HEALTH SYSTEM GOVERNANCE
Used literature
Tutorial 1
Dúran A, Kutzin J, Martin-Moreno JM, Travis P. Understanding health systems: scope, functions
and objectives. In: Figueras J, McKee M. Health systems, health, wealth and societal well-being.
Assessing the case for investing in health systems. Berkshire: Open University Press; 2012: 19-
37.
Murray CJL, Frenk J. A framework for assessing the performance of health systems. Bulletin of
the World Health Organization, 2000;78(6):717-731.
Tutorial 2
Bartolini S. New modes of European governance: an introduction. In: Héritier A, Rhodes M (eds).
New modes of governance in Europe: governing in the shadow of hierarchy. Basingstoke:
Palgrave McMillan; 2011.
Bouckaert G, Peters BG, Verhoest K. The coordination of public sector organizations.
Basingstoke: Palgrave McMillan; 2010: - Chapter 3: Resources, mechanisms and instruments for
coordination (paragraph 3.1; pg. 34-50).
Van den Bovenkamp H, De Mul M, Quartz JGU, Weggelaar-Jansen AJWM, Bal R. Institutional
layering in governing healthcare quality. Public Administration, 2014;92(1):208-23. Brinkerhoff
DW, Bossert TJ. Health governance: principal-agent linkages and health system strengthening.
Health Policy and Planning, 2014;29:685-93.
Greer SL, Wismar M, Figueras J. Strengthening health system governance: better policies,
stronger performance. Berkshire: Open University Press; 2016: - Chapter 2: Governance: a
framework (pg. 27-56)
Helderman JK, Bevan G, France G. The rise of the regulatory state in health care: a comparative
analysis of the Netherlands, England and Italy. Health Economics, Policy and Law, 2012;7(1):103-
124.
Tutorial 3:
Buse K, Mays N, Walt N. Making Health Policy (2nd edition). Berkshire: Open University Press,
2012:
o Chapter 1: The health policy framework (pg. 4-19)
o Chapter 2: Power and the policy process (pg. 20-46)
o Chapter 4: Agenda setting (pg. 64-83)
Greenhalgh T, Russell J. Evidence-based policymaking: a critique. Perspectives in Biology and
Medicine, 2009;52(2):304-18.
Parkhurst JO, Vulimin M. Cervical cancer and the global health agenda: insights from multiple
policy-analysis frameworks. Global Public Health, 2013;8(10):1093-1108.
Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and
case study of maternal mortality. The Lancet, 2007;370:1370-79.
,Tutorial 4:
Bambra C, Fox D, Scott-Samuel A. Towards a politics of health. Health Promotion International,
2005;20(2):187-93.
Elissen A, Nolte E, Knai C, et al. Is Europe putting theory into practice? A qualitative study of the
level of self-management support in chronic care management approaches. BMC Health Services
Research, 2013;13:117.
Huber M, Knottnerus JA, Green L, Van der Horst H, Jadad AR, Kromhout D, Leonard B, Lorig K,
Loureiro MI, Van der Meer JWM, Schnabel P, Smith R, Van Weel C, Smid H. How should we
define health? British Medical Journal, 2011;343:d4163.
Kickbusch I. Responding to the health society. Health Promotion International, 2007;22(2):89-91.
Larson JS. The conceptualization of health. Medical Care Research and Review, 1999;56:123.
Vallis M. Are behavioral interventions doomed to fail? Challenges to self-management support in
chronic diseases. Canadian Journal of Diabetes, 2015;39:330-34.
Tutorial 5:
Light D. The practice and ethics of risk-related health insurance. Journal of the American Medical
Association, 1992;267(18):2503-2508.
Ter Meulen R. Solidarity and justice in health care: a critical analysis of their relationship.
Diametros, 2015;43:1-20.
Mossialos E, Dixon A. Funding health care: an introduction. In: Mossialos E, Dixon A, FiguerasJ,
Kutzin J (eds). Funding health care: options for Europe. Buckingham: Open University Press;
2002: pg. 1-30.
Van Oorschot W. Shared identity and shared utility. On solidarity and its motives. Tilburg: Work
and Organization Research Centre; 1998.
Prainsack B, Buyx A. Solidarity: reflections on an emerging concept in bioethics. Chapter 8 –
Solidarity in practice III: lifestyle-related diseases. London: The Nuffield Foundation; 2011: pg. 80-
90
Tutorial 1: Health system analysis
,1. How can a health system –and its boundaries–be defined, and what are the strengths and
limitations of different definitions?
There is not one simple definition. They vary a lot especially in the way that boundaries are
defined
One end narrow definitions medical care with patients, clear exit and entry points and
services regarding disease, disability and death
Other end broad approach all those determinants that contribute directly or indirectly to
health
Balance should be found that includes everything which might improve well-being important
for making operational decisions
WHR2000 all the activities whose primary purpose is to promote, restore or maintain health
o Selected intersectoral actions in which stewards of the health system take
responsibility to advocate for improvements in areas outside their direct control, such
as legislation
HSAF health systems assessment framework based on the above definition
Duplessis (1989) defines a health system as..
‘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.
Examples are: education, transportation, social services, housing, the food industry, etc.’
- Disadvantage could be lack of boundaries. Specially the social system does not set clear
boundaries
- When definitions are confined to health care alone, it will exclude interventions with great
potential to improve health
+ But on the other hand; a very narrow definition is limiting, considering health promotion as
outside the boundaries so it can also be a strength that this definition is so all-encompassing.
