Health System

Health system :
• all activities whose
primary
purpose is to promote,
restore or
maintain health.
• Formal Health services, including the
professional delivery of personal
medical attention, are clearly within
these boundaries.
• So are actions by traditional healers,
and all use of medication, whether
prescribed by provider or not, Such
traditional public health activities as
health promotion and disease
prevention, and other health enhancing
intervention like road and environmental
safety improvement, specific health-
related education, are also part of the
system[i].
[i] WHO, 2000. World Health Report 2000: Health System Performance.
Geneva.

players engaged → provision and

financing of health services :
• public,
• nonprofit, and for-profit private
sectors,
• international and bilateral
donors,
• foundations, and
• voluntary organizations →
involved in funding or
implementing
health activities.
Health systems encompass all levels:
central, regional, district, community,
and household.
central
regional
district
community
household

Objectives
• Health status
– Mortality, morbidity, nutritional
status
• Risk protection
• Satisfaction
– Responsiveness
– Safety : individual, community
Functions the system performs
Objectives of the system

Stewardship (oversight)

Responsiveness (to people's non-medical

expectations)

Creating resources investment and training)

Delivering services
(provision)
Health

Fair (financial) contribution

Financing (collecting, pooling

and purchasing)

four key functions of the health

system:
(1) stewardship /governance/
oversight
(2) financing,
(3) human and physical
resources, and
(4) organization and
management of service
delivery.
EFFECTIVE MANAGEMENT SYSTEMS
Management and Health
Systems "Building blocks"
HAPPY SATISFIED CLIENT
THE WHO HEALTH SYSTEM FRAMEWORK

SYSTEM BUILDING BLOCKS

OVERALL GOALS / OUTCOMES

SERVICE DELIVERY
HEALTH WORKFORCE
ACCESS
IMPROVED HEALTH (LEVEL AND EQUITY)

COVERAGE

INFORMATION
RESPONSIVENESS

MEDICAL PRODUCTS, VACCINES &

TECHNOLOGIES
SOCIAL AND FINANCIAL RISK PROTECTION

QUALITY

FINANCING
SAFETY
IMPROVED EFFICIENCY

LEADERSHIP / GOVERNANCE
Stewardship (Governance), Policy,
and Advocacy
The stewardship, or governance,
function reflects
the fact that people entrust both their
lives and their resources to the health
system.
The government in particular is called
upon to play
the role of a steward, because :
• it spends revenues that people pay
through taxes and social insurance,
and
• makes many of the regulations that
govern the operation of health
services in other private and
voluntary transactions
The government exercises its

stewardship function by developing,

implementing, and enforcing policies

that affect the other health system

functions.
WHO has recommended that one of

the primary roles of a Ministry of

Health is to develop health sector

policy, with the aims of improving

health system performance and

promoting the health of the people

Governments have a variety of so-

called policy levers they exercise to

affect health programs and health

outcomes

Health financing
is a key determinant of
health system
performance in terms of :
• equity,
• efficiency,
• quality.
resource Health financing
mobilization,
encompasses :
allocation,
distribution at all levels (national to
local),
including how providers are paid.
Health financing refers to :
“the methods used to mobilize
the
resources that support basic
public health
programs, provide access to
basic health
services, and configure health
service
delivery systems”
Q• Are resource mobilization
mechanisms equitable? Do the
wealthier subsidize the poor and

those most in need?

• Is the distribution of resources

equitable? Efficient? Or are

wealthier populations benefiting

more from public financing than

are poorer populations?

• Do provider payments reward

efficiency? Quality?
financing flows in the health
system
Sources of health financing :
• Public sources are
governments that raise funds
through taxes, fees, donor
grants, and loans
• Typically the Ministry of Finance
allocates general tax revenue to
finance the Ministry of Health
budget.
• Private sources include
households and employers who pay
fees directly to providers in both
public and private sectors, pay
insurance premiums (including
payroll taxes for social health
insurance), and pay into medical
savings accounts and to charitable
organizations that provide health
services.
– Household out-of-pocket payments form a
large source of health financing in many
developing countries
• Donors finance health systems
through grants, loans, and in-kind
contributions.
Percentage Expenditure on Health—Private versus
Public (who 2006)

Human and Physical

Resources
• recruitment, training,
deployment, and
retention of qualified human
resources;
• procurement, allocation, and
distribution of
essential medicines and supplies;
• investment in physical health
infrastructure
(e.g., facilities, equipment).
Human resource
actions
Workforce objectives
Health system performance
Health outcomes

Equitable
• Numeric adequacy
• Skil mix
• Social outreach
Coverage social and physical

• Satisfactory
remuneration
• Work environment
• Systems support
Motivation: systems and
support
Efficiency and effectiveness
Health of the population
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• Appropriate skills
• Training and
learning
• Leadership and
entrepreneurship
Competence: training and learning
Quality
and responsiveness

Medicines, Supplies, and Logistics

Systems
Access to essential medicines
and supplies
is fundamental to the good
performance of the health care
delivery system.
Availability of medicines is
commonly cited
as the most important element of
quality by health care
consumers, and the absence of
medicines is a key factor in the
under use of government health
services.
one-third of the world’s population →

lacks access to essential medicines.

