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Complete summary cases (HPI4009)
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Summary – Health system governanceCase 1 – Health systems analysis
What is health system governance?
‘Systematic, patterned way in which decisions are made and implemented’
‘The way that policymakers try to manage, coordinate, or control the activities of
healthcare actors’
‘The specific mode of production of norms (decision, rules, policies) that can be called
co-production where co-producers are different kinds of actors (private and public)
How things are done
First step to understanding health system governance, is understanding what health systems
entail. In other words: what is the subject of health system governance.
- In a generic fashion (i.e., system-neutral)
- Without drowning in detail
Analytic model for health systems review
,This model, which is based on a framework developed by the World Health Organization
(WHO), is structured as an input-output model. It shows, first of all, that health systems
function in a broader environment, which consists of two parts: the task environment and
the context. Where the term task environment refers to the health problems that should be
targeted by a health system, context signifies other external factors which have an influence
on that system. The healthcare demands existing in the task environment are inputs into the
health system. There, they are turned into outputs during a process called conversion. Outputs
can be either of an intermediate or final nature, with intermediate outputs referring to the
accomplishment of certain intermediate objectives that are instrumental to realizing the end
goals of the health system. The latter are referred to as health system goals in Figure 1. The
analytic model also includes a feedback loop to indicate that outputs can flow back into the
health system as new inputs. It goes without saying that this analytic model constitutes a
simplified and abstract representation of the complex reality of health systems.
Duran et al. (2012)
Recent years have seen a new interest in health systems, in all parts of the world. They are
now recognized as playing a vital role in preventing disability and premature death. Yet there
are also demands that they do so as efficiently as possible at a time when some countries are
implementing deep cuts in public spending.
Health systems pose many challenges to politicians. Advances in medical technology have
raised expectations about what health systems can deliver, causing continuing upward
pressure on costs.
Health ministers can be disadvantaged by the lack of clarity about the boundaries of the health
system. Often clinicians by background, many ministers are frustrated by the apparent lack of
mechanisms at their disposal to bring about change, while the political dimension of health
policies adds to the complexity (as they often assume responsibility for failure but may have
little control over the actions necessary for success).
,Understanding and defining health systems
Main definitions
Analysts define health systems in different ways. In essence, the different names mainly
reflect different understandings of the health system boundaries and, specifically what to
include.
Duplessis et al.
. . . organizations providing health services (hospital, health care centers, professional
officers, and public health services) and also other networks, sectors, institutions, ministries
and organizations which have a definite influence on the ultimate objective of the system –
health. Important in this respect are education, transportation, social services, housing, the
food industry, etc.
The WHO definition
‘a health system consists of all organizations, people and institutions producing actions
whose primary intent is to promote, restore or maintain health’. This definition is now used
by other organizations, such as the World Bank (2006) and the EU.
This 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.
Health system functions
By function, we mean a group of interdependent activities that every health system undertakes
(in a positive, descriptive, non-normative sense) in order to achieve its goals. Four of these
determine the way inputs are transformed into outputs and outcomes:
- Providing (personal and population) services
- Financing
- Generating resources
- Providing stewardship of health services and related intersectoral actions.
, The first function used to pursue the goals of the health system is the production of health
services (resource generation). The 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; these include the doctor and nurse who treat a patient, but also
the trainer who provides health education and the producer of a television anti-tobacco
campaign.
The second health system function is financing. Dealing with the sources, accumulation
and allocation of funds used for the health system (revenue collection); pooling; and
purchasing (the last is the allocation of resources from the pool to providers).
The third vital health system function relates to the identification, creation, and
development of the resources required to produce health services and to build a health system:
knowledge, staff, facilities, and technologies (service delivery). 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).
Finally, the stewardship function is 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 system goals. Definition of the WHO: ‘the
careful and responsible management of the well-being of the population’: protecting
the public interest with regard to health issues.
For conceptual clarity, it is useful to disaggregate stewardship into three specific dimensions:
- Formulating and coordinating health policy
- Exerting influence
- Collecting and using intelligence to assure quality
Elements of good stewardship:
Because of its overriding importance to the performance of the system, we note some
elements of good health stewardship. They apply to all interventions with a significant impact
on health, regardless of their primary purpose. These elements are:
- Steering – leading and providing vision, rather than managing all operations
- Governing – ensuring clear rules and good use of resource
- Accountability – for both performance outcomes and fair/reasonable processes.
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