WHR2000 – WHO defines a health system as..
‘a health system consists of all organizations, people and institutions producing actions whose
primary intent is to promote, restore or maintain health’
Services are defined by 1) their place in the evolution of a disease, technology involved and
who delivers them. Services can be categorized in personal and population services:
- Personal services are delivered to individuals on an one to one basic and can be curative,
preventive or promotional.
- Population services are delivered to a group or an entire population and can only be
preventive or promotional.
The definition of WHO includes:
1. Health services (personal and population based) and the activities to enable their delivery
provided by finance, resource generation and stewardship functions;
2. Stewardship, which includes activities seeking to influence the positive health impact of
other sectors – even though the primary purpose of those other sectors is not improve health
+ The criterion of ‘primary intent’ is chosen for a specific reason: to create a definition that
makes comparison and ranking of systems worldwide possible.
- Not all factors that affect health are covered by the assigned bodies that are in charge of
health. E.g. immunization campaigns
- The criterion of primary intent can also create difficulties: it is arguable whether the primary
purpose of a specific action is health related and if the primary intent is to improve health (e.g.
education).
, Include the pragmatic notion of mandate. This is done to adapt the boundaries of the health
system to national contexts
Assigned responsibilities which bodies are designated as in charge of health?
The definition of WHR2000 does not imply any particular degree of integration, nor that
anyone is in overall charge of the activities that compose it.
o Every country has a health system however fragmented it may be among different
organizations or however unsystematically it may seem to operate
o Integration does not determine the system but may greatly influence the performance
2. What is meant by the health system context (including the task environment) and how does it
influence other elements of the health system analytic framework?
Boundaries
- Health action any set of activities whose primary intent is to improve or maintain health
- A health system includes the resources, actors, and institutions related to the financing,
regulation and provision of health actions
- Primary intent criterion includes all actors and institutions who see their primary purpose as
contributing to health
- Efforts to influence other sectors are clearly part of the health system when they improve
determinants of health
Important to identify the boundaries
In the model is showed that health systems function in a broader environment, which consists
of two parts: 1) the task environment and 2) the context.
Task environment
The task environment refers to the health problems that should be targeted by a health system.
Task environment is influences by the goals of the health system and influences the functions
of the health system.
When you achieve your goals then the task environment changes because new problems will
emerge.
Context
The context marks the other external factors which have an influence on that system. E.g.
culture, technology, economy, demography, politics, and internationalization are all factors
arising from outside the health system. The context has an indirect influence on the task
environment and a direct influence on the health system.
Context is more broad than the task environment, can be medical or non-medical.
3. Which health system functions can be distinguished and what do these functions entail?
Functions are a group of interdependent activities that every health system undertakes
in order to achieve its goals. There are four that determine the way inputs are transformed
into outputs and outcomes:
1. Service delivery (person or population based): the combination of inputs into a production
process that takes place in a particular organization and leads to the delivery of a health
service. Services can be personal (directly consumed by an individual) or for a whole
population (collectivities such as mass health education and non-human such as basic
sanitation), they are there to improve health.
2. Financing: where revenues are collected, accumulated in fund pools and allocated to
provider activities. Financing has three sub-functions:
- Revenue collection: refers to the mobilization of money from primary sources (households,
, firms) and secondary sources (government). Funds can be mobilized through eight basis
mechanisms, e.g. out-of-pocket payments, compulsory insurance, and taxes.
- Fund pooling: the accumulation (openeenhoping) of revenues for the common advantage of
participants. When financial resources are in the pool, they are not longer tied to a particular
contributor.
- Purchasing: the process through which revenues that have been collected in fund pools are
allocated to institutional or individual providers to deliver an intervention. This can range from
simple budgeting exercises to programmes for staff and more complicated strategies.
3. Generating resources: health systems are not limited to institutions that finance or provide
services. There are also diverse groups of organizations that produce inputs to those services,
such as knowledge, staff, equipment, facilities and technology.
4. Governance/Providing stewardship of health services and related intersectoral actions: the
ensemble of activities aimed at ensuring that health actions have a clear direction and are
carried out in ways that maximize the likelihood of achieve the systems goals. The careful and
responsible management of the well-being of the population. Elements of a good stewardship
are steering, governing (clear rules and good use of resources) and ensuring accountability.
Functions should be organized in such a way that intermediate (instrumental) objectives can
be reached. Instrumental objectives must be normative/operational (effective) to reach the
health system goals.
Not only each function is important in itself, their interconnectedness is also very important.
They are linked with each other.
4. What are health system goals, both intermediary objectives and end goals, and how do these
interrelate?
Health is one of several social systems each with a defining goal to improve health although
this may affect the defining goals of other systems.
Instrumental/intermediary objectives
Your instrument to achieve the end goal. E.g. it is not to have good quality of care but it is to
have health care. Instrumental goals are not set, it is not only imitated to the ones in the
system. It also depends on the definition of term, e.g. quality has a complete different quality 20
years ago then it does have no.
Objectives that interim results that provide a sense of progress toward reaching the long-term
objectives (end goals). The intermediary objectives are:
- Quality
- Equity in utilization and resource distribution
- Efficiency
- Transparency and accountability
- Choice
Average covering and technical efficiency
Instrumental goals generic but specific broad for all countries
- Effective coverage the probability that individuals will obtain a health care intervention if
they need it and they will derive benefit from it
* Narrow the gap between the need for a service and the demand
* Narrow the gap between the need and their use
