insurance)
on group instead of 1 person); and purchasing (the last is the allocation of resources
from the pool to providers). all health systems fund personal care and public health
measures that contribute to health improvements in individuals and populations. Many
different ways to do this.
- generating resources: the identification, creation and development of the resources
required to produce health services and to build a health system: knowledge, staff,
facilities and technology. Given the labour-intensive nature of health services, human
resources are the most important input to any health system; appropriate mechanisms
for training, deployment and retention are essential to avoid inadequate skill mix and
brain drain. Effective services demand modern equipment and technologies for both
personal (pharmaceuticals and consumable medical goods) and population-based
services (communication/information and organization of health technologies).
- providing stewardship of health services and related intersectoral actions: the
ensemble of activities aimed at ensuring that health actions (including intersectoral
measures) have a clear direction and are carried out in ways that maximize the
likelihood of achieving the systems goals. the careful and responsible management of
the well-being of the population’: protecting the public interest with regard to health
issues. For conceptual (and hence operational) clarity, it is useful to disaggregate
stewardship into three specific dimensions: (i) formulating and coordinating health
policy, (ii) exerting influence, and (iii) collecting and using intelligence to assure
quality. Steward: assistant
,Intermediate objectives:
This framework can be used to support national decision-making in two related ways: (i)
in development of a coherent, goal-oriented health reform strategy, and (ii) for performance
assessment and monitoring. Both involve working backwards from the broad goals to identify
country-specific objectives that are measurable and actionable by policy. This involves
defining intermediate objectives associated with a particular function by considering the goals
that it is likely to influence as well as the means or pathways by which this can occur. These
objectives must have a plausible link to both the function and the goals.
This is the real purpose of this framework: to provide a means to organize thinking in a
comprehensive, coherent manner that provides a basis for action.
2. How are they inter related?
Implementing the framework:
Policy and managerial issues:
- Difficult to assess performance of a system when its mail goal (health) is strongly
influenced by external factors and activities with impacts that are difficult to
disentangle from that of the health system.
- Difficult to operationalize the goals in practice.
- Accounting for ‘all health system activities, organizations and institutions whose
primary intent/mandate is to improve health’ under each of the functions poses another
major technical challenge.
- A further issue is that of accountability. The formal responsibilities of health
ministry’s vary enormously. The concept of stewardship implies that the health
ministry is at the helm – accountable for the operation and impact of health services,
for advocating healthy public policy and for exercising stewardship in other sectors to
ensure that health implications are considered in all public policies. This envisages
that the health ministry should be held accountable for influencing primary intent
actions in other sectors. Clearly, this is not the reality in most countries. Even
responsibility for the formal health care sector is often distributed among different
tiers of government with different ministries and agencies, such as insurance funds,
professional bodies and provider associations. Many health ministries have a low
status in the political hierarchy.
- One final major challenge in implementing the framework is the quality of available
data needed to assess performance and inform decision-making. Few countries have
sufficiently reliable, population-based data to operationalize and measure the many
variables included in this framework.
All things considered, however, the advantages of adopting the health systems framework
outnumber the problems. What is important, when applying it, is to consider the specific
, political and institutional contexts with a clear understanding of the differences between
political and managerial responsibilities.
Implications for research:
- There is a need for more experience in the implementation of the framework in
different countries. In particular, there is a need for better understanding of the impact
of the political context within which health systems operate. A rightly warning against
presenting health outcomes as the mere product of a set of physical inputs, human
resources, organizational structures and managerial processes – hence seeing health
system reforms as mere mechanistic adaptations. Instead, health systems should be
seen as complex adaptive systems. This would focus efforts on working with political
actors and other stakeholders towards achieving specific objectives rather than on
producing an overdetailed set of managerial arrangements and incentives.
- There is also a need for more research on mapping institutional accountability. This
would include, for instance, a review of the responsibilities and accountabilities of
ministries of health, examining their particular roles, functions and organizational
structures.
- The same applies to the need to map political values (as well as their inherent trade-
offs), which are often used in debates to justify policy instruments. The health systems
framework analysed here is rooted in a series of values translated into a series of goals
and objectives. There is a need to make these values explicit in any analysis and
ascertain whether they are reflected in the objectives of the health system.
Conclusion: The concept of the health system framework offers a useful policy perspective.
This chapter has shown that the health systems framework offers a generic tool that can be
adapted to support decision-making and analysis. The proposed framework brings together in
a coherent way the positive (what is – the functions that all health systems perform) and
normative (what should be – the goals that all health systems should strive to achieve given
the constraints of available resources) aspects. Overall, the health systems framework offers a
solid conceptual basis to understand health systems. The challenge is to generate further
experience of using it in different settings.
4. Compare countries: powerpoints
5. What are the major reform trends across Europe in the four functions of the
analytic model? (Europe in general)
Saltman RB, Allin S, Mossialos E, Wismar M, Kutzin J. (2012) Assessing health reform
trends in Europe.
Health system functions of the model:
1.Health service delivery: They bear, in particular, the brunt of both demographic change
and the ageing of the population, and of the consequent rapid increase in chronic disease.
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