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Lecture notes of 136 pages for the course International Comparative Analysis of Healthcare S at VU
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WEEK 19.00-12:30WN
- M129(100/33T)
Tomris Cesuroglu
Introduction to the course (incl. Assignment-1)
Objectives Knowledge and insights
• Different ways in which health systems in different countries are formed
• To understand and analyze outcomes of health systems with respect to equity, fair
financial contribution, and health status
• Complex adaptive nature of health systems and their constitution
• To understand the underlying reasons for health system reform and to recognize
different health care reform strategies
• Different conceptual frameworks for carrying out a comparative analysis
• To understand different methods in analyzing and comparing health systems: health
system performance assessment benchmarking, case study analysis,
cost-effectiveness analysis
• To apply the acquired knowledge in the context of high, middle, and low-income
countries
Objectives Skills
• To design, carry out and reflect on a comparative analysis, of high, middle, and
low-income countries, making use of a framework for comparative analysis
• To make a clear and structured presentation in the form of a lecture and present it in
a lecture session; and in the form of a poster and present it in a poster presentation
session
• Learning activities:
– Lectures
– Reading articles, book chapters, reports
• • Methodology lectures by Jacqueline Broerse
– Case study approach for carrying out a comparative analysis (theory and practice)
– qualitative research
– This afternoon, 13:30-15:00 – Methodology for comparative analysis
– Friday, 9:30-10:30 – Question and answers on methods for comparative analysis
• Strongly advised to read Yin’s Case Study, Chapter 1 & 2 this week.
Other lectures
• Health finance lecture (3/11)
• Health system frameworks lecture (9/11)
9.00-12:30WN
- M129(100/33T)
Tomris Cesuroglu
Introduction to health systems
,• Background
1. Pre-modern states - before 19th century
a. Epidemics
b. Hospitals run as a religious charity
c. State intervention: quarantine/isolation for infectious diseases
2. Modern states - beginning of 18th - 19th century
a. French revolution → “the right to health”
b. Industrial revolution (19th century) → wealth
c. The emergence of a welfare state →
i. Responsibility of the state for population health measures
and health care services
d. Scientific developments
i. Sanitation & hygiene, better control of epidemics
ii. Vaccination & antibiotics saved lives →
iii. The biomedical paradigm that dominated the health field in 19
and 20th centuries → Focused on ‘health care’ rather than
‘health’
e. “Crumbling welfare states” - the 1980s-1990s Health reform
i. Population growth (past decades)
ii. Population aging !!!
iii. Higher levels of chronic diseases and disability
iv. Increased availability of technology
v. Rising expectations of the public → Increasing health care
costs
vi. Unable to cope with the cost of care for the aging population
vii. Solution: health reform/innovation for more efficiency
More on the evolution of a health system in its historical context:
T. J. Schuitmaker; The case of the Dutch Health System (lecture)
There are varying contexts in which health systems function
State Responsibility for Health
1. Countries responded differently to their responsibility:
a. A different political, social, economic, and technological context
b. DifferentHistorical developments, national & global
c. Different scope of the responsibility (?)
d. Different actors, structures, and processes???
2. For instance, different examples from health finance:
a. Germany, Bismarck - social health insurance with income-based
contribution from wages
b. UK + Sweden, Beveridge - tax-based financing, equitable access,
National Health System
More on finance function of health systems: later in this lecture and
K. Vaughan; Health finance
,• Efforts to define health systems and what they do came after they were formed and
functioning.
• It is a challenge to define, compare and analyze health systems. (apples and pears)
Why do we try to define what a health system is and what it does?
1. To measure the performance
a. “You cannot manage what you don’t measure”
b. Not a universal law, but in general, to improve something, you need to
measure its performance.
c. To measure the performance, you need to define what it is and does.
d. to benchmark (van elkaar leren en verbeteren)
2. To define concepts, draw borders and assign responsibilities
a. To strengthen or reform the system, you need to define it as a
whole, as well as the components.
How to measure the performance of different health systems?:
O.B. Fernandes & V. Bos (Amsterdam UMC); Health system performance
assessment
For example a production system perspective:
Health systems Frameworks
❖ Performance assessment and benchmarking
➢ WHO Framework, Murray & Frenk, 2000
❖ Program development for health systems strengthening
➢ WHO, Building Blocks, 2007
❖ Intervention development
➢ Complex adaptive systems (2008)
❖ Guide health reforms
➢ Roberts, 2004
❖ Analyze investments for health system strengthening
➢ Shakarishvili et al, 2011
Overview of health systems frameworks & complex adaptive systems: D.
Essink; Health systems frameworks & Systems & complex adaptive systems
There is often confusion on concepts, some points:
● Different perspectives and frameworks to health, health policy, public health,
and health systems don’t necessarily match coherently.
, ● They are mostly defined coherently in their contexts, but when brought
together, they don’t match.
● Examples: A proposal for a coherent framework (Savas & Cesuroglu, 2016),
based on the WHO Health System Framework by Murray & Frank, 2000
(elaborated)
• Context
➢ Mid 20th century
○ There was a biomedical paradigm for health: the focus was on
diseases, rather than health
○ World Health Organization / Global health agenda had a lot of vertical
programs to combat diseases
➢ Things started to change in the 1970s
○ Alma Ata International Conference on Primary Health Care: 1978
➢ WHO strategy: ‘Health for All’ in 1981
○ WHO Objective: “the attainment by all peoples of the highest
possible level of health”
○ Taking into account the political, economic and social dimensions of
health
○ Definition of Health for All:
Equity for all and Responsibility of all
➢ Ottawa Charter for Health Promotion → 1986
○ Health is not merely a
product of health services
○ Recognition of prerequisites
for health and the role of
non-health sectors on health
Prerequisites for Health
The fundamental conditions and
resources for health, are (social
determinants of health):
● peace,
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