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A health system, also sometimes referred to as health care system or healthcare system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations.
There is a wide variety of health systems around the world, with as many histories and organizational structures as there are nations. In some countries, health system planning is distributed among market participants. In others, there is a concerted effort among governments, trade unions, charities, religious, 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.[1][2]
Goals
The goals for health systems, according to the
Definitions
Often health system has been defined with a reductionist perspective, for example reducing it to health care system. In many publications, for example, both expressions are used interchangeably. Some authors[6] 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."[6]
World Health Organization Definition
The World Health Organization defines health system 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."[7]
Providers
Health care providers are institutions or individuals providing health care services. Individuals including health professionals and
Financial resources
There are generally five primary methods of funding health systems:[8]
- general taxationto the state, county or municipality
- social health insurance
- voluntary or private health insurance
- out-of-pocket payments
- charities
Most countries' systems feature a mix of all five models. One study [9] 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
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.[10]
Many forms of commercial health insurance control their costs by restricting the benefits that are paid by through
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, or negotiating standard fees with the medical profession. 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
Payment models
In most countries, wage costs for health care practitioners are estimated to represent between 65% and 80% of renewable health system expenditures.[13][14] 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.[15]
Fee-for-service
Fee-for-service arrangements pay general practitioners (GPs) based on the service.[15] They are even more widely used for specialists working in ambulatory care.[15]
There are two ways to set fee levels:[15]
- 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.[15] 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."[15]
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."[15]
Salary arrangements
In several OECD countries, general practitioners (GPs) are employed on salaries for the government.[15] 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."[15] There has been movement away from this system.[15]
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
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.[16]
Management
The management of any health system is typically directed through a set of
Public health is concerned with threats to the overall health of a community based on
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
Health systems performance
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.[20] Like most social systems, health systems are complex adaptive systems where change does not necessarily follow rigid epidemiological models. In complex systems path dependency, emergent properties and other non-linear patterns are under-explored and unmeasured,[21] which can lead to the development of inappropriate guidelines for developing responsive health systems.[22]
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
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.[26] 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 in to health systems by generating a complex understanding of context in order to enhance health policy learning.[27] 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.[28]
International comparisons
Health systems can vary substantially from country to country, and in the last few years, comparisons have been made on an international basis. The
Direct comparisons of health statistics across nations are complex. The
Country | Life expectancy | Infant mortality rate[38] | Mortality amenable to health care (per 100 000 people in 2007)[39] | Physicians per 1000 people | Nurses per 1000 people
|
Per capita expenditure on health (USD PPP) | Healthcare costs as a percent of GDP | % of government revenue spent on health | % of health costs paid by government |
---|---|---|---|---|---|---|---|---|---|
Australia | 81.4 | 4.2 | 57 | 2.8 | 10.1 | 3,353 | 8.5 | 17.7 | 67.5 |
Canada
|
81.4 | 5.2 | 77[40] | 2.2 | 9.0 | 3,844 | 10.0 | 16.7 | 70.2 |
France | 81.0 | 3.5 | 55 | 3.3 | 7.7 | 3,679 | 11.0 | 14.2 | 78.3 |
Germany
|
79.8 | 3.7 | 76 | 3.5 | 10.5 | 3,724 | 10.4 | 17.6 | 76.4 |
Italy
|
80.5 | 3.5 | 60 | 4.2 | 6.1 | 2,771 | 8.7 | 14.1 | 76.6 |
Japan
|
82.6 | 2.6 | 61 | 2.1 | 9.4 | 2,750 | 8.2 | 16.8 | 80.4 |
Norway | 80.0 | 3.0 | 64 | 3.8 | 16.2 | 4,885 | 8.9 | 17.9 | 84.1 |
Sweden | 81.0 | 2.5 | 61 | 3.6 | 10.8 | 3,432 | 8.9 | 13.6 | 81.4 |
UK
|
80.1 | 4.9 | 83 | 2.5 | 9.5 | 3,051 | 8.4 | 15.8 | 81.3 |
USA
|
78.1 | 6.8 | 96 | 2.4 | 10.6 | 7,437 | 16.0 | 18.5 | 45.1 |
Physicians and hospital beds per 1000 inhabitants vs Health Care Spending in 2008 for OECD Countries. The data source is http://www.oecd.org.[34][35]
See also
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References
- ^ a b "Health care system". Liverpool-ha.org.uk. Retrieved 2011-08-06.
