Official Lecture#2: Health Systems

Saturday, 20 August 2022 11:31 AM

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1ST SEMESTER DISCUSSION NOTES
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Health System
- The combination of resources, organization, financing, & management that culminate in the delivery of health services to the population (Roemer, 1991).
In the World Health Report (WHO, 2000), a health system is defined as "all the organizations, institutions, resources, & people whose primary purpose is to improve
health."―thus, a well-performing health system provides direct health-improving activities whether in personal health care, public health services, or intersectoral
initiatives in order to achieve high health equity.
→ In the quest for "improving health", it refers to the general population (does not select
nor divide the population into those worthy of receiving health services).
- The overall goal of each health system is to: Achieve high health equity.
- Components of a health system include:
► Community
► Department or ministries of health
► Health care providers
► Health service organizations
► Pharmaceutical companies
► Health financing bodies
► Other organizations related to the health sector
- Each plays a role in the system such as governance, health service provision, and financing &
managing resources.
- Without a health system, there would exist no "thriving" of the general population; thus, mankind could run into extinction; however, the presence of a health system
provides a "resistance" to possibilities of death.
- Care for the health of the population will increase the life expectancy and decrease the chances of death of the populace.

Goals & Functions of a Health System

- The World Health Organization [WHO] identifies (3) main goals of a health system:
(1) Improving the health of populations
- The overarching goal of a health system.
- Health status should be measured over the entire population and across different socioeconomic groups.
- Populations must be protected from (2) things:
(1) Existing health risks - already present; most likely a long-term issue faced and dealt by the population.
(2) Emerging health risks - new & poses a threat to the population (e.g., COVID-19 in 2020).
- Intensive preparations for resilience to impending, but still unknown health risks must be executed to ensure the safety of populations (number#1 goal).
- Health systems should strive for equity in health by minimizing inequitable disparities.
→ Minimizing inequitable disparities is accomplished not necessarily by giving people equal treatment, but by giving them what they need.
→ Extra measures should be taken to ensure that existing inequitable disparities should not cause any differences in the delivery of healthcare to the general
population; hence, equity should be one of the foremost goals of every health system.
→ A needs assessment is therefore crucial.
→ Disparities of which may be caused by certain factors:
► Income, ethnicity, occupation, gender, geographic location, sexual orientation, etc.
- There are significant variations in health outcomes across the world, within regions, and within countries―these are inequitable disparities.
- Countries & regions with relatively similar socioeconomic status may have quite disparate health outcomes.
- The way health systems are organized contributes to this disparity―these disparities are most effectively reduced when they are recognized and their
minimization becomes an explicit national goal.
(2) Improving the responsiveness of the health system
- Responsiveness refers to providing satisfactory health services and engaging people as active partners (how fast a health system can respond to the needs of
the general population).
- It embodies the values of respectfulness, dignity, confidentiality, autonomy, quality, & timeliness in the delivery of health services.
→ Provision of services should not be delayed―if people require the administration of a certain type of health service within a certain timeframe, it should be
readily available.
- Health systems have an obligation to respond to the legitimate non-health needs & expectations of populations.
- Responsive health systems maximize people's autonomy & control, allowing them to make choices and placing them at the center of the health system.
→ Health systems should not dictate what people should do (the people should maintain autonomy & control over their preferences).
- Note that the center of a health system are the: People (general population).
→ Therefore, health systems should adjust to the needs of the people, which also cultivates the quality of reacting quickly & positively.
(3) Providing fair health financing
- An ideal health system provides social & financial risk protection in health.
- All health systems must be adequately funded to provide essential services to all citizens.
- WHO defines a fairly financed health system as one that does not deter individuals from receiving needed care due to payments required at the time of service,
and one in which each individual pays approximately the same percentage of their income for needed services regardless of social status in life.
→ A health system is "fairly financed" if even those with the most disadvantageous socioeconomic status are able to access healthcare.
→ This is evident in public hospitals, where patients are not pressured with initial down-payments before receiving the medical attention they need.
 In contrast with private hospitals, which strictly require down-payments prior to performing a certain service.
- A health financing system that dissuades people form seeking needed services or impoverishes individuals & families worsens health outcomes.
→ Discouragement expressed by the people as a result of lack of funds to receive health services is a sign of that a health system is not functioning well.

