There is a wide variety of health systems around the world, with as many histories and organizational structures
as there are nations. Implicitly, nations must design and develop
health systems in accordance with their needs and resources, although
common elements in virtually all health systems are primary healthcare and public health measures. In some countries, health system planning is distributed among market participants. In others, there is a concerted effort among governments, trade unions, charities,
religious organizations, or other co-ordinated bodies to deliver
planned health care services targeted to the populations they serve.
However, health care planning has been described as often evolutionary
rather than revolutionary.
Goals
The World Health Organization (WHO), the directing and coordinating authority for health within the United Nations system, is promoting a goal of universal health care:
to ensure that all people obtain the health services they need without
suffering financial hardship when paying for them. According to WHO,
healthcare systems' goals are good health for the citizens,
responsiveness to the expectations of the population, and fair means of
funding operations. Progress towards them depends on how systems carry
out four vital functions: provision of health care services, resource generation, financing, and stewardship. Other dimensions for the evaluation of health systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness. Also, continuity of health care is a major goal.
Definitions
Often health system has been defined with a reductionist perspective, for example reducing it to healthcare system. In many publications, for example, both expressions are used interchangeably. Some authors have developed arguments to expand the concept of health systems, indicating additional dimensions that should be considered:
- Health systems should not be expressed in terms of their components only, but also of their interrelationships;
- Health systems should include not only the institutional or supply side of the health system, but also the population;
- Health systems must be seen in terms of their goals, which include not only health improvement, but also equity, responsiveness to legitimate expectations, respect of dignity, and fair financing, among others;
- Health systems must also be defined in terms of their functions, including the direct provision of services, whether they are medical or public health services, but also "other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce."
World Health Organization definition
The World Health Organization defines health systems as follows:
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health.
Providers
Healthcare providers are institutions or individuals providing
healthcare services. Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital, clinic,
or other health care institution, whether government operated, private
for-profit, or private not-for-profit (e.g. non-governmental
organization). They may also work outside of direct patient care such as
in a government health department or other agency, medical laboratory, or health training institution. Examples of health workers are doctors, nurses, midwives, dietitians, paramedics, dentists, medical laboratory technologists, therapists, psychologists, pharmacists, chiropractors, optometrists, community health workers, traditional medicine practitioners, and others.
Financial resources
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Norfolk and Norwich University Hospital, a National Health Service hospital in the United Kingdom.
There are generally five primary methods of funding health systems:
- general taxation to the state, county or municipality
- national health insurance
- voluntary or private health insurance
- out-of-pocket payments
- donations to charities
Most countries' systems feature a mix of all five models. One study based on data from the OECD
concluded that all types of health care finance "are compatible with"
an efficient health system. The study also found no relationship between
financing and cost control.
The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a social insurance
program, or from private insurance companies. It may be obtained on a
group basis (e.g., by a firm to cover its employees) or purchased by
individual consumers. In each case premiums or taxes protect the insured
from high or unexpected health care expenses.
By estimating the overall cost of health care expenses, a routine
finance structure (such as a monthly premium or annual tax) can be
developed, ensuring that money is available to pay for the health care
benefits specified in the insurance agreement. The benefit is typically
administered by a government agency, a non-profit health fund or a
corporation operating seeking to make a profit.
Many forms of commercial health insurance control their costs by restricting the benefits that are paid by through deductibles, co-payments, coinsurance,
policy exclusions, and total coverage limits and will severely restrict
or refuse coverage of pre-existing conditions. Many government schemes
also have co-payment schemes but exclusions are rare because of
political pressure. The larger insurance schemes may also negotiate fees
with providers.
Many forms of social insurance schemes control their costs by
using the bargaining power of their community they represent to control
costs in the health care delivery system. For example, by negotiating
drug prices directly with pharmaceutical companies negotiating standard
fees with the medical profession, or reducing unnecessary health care costs. Social schemes sometimes feature contributions related to earnings as part of a scheme to deliver universal health care,
which may or may not also involve the use of commercial and
non-commercial insurers. Essentially the more wealthy pay
proportionately more into the scheme to cover the needs of the
relatively poor who therefore contribute proportionately less. There are
usually caps on the contributions of the wealthy and minimum payments
that must be made by the insured (often in the form of a minimum
contribution, similar to a deductible in commercial insurance models).
