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HPI4009 Exam summary of all cases (Health Systems Governance)
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Summary of all five cases of the course HPI4009. Important lecture notes are also included.
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HPI4009 – Health Systems GovernanceCase 1 – health systems analysis
Analytical model
Two main applications of the analytical model:
1. To describe and compare individual health
systems
2. To support decision making on a national
level, this involves:
- Backward approach (health system
reform strategy)
- Forward approach (performance
measurement)
Boundaries of the health system
This can be looked at narrow (nurses, doctors, the hospital, etc.) or broader (also looking at other
sectors, prevention and promotion, etc.). a disadvantage of a narrow view is that the context is left
out and one might miss the source of the problem (and no health promotion). With a broader view,
policy and managerial problems arise due to unclarity. To find a balance, the primary intent criterion
is introduced.
WHO definition of a health system: a health system consists of all organizations, people and
institutions producing actions whose primary intent is to promote, restore or maintain health.
Health action: any set of activities whose primary intent it is to improve or maintain health. And a
health system includes the resources, actors and institutions related to the financing, regulation and
provision of health actions. This primary intent criterion leads to a broad definition of the health
system.
Stewardship: incorporation of selected intersectoral actions in which the stewards of the health
system take responsibility to advocate for improvements in areas outside their direct control, such as
legislation to reduce fatalities from traffic accidents.
Health system context and task environment:
- General context: the external factors that influence the health system, e.g. ageing,
economy, globalisation etc. This directly influences the intermediate objectives (and end
goals) and 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 system certain outcomes are generated.
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.
Health system functions:
- Provision of health services – the combination of inputs into a production process that takes
place in a particular organizational setting and that leads to the delivery of a series of
interventions
o Personal health services: services that are consumed directly by an individual
o Non-personal health services: actions that are applied either to collectivities or to the
non-human components of the environment
, - Financing – the process by which revenues are collected from primary and secondary
sources, accumulated in fund pools and allocated to provider activities
o Revenue collection: the mobilization of money from primary sources (households
and firms) and secondary sources (governments and donor agencies)
o Fund pooling: the accumulation of revenues for the common advantage of
participants. Financial resources in the pool are no longer tied to a particular
contributor and contributors share financial risk
o Purchasing: process through which revenues that have been collected in fund pools
are allocated to institutional or individual providers to deliver a set of interventions
- Resource generation – health systems are not limited to institutions that finance or provide
services, but include a diverse group of organizations that produce inputs to those services,
particularly human resources, physical resources such as facilities and equipment, and
knowledge
- Stewardship – goes beyond the conventional notion of regulation. It involves three key
aspects: (1) setting, implementing and monitoring the rules for the health system, (2)
assuring a level playing field for all actors in the system; and (3) defining strategic directions
for the health system as a whole
Health system (end) 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)
- 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
Feedback loop: within the health system the input is turned into output by a process called
conversion (input conversion output). The output is an intermediate objective 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 the feedback loop)
Case 2 – governance in healthcare policymaking: actors and institutions
Governance (stewardship): as the context and task environment are outside the health system, this is
where the health system starts. Governance determines the regulation of functions (which in itself
determines whether intermediate objectives and the goals are reached).
Health system governance development over time: old traditional governance was an aspect of the
government (political steering). This was more hierarchical. New governance is seen as a more
cooperative mode where the government and non-government actors participate in mixed
public/private networks (hybrid forms). Shift from government to governance (focus on consensus,
actor competences).
Actors in the health system:
1. State actors (politicians, policy-makers and other government officials)
2. Health service providers
3. Clients/citizens (service users, the general public and organized civil society)
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