Four (4) Functions of a Health System

- Note that health systems actually go beyond hospital settings, and includes both the community & agencies aimed at promoting healthcare.
(1) Health service provision
- The most visible product of the health system is: Public & private health service provision (concrete evidences of health systems).
- A health service is any service, not limited to clinical services, aimed at improving the health of populations.

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 - A health service is any service, not limited to clinical services, aimed at improving the health of populations.
- Preventive measures as well as the promotion of a healthy way of living to avoid illnesses also form part of the best systems.
→ Services provided must not only be limited to healing nor treatment, but must be inclusive of prevention & different surveillance programs that will lead to the
improvement of the quality of life of the general population (e.g., educational materials).
→ Evident in the posters publicized by the DOH (e.g., campaigns against smoking/drinking).
- Therefore, each health system has to perform a wide range of activities to cater to these various demands.
(2) Health service inputs
- Also called: Managing resources.
- Refers to generating the essential physical resources for the delivery of health services which include:
► Medications
► Human resources (trained doctors & medical staff)
► Medical equipment
- Medicines that are not expired, state-of-the-art medical equipment, and updated, trained, & competent human resources are part of health service inputs.
- These are the different resources that need to be managed well in order to guarantee that health services will be provided efficiently to the population.
- Resources such as trained doctors, medical staff, & supply of medications often take time to be produced; hence, the health system policymakers have to respond
and use the available resources to address short-term population needs as soon as possible.
→ Note that almost all health needs are immediate, excluding chronic illnesses (which require management).
- It is the responsibility of health system policymakers.
(3) Stewardship
- Also called: Overall system oversight.
- The main responsibility of the government.
- Stewardship is defined as the supervision, or taking care of something.
- This function sets the direction, context, and policy framework for the overall health system.
- The cores of stewardship include:
(1) Identifying health priorities for the allocation of public resources
→ Performing a needs assessment is truly crucial given that for every population, there exists a different need―as such, there is the need to assess first the needs
of the population in order to prioritize the resources (i.e., buying drugs for drug cases that are not prevalent in the population).
→ Example:
► Fight against mycobacterium tuberculosis in the Philippines.
- For other countries, purchasing vaccines/drugs against mycobacterium tuberculosis would be a waste of their budgets/resources , since it is an illness
that is not prevalent in their country; however, it is one of the main health issues prioritized by the Philippines.
→ For every country & location, there will be different health risks & needs of the general population; hence, identification & prioritization of health needs of a
certain population are important before allocating a budget/resources.
(2) Identifying an institutional framework
(3) Coordinating activities with other systems related to external health care
(4) Analyzing health priorities & resource generation trends + their implications
→ Trends about the population, death tolls, usual causes of death in a certain area, and other pertinent information must be known.
(5) Generating appropriate data for effective decision-making and policymaking on health matters (research)
→ Has to have a special study in order for us to have a scientific & sound basis of why we are prioritizing a certain project.
→ Note that a budget can only do so little if not used properly.
(4) Health financing
- Health system financing includes raising & pooling resources to pay for health services.
- More on looking for the resources used to sustain a health system (e.g., buying medicine/medical equipment, paying for health professionals, etc.).
- Includes:
(1) Revenue collection
- Revenue is the money earned from payments for healthcare services.
- Each source of health financing is associated with a specific manner of organizing & pooling
of funds and purchasing services.
- The mechanisms for revenue collection include:
► General taxation
- Public health systems rely on general taxation for its financing.
► Direct household out-of-pocket expenditures
► Mandatory payroll contributions
- Social security organizations are funded through mandatory payroll
contributions from workers & employers.
► Mandatory or voluntary risk-rated contributions
► Donor financing
► Other forms of personal savings
(2) Risk pooling
- Involves gathering together or combining funds from people's taxes or income to finance
or pay for another person's expenses (health risks).
- Financial risk pooling is a form of risk management which aims to spread financial risks
from an individual to all pool members.
→ Instead of one individual shouldering the financial responsibility, all pool members
will be involved in the funding (finances are divided among the members). Shows the money allocated for medical healthcare in
- It is considered as a core function of health insurance companies. each country in dollars (with an increment of every 5
- This mechanism prevents outright payment for health services (which discourages years since 2000).
patients belonging to the poor sector from seeking healthcare).
- Participation in effective risk pooling helps families from financial losses due to health USA is ranked first not because of any political factor,
shocks; thus, ensuring financial protection. but because of high costs of medical treatment and
- Each country has its own approach to managing its financial risks to finance its healthcare malpractice insurance. Hence, allocation is higher in
system―multiple & fragmented forms of risk pooling arrangements exist in most them (the value is high primarily because the cost of
developing countries. healthcare services are also high).
- Most high-income countries follow one of the (2) main models of risk pooling:
(1) Bismarck Model - Bismarck's Law on Health Insurance of 1883. By 2015, in the Philippines, approximately Php 16,000
- Named after the Prussian Chancellor, Otto von Bismarck, which is known for per person is allocated as a budget for their health or
inventing the welfare state in the 19th century as part of the unification of Germany. medical needs.
- The Bismarck model uses an insurance system where the sickness fund finances both
the employers & the employees through payroll deduction.
- However, unlike the US insurance industry, the Bismarck-type health insurance plan covers everybody; thus ultimately collecting no profit at all.
- This is considered as a: Multi-payer model, with tight regulation giving the government the cost-control clout.

