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Health Systems Functions and Structure

HS Building Blocks

Contents
• • • • • • • Definition of Health System Health System Goals Attributes of a Good Health System Health System Functions Health System Challenges (Global Facts) Six Health System Building Blocks Ten Essential Public Health Functions

Definition
• A System is an arrangement of parts and their interconnections that come together for a purpose.
• A health system, like any other system, is a set of inter-connected parts that have to function together to be affective

Definition
• A health system has many parts. In addition to patients, families, and communities, ministries of health, health providers, health financing bodies, and other organization play important roles. • The interconnections of the health system can be viewed as the functions and roles played by these parts. These functions include oversight (e.g. policymaking, regulation), health service provision (e.g. preventive services, clinical services, health promotion), financing, and managing resources (e.g. pharmaceutical, medical equipment, information).

A Health System can be defined as:
• “… the combination of resources, organization, financing and management that culminates in the delivery of health services to the population.” • “… all activities whose primary purpose is to promote, restore, and maintain health.” (WHO 2000). In recent years, the definition of “purpose” has been further extended to include the prevention of household poverty due to illness. • “… A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health.”

for example. This includes efforts to influence determinants of health as well as more direct health improving activities. health insurance organizations. • It includes the full range of stakeholders in a health sector. private for profit and not for profit service providers. and consumers. . public safety legislation. people and actions whose primary intent is to promote. as well as mother caring for sick children.Definition • A health system consists of all organizations. restore or maintain health (WHO 2007). patients. • Health System is much broader than public health service delivery system that is often the focus of public health officials. community outreach workers.

• A health system is therefore more than the pyramid of public owned facilities that deliver personal health services. occupational health and safety legislation. .Definition • WHO (2007) also defined health system strengthening. health insurance organizations. behaviour change programs. It includes. for example. a mother caring for a sick child at home. vector control campaigns. as: • … improving [the] six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.

transport. a well known determinant of health. supplies. for example. • A health system needs staff.Definition • It includes inter-sectoral action by health staff. while treating people decently. • The ultimate responsibility for the overall performance of a country’s health system lies with government. information. And it needs to provide services that are responsive and financially fair. encouraging the ministry of education to promote female education. funds. communications and overall guidance and direction. . but good steward ship by regions and individual health institutions in also vital.

Health System Goals • Health systems have multiple goals. financially fair. The World Health Report 2000 defined overall health system outcomes or goals as: improving health and health equity. and make the best. in ways that are responsive. without compromising efforts to ensure provider quality and safety. use of available resources. • There are important intermediate goals: the route from inputs to health outcomes in through achieving greater access to and coverage for effective health interventions. . or most efficient.

well maintained facilities and logistics to deliver quality medicines and techniologies. when and where they need them. reliable information on which to base decisions and policies. .A Good Health System • A good health system delivers quality services to all people. but in all cases requires a forceful financing mechanism. a well – trained and adequately paid workforce. • The exact configuration of services varies from country to country.

Health system functions • The World Health Report (2000) identifies the four functions of a health system: • 1) stewardship (often referred to as governance or oversight). • 2) financing • 3) Human and physical resources. and • 4) organization and management of service delivery .

Functions of a health system Stewardship (Oversight) Creating resources (Investment and training) Delivery of services (provision) Financing (collection. pooling and purchasing) .

html .Functions of a health system • In a 2005 World Health Assembly resolution.who.int/features/factfiles/universal_ health_coverage/facts/en/index. WHO member states committed to develop their health systems to ensure that all people have access to health services without being subject to financial hardship paying foe them – a goal defined as universal health coverage (WHO 2010) • http://www.

. which is about oversight and guidance of the whole system). develop health workers and other key resources. regardless of how they are organized: they have to provide services.Health System Building Blocks • To achieve their goals. and ensure health system leadership and governance(also known as stewardship. • For the purpose of clearly articulating what WHO will do to help strengthen health systems. All are needed to improve outcomes. This is WHO’s health system framework. mobilize and allocate finances. the functions identified in the World health report 2000 have been broken down into a set of six essential ‘building blocks’. all health systems have to carry out some basic functions.

Human resources for health 5. Service delivery 4. Leadership and governance 2 Health financing 3. Medical products. .Health System functions/ building bloc ks • • • • • • 1. and now provides a common terminology for discussing key health system functions. vaccines and technologies 6. Health information systems • This WHO enumeration and definition of the building blocks has been adopted widely.

