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Summary and case notes of HPI4009 Health Systems Governance, master HPIM
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Summary and case notes of HPI4009 Health Systems Governance.
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SummaryHealth Systems Governance
HPI4009
Case 1 – Health systems analysis ............................................................................................................ 2
Case 2 – Governance in healthcare policy making .................................................................................. 6
Case 3 – Health policy: content, process, actors and context............................................................... 11
Case 4 – The politics of health ............................................................................................................... 17
Case 5 – Solidarity in healthcare financing............................................................................................ 22
1
,Case 1 – Health systems analysis
Topic introduction
Governance (the formal definition): “Process of deliberately using power in order to coordinate
sizeable groups of people’s performances to bring about desirable aggregate results and avoidance
of risks and undesirable outcomes” (Hoppe, 2010) – in short: power to bring about a certain
behaviour.
Health systems: all countries have a unique health system. Plus, over the years mixed forms are
arising as outcomes and efficiency are improved by changes in different health system components.
Thus, a lot of structure variation between countries but functions are equivalent.
Health systems governance: how things are done in organizing health care. There is no consensus,
some definitions focus on decision making, some on power, and other on co-production. Notable,
that lately there is a shift to more groups with power → besides the government also insurance
companies, patient groups etc. gain power.
Why study health system governance? ‘..the governance of a health system shapes its ability to
respond to various challenges that health systems face today” (Greer et al. 2016). This is important
as current challenges are frequent and complex (e.g. decreasing vaccination rate, scarcity in
resources, rising costs (+ allocation - how to achieve a solidary system)). And also important due to
contextual developments like public confidence and IRA’s in the public sector.
The analytic model for health system review
Analytic model: to gain insight into the structure of any health system - offers a conceptual
framework for systematic description. A good analytic model helps to identify distinctive features of
the health system and helps to determine the most important similarities and differences between
international systems. Also, essential in the reforms of those systems made over time. In this course,
a framework based on one by the WHO is used. This is structured as an input-output model.
The two main applications of the analytic model:
- To describe and compare individual health systems (as all health systems differ)
- To support decision making on a national level, this involves:
o Backward approach: health system reform strategy (coherent and goal-orientated) –
look at how the goals and objectives are reached and see what needs to be reformed
o Forward approach: performance measurement (assessment and monitoring) – look
at the functions and measure their performances on different objectives and goals
The analytic model for health systems review
Context: Health systems operate in a broad context
- General context: The external factors that influence the health system. E.g. aging, economy,
globalisation etc. This directly influences the intermediate objectives (and end goals) &
indirectly influences the health system through the task environment:
- Task environment: The health problems that should be targeted by a health system – the
inputs of the system. In the health systems certain outcomes are generated.
o Task environment is the operationalisation of health system goals in tangible things
As the context changes over time, the task environment changes too. Due to this it is important to
adapt the health system to be able to deal with the new problems / challenges that arise.
2
,Health system, consists of:
Functions, the four basic functions of the health system. These are all interdependent activities
undertaken to achieve the health system goals. How and what is dependent on priorities:
- Governance (stewardship): coordination of the health system / ‘how things are done’ →
making policies to ensure adequate delivery of other functions. Three main aspects: setting,
implementing and monitoring. To do this, six subfunctions:
1. Overall system design 4. Intersectoral advocacy
2. Performance assessment 5. Regulation
3. Priority setting 6. Consumer protection
Good (health) stewardship (Duran):
o Steering: leading and providing vision rather than managing all operations
o Governing: ensuring clear rules and goo use of resources
o Accountability: for both performance outcomes and fair/reasonable processes
Important is an understanding of interconnectedness between health and other sectors.
- Resource generation: all resources that are non-financial (e.g. knowledge, staff, technology)
o Generation by e.g. investment, training, pharmaceutical company (drugs) etc.
- Financing: concerning the financial resources, consisting of:
o Revenue collection
o Risk pooling
o Purchasing (who buys what, and what is insured)
- Service delivery: most important function – what care services are delivered and how
(provision)
o Personal health services – on an individual patient level
o Non-personal health services (population) – responsibility in prevention and
promotion (e.g. vaccinations)
3
, Intermediate objectives – ambiguous and open to multiple and changing interpretation
These are outputs with an intermediate nature, and need to be achieved to be able to achieve the
end goal. These are generic and interpreted differently in every country. The intermediate objectives:
- Quality
- Equity in utilization & resource distribution
- Efficiency (e.g. in terms of cost-effectiveness)
- Transparency & accountability
- Choice (for the patients, and responsiveness to their needs)
Health system goals – ambiguous and open to multiple and changing interpretation
Outputs with a final nature: the purpose of the health system. These outputs can lead to new inputs
(see feedback loop).
- Health gain (most important goal!!)
- Equity in health
- Financial protection (connected to solidarity)
- Equity in finance
- Responsiveness
Intrinsic vs instrumental goals:
- Instrumental goals: more generic, equals intermediate objectives
- Intrinsic goals: the health system goals
Another way to define the health system goals
- Normative: that the health system should try to achieve → goals are normative
- Rationale: health as an intrinsic component of welfare
Or as: health system is a type of social system with one defining goal = to improve health. Plus
additional goals contributing to social welfare by e.g. improving the overall health status of the
population, the distribution and system responsiveness and equity in finance.
For example:
Intermediate goal End goal
Have a university Have sufficient resources (doctors)
Have insurance companies Have equity in finance
Health system attainment: the level of progress towards each goal (does not take context into
account, only looks at the goal, health system goals can never be fully attained)
Health system performance: the level of attainment relative to what could be achieved given
contextual factors, measuring the overall health system efficiency (relative) (most obvious is a
country’s income level).
Feedback loop
Within the health system the input is turned into output by a process called conversion:
- Input --- conversion ---> output
The output is: intermediate (of an intermediate objective) of final (of a health system goal).
This leads to new input if:
- Health system goals are partially accomplished, this output creates new inputs in the task
environment (re-enters through feedback loop)
- Health systems goals are accomplished this can also lead to new input (e.g. a deadly disease
that is now manageable)
4
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