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 - This is considered as a: Multi-payer model, with tight regulation giving the government the cost-control clout.
- Underlying principle: Health insurance covers everybody.
- Countries using the Bismarck model include:
► Germany
► France
► Belgium
► Netherlands
► Japan
► Switzerland
► Latin America (to a certain degree)
(2) Beveridge Model - Beveridge Report of the Social Insurance & Allied
Services of 1942
- Named after William Beveridge, the social reformer responsible for
designing Britain's Social Security System and the National Health Service.
- In the Beveridge model, healthcare is provided & funded by the government through tax payments (shared by the government).
- The government owns many, but not all, hospitals & clinic in the country.
→ You can seek healthcare provision from doctors of either government-owned facilities or private-owned facilities.
→ Professional fees to fund the services of these healthcare professionals will be handled by the gov't.
- Doctors may be government or private employees who collect their professional fees from the government.
- This results in low cost per capita since the government controls the healthcare services.
- Underlying principle: Healthcare is a basic human right.
- Countries using the Beveridge plan include:
► Hong Kong
► Great Britain
► Spain
► Scandinavia (most)
► New Zealand
► Cuba (the Cuban government uses total government control)
(3) Strategic purchasing
- Employs a plan of action or involves research prior to "purchasing" in order to minimize costs & maximize quality (worth the money).
- In both passive purchasing or impulsive buying, it is important to employ strategic purchasing.
- In strategic purchasing, risk-pooling organizations use collected funds and pooled financial resources wisely to finance healthcare services for the members.
- The purchaser defines the substantial part of the health provider's external incentives to develop the provider-user interaction & the health service delivery
models.
- Money saved through strategic purchasing can be used to spend for healthcare needs during "rainy days" (no need to exhaust all the funds).
→ Functions as a back-up plan.
- Important part of boosting efficiency & profitability in your company/institution.
- Able to save more by getting the best deals.

WHO Health System Framework

- In its World Health Report 2000, WHO released a single framework with (6) clearly defined building blocks & priorities which are necessary in strengthening health
systems and improving the overall health outcomes.
- This framework functions to ensure that the health system has improved efficiently in its services, have social & financial risk protections, improve the level & equity
of health, improve responsiveness, safety from non-desirable outcomes (harm), and possession of a contingency plan (back-up plan).