• 2. fairly distributed. i. given available resources and circumstances. they are competent. when and where needed.e. .A well-performing health workforce is one which works in ways that are responsive.Good health services are those which deliver effective. responsive and productive. quality personal and non-personal health interventions to those who need them.The six building block s of a health system a re • 1. There are sufficient numbers and mix of staff. safe. fair and efficient to achieve the best health outcomes possible. with minimum waste of resources.

analysis. vaccines and technologies of assured quality. safety. dissemination and use of reliable and timely information on health determinants. health systems performance and health status. • 4. and their scientifically sound and cost-effective use . efficacy and cost-effectiveness.A well-functioning health system ensures equitable access to essential medical products. A well-functioning health information system is one that ensures the production.The six building blocks of a health system are • 3.

Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight.The six building blocks of a health system are • 5. • 6. attention to system-design. in ways that ensure people can use needed services. and are protected from financial catastrophe or impoverishment associated with having to pay for them. the provision of appropriate regulations and incentives.A good health financing system raises adequate funds for health. coalition building. and accountability .

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social security payments. and public servants. also called the government sector.Health System Actors • 1 Public Sector . • Public health funding comes from a variety of sources such as taxes.The public sector. is a complex group of actors that includes ministries of health (MOHs). line ministries. and donors .

11 Essential Public Health Functions (EPHF) by The public sector – as defined by a WHO study in 41 countries • EPHF 1 .Development of policies and institutional capacity for public health planning and management .Surveillance. and control of the risks and threats to public health • EPHF 3 .Monitoring.Social participation in health • EPHF 5 . evaluation. research.Health promotion • EPHF 4 . and analysis of health status • EPHF 2 .

Strengthening of public health regulation and enforcement capacity • EPHF 7 .11 Essential Public Health Functions (EPHF) by The public sector – as defined by a WHO study in 41 countries • EPHF 6 .Human resources development and training in public health • EPHF 9 .Research in public health • EPHF 11 .Reduction of the impact of emergencies and disasters on health .Evaluation and promotion of equitable access to necessary health services • EPHF 8 .Quality assurance in personal and populationbased health services • EPHF 10 .

and health reform .Challenges Facing public health Sector • Public health sectors face many challenges in carrying out their essential functions. • Others are environmental. insufficient management skills. and corruption. globalization. Some are internal. new medical technology. such as lack of financing. such as changing epidemiologic and demographic trends and emerging diseases.

• Therefore. Private Sector • Reliance on government health services alone is often insufficient in achieving improvements in health status indicators such as child mortality or the prevention of HIV/AIDS. and its coverage is rapidly expanding. (IFC 2007). • In many developing countries. • The private sector is a key source of health services.2. including the private health sector in the HSA provides a more complete and accurate understanding of a country’s health sector . there is high utilization of the private sector for essential health services.

Private Sector • The private health sector is typically described as comprising “all providers who exist outside of the public sector.2. whether their aim is charitable or commercial. the Christian Health Association in Malawi (CHAM). commercial entities and the not-for-profit organizations like nongovernmental organizations (NGOs) and faith-based organizations (FBOs) that engage in health care e. . and whose aim is to treat illness or prevent disease”. • The private health sector comprises both for profit.g.

. – Private pharmacists and drug sellers are often the first-line providers in the formal health sector that serves people in poor and remote communities. and market drug sellers. • 2-The informal health sector consists of traditional healers. Private Sector • There are also a variety of private providers.2. traditional birth attendants (TBAs). and paramedical staff such as clinical officers and physician assistants. midwives. • 1-Formally trained and licensed private providers include doctors. nurses. indigenous systems medical providers (ISMPs).

although not well documented. and their role could be an important consideration when assessing service delivery and human resources . • These providers constitute an important component that spans the public and private sector. particularly for rural and poor populations. source of health care. Private Sector • The informal sector is a significant. • A substantial number of public sector health practitioners in developing countries also work for private clients during evenings and weekends.2.

as care providers. • The World Health Report 2000 (WHO 2000) recognized the importance of people as financiers of care. as citizens with a role in health governance. Communities and Patients • With their focus on the supply side of health care (service provision). . the six building blocks do not always capture the importance of the demand side.3. and as consumers. which comprises communities and patients.

. • Health outcomes are unacceptably low across much of the developing world. • Some rich countries have large populations without access to care because of inequitable arrangements for social protection. • Others are struggling with escalating costs because of inefficient use of resources. and the persistence of deep inequities in health status is a problem from which no country in the world is exempt.Problems with health systems • Problems with health systems are not confined to poor countries.

• Failing or inadequate health systems are one of the main obstacles to scaling-up interventions to make achievement of internationally agreed goals such as the MDGs a realistic prospect.Problems with health systems • At the centre of this human crisis is a failure of health systems . .