- ^ New Yorker magazine article: "Getting there from here." 26 Jan 2009
- ^ a b World Health Organization. (2000). World Health Report 2000 - Health systems: improving performance. Geneva, WHO http://www.who.int/whr/2000/en/index.html
- ^ Remarks by Johns Hopkins University President William Brody: "Health Care '08: What's Promised/What's Possible?" 7 Sept 2007
- PMID 10720370.
- ^ a b Frenk J, The Global Health System : strengthening national health systems as the next step for global progress, Plos Medicine, January 2010, Vol 7, issue 1, 3pp., available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797599/
- ^ "Everybody's business. Strengthening health systems to improve health outcomes : WHO's framework for action" (Document). WHO. 2007.
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ignored (help) - ^ "Regional Overview of Social Health Insurance in South-East Asia, World Health Organization. And Overview of Health Care Financing". Retrieved August 18, 2006.
- ^ Glied, Sherry A. "Health Care Financing, Efficiency, and Equity." National Bureau of Economic Research, March 2008. Accessed March 20th, 2008.
- ^ How Private Insurance Works: A Primer by Gary Claxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation
- PMID 18316147. Retrieved 26 May 2012.)
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suggested) (help - ^ UNITAID. Republic of Guinea Introduces Air Solidarity Levy to Fight AIDS, TB and Malaria. Geneva, 30 June 2011. Accessed 5 July 2011.
- ^ Saltman RB, Von Otter C. Implementing Planned Markets in Health Care: Balancing Social and Economic Responsibility. Buckingham: Open University Press 1995.
- ^ Kolehamainen-Aiken RL. Decentralization and human resources: implications and impact. Human Resources for Health Development 1997, 2(1):1-14.
- ^ a b c d e f g h i j Elizabeth Docteur and Howard Oxley (2003). "Health-Care Systems: Lessons from the Reform Experience" (PDF). OECD.
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(help) - PMID 18343005. Retrieved 26 May 2012.
- ^ "European Union Public Health Information System - HIV/Aides page". Euphix.org. Retrieved 2011-08-06.
- ^ "European Union Public Health Information System - Diabetes page". Euphix.org. Retrieved 2011-08-06.
- ^ "European Union Public Health Information System - Smoking Behaviors page". Euphix.org. Retrieved 2011-08-06.
- ^ Handler A, Issel M, Turnock B. A conceptual framework to measure performance of the public health system. American Journal of Public Health, 2001, 91(8): 1235-1239.
- PMID 21821667. Retrieved 18 May 2012.)
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ignored (help - ^ PMID 22448148. Retrieved 18 May 2012.)
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: CS1 maint: date and year (link) CS1 maint: unflagged free DOI (link - ^ World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva, WHO Press, 2010.
- ^ Dal Poz MR et al. Handbook on monitoring and evaluation of human resources for health. Geneva, WHO Press, 2009
- PMID 17974000. Retrieved 26 May 2012.)
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: CS1 maint: date and year (link) CS1 maint: unflagged free DOI (link - ^ World Health Organization. (2000) World Health Report 2000 - Health systems: improving performance. Geneva, WHO Press.
- ^ World Health Organization. Health Systems Performance: Overall Framework. Accessed 15 March 2011.
- ^ Navarro V. Assessment of the World Health Report 2000. Lancet 2000; 356: 1598–601
- ^ "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care". The Commonwealth Fund. May 15, 2007. Retrieved March 7, 2009.
- Organisation for Economic Co-operation and Development. "OECD Health Data 2008: How Does Canada Compare"(PDF). Retrieved 2009-01-09.
- ^ a b "Updated statistics from a 2009 report". Oecd.org. Retrieved 2011-08-06.
- ^ a b "OECD Health Data 2009 - Frequently Requested Data". Oecd.org. Retrieved 2011-08-06.
- ^ "The Euro Consumer Diabetes Index 2008". Health Consumer Powerhouse. Retrieved 29 April 2013.
- ^ "Euro Hepatitis Care Index 2012". Health Consumer Powerhouse. Retrieved 29 April 2013.
- ^ United Nations World Population Prospects: 2011 revision - 2011 revision
- ^ Nolte, Ellen. "Variations in Amenable Mortality—Trends in 16 High-Income Nations". Commonwealth Fund. Retrieved 10 February 2012.
- ^ data for 2003
Nolte, Ellen. "Measuring the Health of Nations: Updating an Earlier Analysis". Commonwealth Fund. Retrieved 8 January 2012.
External links
- World Health Organization: Health Systems
- HRC/Eldis Health Systems Resource Guide research and other resources on health systems in developing countries
- OECD: Health policies, a list of latest publications by OECD
Category:Public health Category:Health fields Category:Health care Category:Health economics Category:Health policy