(1) Service delivery

- Refers to the timely delivery of quality & cost-effective personal & non-personal health services.
- Pertains to service provision that is not delayed; Usually done or occurring at a favorable time wherein it is most needed or useful.
- Quick turn-around-time [TAT] for a patient who is dying and timely delivery of service is crucial, especially in the medical field.
(2) Health workforce
- Includes individuals & groups working towards the achievement of the best health outcomes by being responsive, fair, & efficient (e.g., frontliners).
- The number of staff should be sufficient & fairly distributed to ensure competency, responsiveness, & productivity (involves collaboration).
- The most critical building block in a health system in order to ensure the provision of services―they are able to improvise in the absence of healthcare resources.
(3) Information (Health information system)
- Analyzes (requires scrutinizing data), disseminates (distribute information), and uses reliable (dependable) & relevant (timely) information on health status,
determinants, and systems performance.
- The right information can help in the proper management of patients.
- Hence, HIS is crucial in order to ascertain the best ways to augment patient care by having reliable & relevant information t o be used in the community care.
(4) Health/medical products, vaccines, & technologies

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(4) Health/medical products, vaccines, & technologies
- Made accessible through uninterrupted supply (supply is consistent, continuous, & timely to prevent scarcity), well-managed pharmaceutical services, and education
on the proper use of medication.
(5) Financing (Health financing system)
- Pertains to appropriate funding for healthcare services to guarantee that people can use health services when needed without fear of not having enough resources
to pay for them―helps those who do not have the financial capacity.
(6) Leadership & Governance
- Involves the task of ensuring effective stewardship of the entire health system.
- Excellent leaders & managers are needed in order to provide effective supervision.
- Also covers the monitoring of the accountability of private & public health agencies, proper system design (those behind the designing of the health system), and
appropriate regulation of health systems.

The Philippine Health System

- The health reform initiatives carried out over the years in the Philippines were primarily focused on these areas of concern:
► Health service delivery
► Health regulation
► Health financing
- These health reforms aimed at addressing issues such as poor accessibility, inequity, and inefficiency of the Philippine health system.
- How the healthcare system of the Philippines is formed can be summarized with the ff. important milestones in history:
(1) 1979: Adoption of Primary Health Care Strategy (Letter of Instruction [LOI] 949)
- Promoted participatory management of the local health care system.
- The Philippine Health Care system [PHC] is an essential health care system based on methods & technology made universally accessible to individuals.
- Healthcare provision is basic, rather than at a specialized level for people making an initial approach to a doctor or nurse for treatment.
(2) 1982: Reorganization of DOH (Executive Order [EO] 851)
- Integrated the components of health care delivery into its field of operations.
- EO 851 reorganized the DOH to synchronize health structures & operations with the shift to parliamentary form of government (formerly known as the Ministry
of Health)―later, under the presidential form, reverted back as the Department of Health.
→ The Ministry of Health has a head (minister) and departments run through a parliamentary system (state governance) by a group of people.
(3) 1988: The Generics Act (RA 6675)
- Ushered the writing of prescriptions using the generic name of the drug.
- Instead of forcing patients to by branded medicine (specific, branded drugs are not accessible & affordable to everyone) with physicians commonly prescribing
medications to patients by writing specific brand names, physicians were mandated to give out generic prescriptions.
(4) 1991: Local Government Code (RA 7160)
- Transferred the responsibility of providing health service to the local government units.
- Establishes the system and defines powers of provincial, city, municipal, & barangay governments in the Philippines―the act transferred the responsibility of
providing health services to the local government units [LGUs].
- This course of action provides for a more responsive local government structure.
→ Prevents people forced to travel to national government healthcare facilities/units to avail quality health services; as such, LGUs were delegated the specific
responsibilities & duties in order to speed up the rate of response to patient needs.
→ This response is instituted through the establishment of a decentralized system―where LGUs are delegated power, authority, responsibility, & resources to
possess the capacity to respond accordingly to patient needs.
- This is crucial development because the Philippines is an archipelago comprised of multiple, widely-dispersed islands; thus, making both communication and
transportation relatively difficult to accomplish.
- A centralized system for decision-making was deemed infeasible.
(5) 1995: National Health Insurance Act (RA 7875)
- Instituted a national health insurance mechanism for financial protection with priority given to the poor.
- Where PhilHealth plays a major role.
(6) 1999: Health Sector Reform Agenda
- Ordered the major organizational restructuring of the DOH to improve the way health care is delivered, regulated, & financed.
(7) 2005: FOURmula One [F1] for Health
- Adopted an operational framework to undertake reforms with speed, precision, & effective coordination and to improve the Philippine health system.
- Focuses on timely delivery of services.
(8) 2008: Universally Accessible Cheaper and Quality Medicines Act (RA 9502)
- Promoted and ensured access to affordable quality drugs & medicines for all.
(9) 2010: Kalusugang Pangkalahatan or Universal Health Care (Administrative Order [AO] 2010-0036)
- Provided universal health coverage & access to quality healthcare for all Filipinos.