In addition to these traditional health care financing methods,
some lower income countries and development partners are also
implementing non-traditional or innovative financing mechanisms for scaling up delivery and sustainability of health care, such as micro-contributions, public-private partnerships, and market-based financial transaction taxes. For example, as of June 2011, UNITAID
had collected more than one billion dollars from 29 member countries,
including several from Africa, through an air ticket solidarity levy to
expand access to care and treatment for HIV/AIDS, tuberculosis and
malaria in 94 countries.
Payment models
In most countries, wage costs for healthcare practitioners are estimated to represent between 65% and 80% of renewable health system expenditures.
There are three ways to pay medical practitioners: fee for service,
capitation, and salary. There has been growing interest in blending
elements of these systems.
Fee-for-service
Fee-for-service arrangements pay general practitioners (GPs) based on the service. They are even more
widely used for specialists working in ambulatory care.
There are two ways to set fee levels:
- By individual practitioners.
- Central negotiations (as in Japan, Germany, Canada and in France) or hybrid model (such as in Australia, France's sector 2, and New Zealand) where GPs can charge extra fees on top of standardized patient reimbursement rates.
Capitation
In capitation payment systems, GPs are paid for each patient on their "list", usually with adjustments for factors such as age and gender.
According to OECD, "these systems are used in Italy (with some fees),
in all four countries of the United Kingdom (with some fees and
allowances for specific services), Austria (with fees for specific
services), Denmark (one third of income with remainder fee for service),
Ireland (since 1989), the Netherlands (fee-for-service for privately
insured patients and public employees) and Sweden (from 1994).
Capitation payments have become more frequent in "managed care"
environments in the United States."
According to OECD, "Capitation systems allow funders to control
the overall level of primary health expenditures, and the allocation of
funding among GPs is determined by patient registrations. However, under
this approach, GPs may register too many patients and under-serve them,
select the better risks and refer on patients who could have been
treated by the GP directly. Freedom of consumer choice over doctors,
coupled with the principle of "money following the patient" may moderate
some of these risks. Aside from selection, these problems are likely to
be less marked than under salary-type arrangements."
Salary arrangements
In several OECD countries, general practitioners (GPs) are employed on salaries for the government.
According to OECD, "Salary arrangements allow funders to control
primary care costs directly; however, they may lead to under-provision
of services (to ease workloads), excessive referrals to secondary
providers and lack of attention to the preferences of patients." There has been movement away from this system.
Value-Based Care
In recent years, providers have been switching from fee-for-service payment models to a value-based care
payment system, where they are compensated for providing value to
patients. In this system, providers are given incentives to close gaps
in care and provide better quality care for patients.
Information resources
Sound information plays an increasingly critical role in the delivery
of modern health care and efficiency of health systems. Health
informatics – the intersection of information science, medicine and healthcare –
deals with the resources, devices, and methods required to optimize the
acquisition and use of information in health and biomedicine. Necessary
tools for proper health information coding and management include clinical guidelines, formal medical terminologies, and computers and other information and communication technologies. The kinds of health data processed may include patients' medical records, hospital administration and clinical functions, and human resources information.
The use of health information lies at the root of evidence-based policy and evidence-based management
in health care. Increasingly, information and communication
technologies are being utilised to improve health systems in developing
countries through: the standardisation of health information;
computer-aided diagnosis and treatment monitoring; informing population
groups on health and treatment.
Management
The management of any health system is typically directed through a set of policies and plans adopted by government, private sector business and other groups in areas such as personal healthcare delivery and financing, pharmaceuticals, health human resources, and public health.
Public health is concerned with threats to the overall health of a community based on population health
analysis. The population in question can be as small as a handful of
people, or as large as all the inhabitants of several continents (for
instance, in the case of a pandemic). Public health is typically divided into epidemiology, biostatistics and health services. Environmental, social, behavioral, and occupational health are also important subfields.
A child being immunized against polio.
Today, most governments recognize the importance of public health
programs in reducing the incidence of disease, disability, the effects
of ageing and health inequities,
although public health generally receives significantly less government
funding compared with medicine. For example, most countries have a vaccination policy, supporting public health programs in providing vaccinations
to promote health. Vaccinations are voluntary in some countries and
mandatory in some countries. Some governments pay all or part of the
costs for vaccines in a national vaccination schedule.
The rapid emergence of many chronic diseases, which require costly long-term care and treatment,
is making many health managers and policy makers re-examine their
healthcare delivery practices. An important health issue facing the
world currently is HIV/AIDS. Another major public health concern is diabetes.