Health system challenges • A few facts and figures – Globally. health is a US$3.5 trillion industry. – Large health inequalities persist: even within rich countries such as USA and Australia. – Recent essential medicines surveys in 39 mainly lowand low-middle-income countries found that. while there was wide variation. or equal to 8% of the worlds GDP. and 56% in the private sector. life expectancy still varies across the population by over 20 years. – Each year. 100 million people are impoverished as a result of health spending . average availability was 20% in the public sector.

– In over 60 countries. 36 of these are in Africa (including Malawi). – Private providers are used by poor as well as rich people. either because of a lack of spare parts or maintenance. or because health workers do not know how to use it. less than a quarter of deaths are recorded by vital registration systems. in Bangladesh. around ¾ of health service contacts are with non-public providers. – An estimated 50% of medical equipment in developing countries is not used.Health system challenges • A few facts and figures – Extreme shortages of health workers exist in 57 countries. . For example.

is given as general budget or sector support). about 20% of all health aid goes to support governments overall programmes (i.Health system challenges • A few facts and figures – In 2000. less than 1% of publications on Medline were on health services and systems research. while an estimated 50% of health aid is off budget. – There has been a rapid increase in global health partnerships. More than 80 now exist.e. of which WHO houses over 30. . – Globally.

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cdc. • This steering committee included representatives from US Public Health Service agencies and other major public health organizations.gov/nphpsp/essentialservices. • The Core Public Health Functions Steering Committee developed the framework for the Essential Services in 1994.html • The Essential Public Health Services provide the fundamental framework of the public health activities that should be undertaken in all communities. .10 Essential Public Health Services • http://www.

• 3. • 2. • 4. . Monitor health status to identify and solve community health problems. Inform. educate. Mobilize community partnerships and action to identify and solve health problems.10 Essential Public Health Services • The Essential Services provide a working definition of public health and a guiding framework for the responsibilities of local public health systems. and empower people about health issues. Diagnose and investigate health problems and health hazards in the community. • 1.

Link people to needed personal health services and assure the provision of health care when otherwise unavailable. • 7. and quality of personal and population-based health services. accessibility. Evaluate effectiveness. • 9. . • 6. • 10. Assure competent public and personal health care workforce. Develop policies and plans that support individual and community health efforts. Research for new insights and innovative solutions to health problems. • 8. Enforce laws and regulations that protect health and ensure safety.10 Essential Public Health Services • 5.

• Interpretation and communication of health information to diverse audiences in different sectors.Essential Service #1 Monitor Health Status to Identify Health Problems • Assessment of statewide health status and its determinants. • Identification of community assets and resources. including the identification of health threats and the determination of health service needs. • Analysis of the health of specific groups that are at higher risk for health threats than the general population. which support the state public health system (SPHS) in promoting health and improving quality of life. • Collaboration in integrating and managing public health related information systems. .

• Rapid screening. • Population-based screening. and active infectious disease epidemiologic investigations.Essential Service #2 Diagnose and Investigate Health Problems and Health Hazards • Epidemiologic investigation of disease outbreaks and patterns of infectious and chronic diseases. injuries. high volume testing. . case finding. and other adverse health conditions. investigation. and the scientific analysis of health problems.

Essential Service #3 Inform. work sites. faith communities. health education. • Accessible health information and educational resources. personal care providers. Educate. • Health education and promotion program partnerships with schools. and Empower People about Health Issues .• Health information. and health promotion activities designed to reduce health risk and promote better health. • Health communication plans and activities such as media advocacy and social marketing. and others to implement and reinforce health promotion programs and messages.

Essential Service #4 Mobilize Partnerships to Identify and Solve Health Problems The organization and leadership to convene.• collaborate with statewide partners (including those not typically considered to be health-related)to identify public health priorities and create effective solutions to solve state and local health problems. • Assistance to partners and communities to organize and undertake actions to improve the health of the state’s communities. facilitate. • The building of a statewide partnership to collaborate in the performance of public health functions and essential services in an effort to utilize the full range of available human and material resources to improve the state’s health status. and .

ordinances. and other policies to enable performance of the Essential Public Health Services. • Development of legislation. develops and tracks measurable health objectives. • The process of dialogue. codes. and state health efforts. community. supporting individual. regulations. and establishes strategies and actions to guide community health improvement at the state and local levels.Essential Service #5 Develop Policies and Plans that Support Individual and Statewide Health Efforts • Systematic health planning that relies on appropriate data. rules. advocacy and debate among groups affected by the proposed health plans and policies prior to adoption of such plans or policies. .