The Philippine Health System: Leadership & Governance

(1) Department of Health [DOH]
- Mandated to provide the appropriate direction for the nation's healthcare industry.
- The incumbent DOH secretary is currently: Francisco Duque.
- Its other tasks include:
(1) Development of plans, guidelines, & standards for the health sector
(2) Technical assistance
(3) Capacity building
(4) Advisory services for disease prevention
(5) Control of medical supplies & vaccines
- DOH coordinates its national health programs through the local government
units [LGUs].
- The DOH is duty-bound to the ff. responsibilities, with the help of LGUs:
(1) Develop policies & programs for the health sector

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 - DOH coordinates its national health programs through the local government
units [LGUs].
- The DOH is duty-bound to the ff. responsibilities, with the help of LGUs:
(1) Develop policies & programs for the health sector
(2) Provide technical assistance to its partners (e.g., local mayors, brgy. tanods, etc.)
(3) Encourage performance of the partners in the priority health programs
→ It is within their responsibility to ensure that health professionals are paid
well and are appropriately & justly compensated for their services.
(4) Develop and enforce policies & standards
(5) Design programs for large segments of the population
→ Examples are feeding programs, diabetes prevention & control programs, health & wellness programs for senior citizens, and many more.
→ Involves lab work & research as well as discussions about the different needs of a community and ensure that these needs are addressed.
 Again, conducting a needs assessment is crucial to prevent offering solutions that are useless, unneeded, and not targeting any problems.
 Hence, designing programs should be heavily research-based (involves analysis of data to determine which pressing issues should be allocated resources).
(6) Provide specialized & tertiary level care
(2) Local Government Units [LGUs]
- Take care of their own health services and are given autonomy under the Local Government Code [LGC] of 1991 (RA 7160).
- 78 provincial governors, 138 city mayors, 1,496 municipal mayors, & 42,025 barangay chairpersons compose the local government units of the country.
- In terms of administration, LGUs are grouped into 17 regions.
- Although they operate in a decentralized system, LGUs are under the supervision of the DOH regional health officers (work hand-in-hand with barangay tanods to
assess health concerns/burdens of disease of each community).
→ A problem should be first established, which results in the development of a need, before a solution can be conceived.
 Problem identification = Needs assessment = Conception of solution/s.
→ It is through coordination with local mayors, barangay tanods, and LGUs that the DOH are able to enact accurate, timely, & necessary national health
programs.
- The provincial government is tasked to provide health services through provincial & district hospitals.
- The city & municipal governments rely on public health & primary health care centers for their primary care.