Problems in access are often related

to inefficiencies in the pharmaceutical

supply management system, such as

inappropriate selection, poor

distribution, deterioration, expiry, and

irrational use. Where medicines are

available, price may be a barrier for

the poor. Pharmaceutical subsidies,

fee waivers, and availability of

affordable generic medicines are some

of the pharmaceutical financing

approaches that can mitigate barriers

to access.
Weak regulation of the
pharmaceutical market is
associated with
• poor quality control,
• presence of fake and substandard
medicines on the market,
• growing drug resistance problems
due to irrational use,
• dispensing by unqualified
practitioners, and
• self-medication in lieu of seeking
qualified health care.
Service Provision
Health system
• service delivery : the way
inputs are
combined to allow the
delivery of a
series of interventions or
health
actions (WHO)
• the service provision function [of the

health system] is the most familiar; the

entire health system is often identified

with just service delivery.” – Discuss :

why agree and why disagree – What about
financing?
• service provision, or service delivery

is the chief function the health system

needs to perform (WHO 2000). –

Discuss : why agree and why disagree –
What about stewardship?
Organization and Management of
Service Delivery
• role of the private sector,
• government contracting of
services,
• decentralization,
• quality assurance,
• sustainability.
private sector role in
service delivery
• For-profit (commercial) and

nonprofit formal health care providers,

including hospitals, health centers, and

clinics
• Traditional and informal
practitioners, including traditional

midwives and healers

• Any membership organizations for

such providers such as professional

associations or unions
• Private companies who may take

actions to protect or promote the

health of their
• employees (such as company

clinics or health education programs)

Inputs
Available and accessible
􀂃 Health financing 􀂃 Human resources 􀂃 Materials and
equipment 􀂃 Pharmaceuticals 􀂃 Physical facilities 􀂃 Clinical guidelines 􀂃
Policies and guidelines 􀂃 Information system
Systemic View of Service
Delivery
Processes What is done 􀂃 Management of health services 􀂃 Case management
Examples: curative, preventive/promotion, palliative, rehabilitative, acute/chronic care 􀂃
Organization of care Examples: referral/counter-referral 􀂃 Quality assurance
processes Examples: supervision, quality improvement teams, accreditation
Outputs Examples: 􀂃 Vaccinated
children 􀂃 Healthier
behaviors 􀂃 Increased
continuity of services 􀂃 Providers who
adhere to clinical
standards of care
Outcomes
Impact
Decreased morbidity Decreased mortality

Assessment
A. Availability of Service Delivery B.
Service Delivery Access, Coverage,

and Utilization C. Service Delivery

Outcomes D. Availability of Service
Delivery E. Service Delivery Access,

Coverage, and Utilization F.

Organization of Service Delivery G.
Quality Assurance of Care H.
Community Participation in Service
Delivery
Health System in Determinant
Social of Health
Health System in
Indonesia
• Perpres 72/2012
LINGKUNGAN ILMU DAN TEKNOLOGI
FUNDAMEN
MORAL: KEMANUSIAAN
LINGKUNGAN SOSIAL, AGAMA, DAN BUDAYA

PENELITIAN DAN PENGEMBANGAN

KESEHATAN

LINGKUNGAN EKONOMI
DERAJAT KESEHATAN
4) SUMBER DAYA 5) KESEHATAN
 PEMBERDAYAAN MASYARAKAT
UPAYA KESEHATAN

Fasilitas Pelayanan
Kesehatan

LINGKUNGAN
SEHAT
MANAJEMEN KESEHATAN

PERUBAHAN SOSIAL BUDAYA

LINGKUNGAN FISIK DAN BIOLOGI
LINGKUNGAN POLITIK DAN
HUKUM

Catatan: 1) subsistem upaya kesehatan termasuk fasilitas pelayanan

kesehatan tampak dalam unsur upaya kesehatan;
2) subsistem penelitian dan pengembangan kesehatan tampak dalam
unsur penelitian dan pengembangan kesehatan; 3) subsistem pembiayaan
kesehatan, 4) subsistem sumber daya manusia kesehatan, dan 5) subsistem
sediaan farmasi, alat kesehatan, dan makanan tampak dalam unsur sumber
daya kesehatan; 6) subsistem manajemen, informasi, dan regulasi
kesehatan tampak dalam unsur manajemen kesehatan; 7)
subsistem pemberdayaan masyarakat tampak dalam unsur pemberdayaan
masyarakat.
Obat/ PMT/ Allkes
Pembiaya an
Fasilitas
Tata kelola
SDM
SIK

Sistem Kesehatan Nasional Daerah

Determinan Sosial Kesehatan dan
Gangguan Gizi
Pelayanan Kesehatan Dasar/ Rujukan PKP/PKM
Cakupan
Perilaku
Kohesi Sosial
Derajat Kesehatan
Morbid itas
Status Gizi
Struktural
Mortali tas

SAM Stuntin g
UHH
AKB
AKI

Penguatan Ketrampilan SDM

Sistem Distribusi Adekuasi
Motivasi

Kesehatan Daerah Kewirausahaan CSR

Contoh: Stunting JKN-KIS Mobilisasi
Sistem informasi KIE : cloud based Dashboard status gizi Knowledge
management
Komprehensif - Holistic HTA
Personalized Pemetaan Dinamis &Faktor Risiko Sistem Surveilans & Respon BM
Mutu pelayanan Ketersediaan Distribusi
Kepuasan
Institusi Penanggulangan Gizi Daerah Ketersediaan
Home visit; Pendampingan ; PGBM
Peningkatkan kapasitas Distribusi Peran serta masy & swasta
TFC; CFC Komitmen politis Agenda strategis nasional dan daerah kebijakan dan
legislasi Perencanaan terpadu dan sustain
Evidence based planning Pengorganisasian dan pengelolaan Mobilisasi
sumberdaya Pedoman dan SOP Penggalangan dana Monev
Obat/ Allkes
SIK
Pembiayaan
Fasilitas
Tata kelola
SDM
Identifikasi dan Penentuan sasaran Pelacakan; skrining
Intervensi responsif & efektif
Pelayanan Kesehatan Dasar/
Peningkatan cakupan Rujukan PKP/PKM
Literasi
Family & Community engagement

• Fin