In 2006, according to the World Health Organization, at least 171
million people worldwide suffered from diabetes. Its incidence is
increasing rapidly, and it is estimated that by the year 2030, this
number will double. A controversial aspect of public health is the
control of tobacco smoking, linked to cancer and other chronic illnesses.
Antibiotic resistance is another major concern, leading to the reemergence of diseases such as tuberculosis. The World Health Organization, for its World Health Day 2011 campaign, is calling for intensified global commitment to safeguard antibiotics and other antimicrobial medicines for future generations.
Health systems performance
Percentage of overweight or obese population in 2010, Data source: OECD's iLibrary, http://stats.oecd.org, retrieved 2013-12-12
Since 2000, more and more initiatives have been taken at the
international and national levels in order to strengthen national health
systems as the core components of the global health
system. Having this scope in mind, it is essential to have a clear, and
unrestricted, vision of national health systems that might generate
further progresses in global health. The elaboration and the selection
of performance indicators are indeed both highly dependent on the conceptual framework adopted for the evaluation of the health systems performances.
Like most social systems, health systems are complex adaptive systems
where change does not necessarily follow rigid management models. In complex systems path dependency, emergent properties and other non-linear patterns are seen, which can lead to the development of inappropriate guidelines for developing responsive health systems.
Percentage of obese population in 2010, Data source: OECD's iLibrary, http://stats.oecd.org, retrieved 2013-12-13
An increasing number of tools and guidelines are being published by
international agencies and development partners to assist health system
decision-makers to monitor and assess health systems strengthening including human resources development
using standard definitions, indicators and measures. In response to a
series of papers published in 2012 by members of the World Health
Organization's Task Force on Developing Health Systems Guidance,
researchers from the Future Health Systems consortium argue that there
is insufficient focus on the 'policy implementation gap'. Recognizing
the diversity of stakeholders and complexity of health systems is
crucial to ensure that evidence-based guidelines are tested with
requisite humility and without a rigid adherence to models dominated by a
limited number of disciplines.
Healthcare services often implement Quality Improvement Initiatives to
overcome this policy implementation gap. Although many deliver improved
healthcare a large proportion fail to sustain. Numerous tools and
frameworks have been created to respond to this challenge and increase
improvement longevity. One tool highlighted the need for these tools to
respond to user preferences and settings to optimize impact.
Health Policy and Systems Research (HPSR) is an emerging
multidisciplinary field that challenges 'disciplinary capture' by
dominant health research traditions, arguing that these traditions
generate premature and inappropriately narrow definitions that impede
rather than enhance health systems strengthening.
HPSR focuses on low- and middle-income countries and draws on the
relativist social science paradigm which recognises that all phenomena
are constructed through human behaviour and interpretation. In using
this approach, HPSR offers insight into health systems by generating a
complex understanding of context in order to enhance health policy
learning.
HPSR calls for greater involvement of local actors, including policy
makers, civil society and researchers, in decisions that are made around
funding health policy research and health systems strengthening.
International comparisons
Chart comparing 2008 health care spending (left) vs. life expectancy (right) in OECD countries.
Health systems can vary substantially from country to country, and in
the last few years, comparisons have been made on an international
basis. The World Health Organization, in its World Health Report 2000, provided a ranking of health systems around the world according to criteria of the overall level and distribution of health in the populations, and the responsiveness and fair financing of health care services. The goals for health systems, according to the WHO's World Health Report 2000 – Health systems: improving performance (WHO, 2000),
are good health, responsiveness to the expectations of the population,
and fair financial contribution. There have been several debates around
the results of this WHO exercise, and especially based on the country ranking linked to it, insofar as it appeared to depend mostly on the choice of the retained indicators.
Direct comparisons of health statistics across nations are complex. The Commonwealth Fund,
in its annual survey, "Mirror, Mirror on the Wall", compares the
performance of the health systems in Australia, New Zealand, the United
Kingdom, Germany, Canada and the United States Its 2007 study found
that, although the United States system is the most expensive, it
consistently underperforms compared to the other countries.
A major difference between the United States and the other countries in
the study is that the United States is the only country without universal health care. The OECD also collects comparative statistics, and has published brief country profiles. Health Consumer Powerhouse makes comparisons between both national health care systems in the Euro health consumer index and specific areas of health care such as diabetes or hepatitis.