and medical device applications. evaluation. including. Essential Service #6 Enforce Laws and Regulations that Protect Health and Ensure Safety . …etc. but not limited to. review of new drug. and codes) designed to protect health and ensure safety to assure that they reflect current scientific knowledge and best practices for achieving compliance. and childhood immunizations. activities occurring during emergency safety seat usage.• The review. and revision of laws (laws refers to all laws. enforcement of clean air and potable water standards. • Enforcement activities of public health concern. ordinances. regulation of health care facilities. biological. safety inspections of workplaces. • Education of persons and entities in the regulated environment and persons and entities that enforce laws designed to protect health and ensure safety. statutes. regulations..

culturally and linguistically appropriate services. • Development of a continuous improvement process to assure the equitable distribution of resources for those in greatest need. private. • Assurances that access is available in a coordinated system of quality care which includes outreach services to link populations to preventive and curative care. enabling social and mental health services. and health care quality review programs. • Partnership with public. Essential Service #7Link People to Needed Personal Health Services and Assure the Provision of Health Care When Otherwise Unavailable . and voluntary sectors to provide populations with a coordinated system of health care. medical services. case management.• Assessment of access to and availability of quality personal health services for the state’s population.

• Continuing education in management. • Partnerships with professional workforce development programs to assure relevant learning experiences for all participants. cultural competence.Essential Service #8 Assure a Competent Public and Personal Health Care Workforce • Education. • Adoption of continuous quality improvement and life-long learning programs. volunteers and other lay community health workers--to meet statewide needs for public and personal health services. development. and leadership development programs. • Efficient processes for credentialing technical and professional health personnel. and assessment of health professionals--including partners. . training.

and quality. effectiveness. are conducted to determine program effectiveness and to provide information necessary for allocating resources and reshaping programs for improved efficiency. .Essential Service #9 Evaluate Effectiveness. and Quality of Personal and Population-Based Health Services • Evaluation and critical review of health programs. based on analyses of health status and service utilization data. • Assessment of and quality improvement in the State Public Health System’s performance and capacity. Accessibility.

• Linkage with research institutions and other institutions of higher learning.Essential Service #10 Research for New Insights and Innovative Solutions to Health Problems • A full continuum of research ranging from field-based efforts to foster improvements in public health practice to formal scientific research. . • Internal capacity to mount timely epidemiologic and economic analyses and conduct needed health services research.

including risk surveillance • The information produced by surveillance is used in planning services and prevention programs. as well as advising on food and drug safety regulations. Health protection: Ensuring that water. analysis. It includes • • • • • The collection and storage of relevant data The integration. air and food are safe. and interpretation of these data The production of tracking and forecasting products with the interpreted data Publication and dissemination of those products Provision of expertise to those developing or contributing to surveillance systems. – 2. maintaining the regulatory framework for the control of infectious disease and protection from environmental threats.Public Health Agency of Canada • Six Essential Activities Of Public health – 1. systematic use of routinely collected health data for the purpose of tracking and forecasting health events or health determinants. Health surveillance: The ongoing. .

to produce better policies and services. Disease and injury prevention: The investigation. and development of preventive and control measures to reduce the risk of infectious disease emergence and outbreaks as well as the promotion of safe. . Population health assessment: Understanding the health of communities or specific populations.Public Health Agency of Canada • Six Essential Activities Of Public health – 3. – 4. healthy lifestyles to reduce preventable illness and injuries. contact tracing. as well as the factors that underlie good health or pose potential risks.

those involving explosives.g. radioactive substances. encouraging safe behaviours.Public Health Agency of Canada • Six Essential Activities Of Public health – 5.g. Emergency preparedness and response: Planning for natural disasters (e. chemicals. dangerous infectious disease) and man.. . community-based interventions. – 6. floods. or biological threats and social disruption). fires. and advocacy or action on environmental and socio-economic determinants of health. Health promotion: Preventing disease. earthquakes..made disasters (e. and improving health through public policy. active public participation.

int/healthinfo/EN_W HS2012_Full.healthsystems2020.pdf http://www.int/healthsystems/en/ http://www.org/ .who.who.who.who.who.int/whr/2000/en/whr00_en.pdf • http://www.who.int/healthsystems/topics/en/ http://www.healthsystems2020.Cited References • • • • • • http://www.int/healthinfo/systems/WHO_MBHSS _2010_full_web.org/content/re source/detail/528/ • http://www.pdf http://www.int/health-systems-performance/ http://www.