- Under the decentralized or devolved structure, the state is represented by national offices & LGUs alongside provincial, city, municipal, & barangay or village offices.
- DOH, LGUs, and the private sector participate, cooperate, & collaborate in the care of the population―Before devolution, the national health system consisted of a
three-tiered system under the direct control of the DOH:
(1) Tertiary hospitals at the national & regional levels
(2) Provincial & district hospitals and city & municipal health centers
(3) Barangay (village) health centers
- With the enactment of the LGC of 1991, the government health system now consists of basic health services―including health promotion & preventive
units―provided by cities and municipalities, provincial & province-run district hospitals of varying capacities, and mostly tertiary medical centers, specialty hospitals,
and a number of re-nationalized provincial hospital managed by DOH.

Directions of the Philippine Health Sector

(1) The Philippine Health Agenda 2016-2022 (DOH Administrative Order 2016-0038)
- Adopts the slogan "All for Health Towards Health for All" as the rallying point of its vision of a healthy Philippines by 2022.
- It expanded the scope of the Universal Health Care [UHC] directions, particularly through a whole-of-government approach (ensures that the entire government is
mobilized for this project).
- With this agenda, the health system guarantees:
► Population- & individual-level interventions for all life stages that promote health and wellness, prevent & treat the triple burden of disease, delay
complications, rehabilitation, and provide palliation for both the well & the sick.
→ The triple burden of disease includes: Communicable diseases, malnutrition, & diseases of rapid urbanization.
→ Life stages primarily focused on: Pregnant women, infants, children, adolescents, young adults, and essentially, all life stages.
► Access to health interventions through functional service delivery networks [SDNs].
► Financial freedom when accessing these interventions through Universal Health Insurance.
→ Ensures that people do not have to worry about paying given that they are insured (have covered medical costs).
→ An expansion of the Universal Health Care [UHC].
- Delayed due to the onset of the COVID-19 pandemic as an unprecedented health risk (a lot of time & attention has been directed to it).
(2) The Philippine Development Plan 2017-2022
- The first of the 4 key medium-term plans to translate the vision of a "matatag (unshaken), maginhawa (comfortable), at panatag (peace achieved from good health
coverage) na buhay" for the Filipinos and the country.
- Spearheaded by the National Economic and Development Authority [NEDA].
(3) NEDA AmBisyon Natin 2040
- A product of the Philippine Development Plan 2017-2022, this collective long-term plan envisions better life for the Filipinos and the country in the next 25 years by
formulating policies & implementing programs and projects to attain this AmBisyon.
- Requires a high level of trust in the government (assurance that this project will be continued regardless of who sits in the presidential position).
→ The project could be impeded depending on whoever new will spearhead the Philippine government.
- This plan focuses on (4) areas:
► Building a prosperous, predominantly middle-class society where no one is poor

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 ► Building a prosperous, predominantly middle-class society where no one is poor
► Promoting a long & healthy life
► Becoming smarter and more innovative
► Building a high-trust society
→ High-trust is dependent upon the success of the government in accomplishing the objectives of this project.
→ Necessitates an "exchange of trust", since trust in the government in the preliminary stages of the project is needed to encourage long-term efforts from
the government to accomplish the objectives of this project and once accomplished, more trust from the people are earned (builds more confidence in the
Filipinos towards their government in terms of implementing future projects).
(4) Sustainable Development Goals 2030
- Also known as the: 2030 Agenda.
- This compilation of 17 global development goals targets to end poverty, fight inequality & injustice, and confront issues involving climate change.
- Involves the "endgame" visions/ "holistic" goals we want to achieve as a country by 2030.
- Note that the presence of an unprecedented pandemic outbreak, COVID -19, has caused a lot of the governmental projects/plans to be delayed; nevertheless, there still
persists a need to ensure that efforts exerted to meet all of these goals are still on track once the pandemic dies.
- It is one of the responsibilities of the health systems and those who serve in the leadership & governance positions to make sure that these goals are still intact even
after the pandemic and work towards achieving them in the soonest possible time (if it cannot be achieved within the target year).

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HIS Lesson 2 Health System Video Link: HIS Lesson 2 Health System

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