Health Systems & Health Policy: About the Course

P.R. Sodani, PhD, MPH

Professor & Course Coordinator, Health Systems and Health Policy PGDHM & PGPHM Institute of Health Management Research Jaipur

About the Course
 This course is a core course and fundamental in the context of health care environment.
 This course is designed to help the students understand the existing health care delivery system and related issues in India.

Course Objectives
 Understand the concept of health systems and objectives of health systems  Describe the concept and principles of primary health care approach  Describe health care delivery system of India  Understand functioning of public health system  Describe issues and challenges in health care services delivery

Course Objectives…
 Understand National Health Policy, Population Policy and Policy linked Schemes/Programs and Issues  Describe issues and challenges in health care services delivery  Describe implementation framework of NRHM  Understand the financing of health in India  Understand health sector reforms in India

Teaching Methods
    Lectures Discussions Assignments Industry Interface

Readings
 Suggested readings for the course is compiled in the Module.  The reading material is compiled from various sources such
     Ministry of Health & Family Welfare WHO and World Bank material Policy documents/approach paper Reference books Research papers publishsed

Contents
         Health Systems Basic Concepts Health Planning in India Primary Health Care Approach Health Care Delivery System in India National Health Policy National Population Policy National Rural Health Mission Financing Health Care in India Health Sector Reforms

Methods of Grading and Evaluation
1 2 Mid-term Examination
Written and closed book

30% 70% 100

Final Examination
Written and closed book

Total

Health Systems: An Overview
P.R. Sodani, PhD, MPH Professor Health Systems, Health Economics and Financing Institute of Health Management Research Jaipur

Session Plan
 What is a health system?  Why health systems matter?  What are the objectives of health systems?

 Health systems have contributed enormously to better health and influenced the lives and well-being of billions of men, women and children around the world. Their role has become increasingly important.

 Enormous gaps remain, however, between the potential of health systems and their actual performance. There is far too much variations in outcomes among countries which seems to have the same resources.

What do we mean by Health System?

What is a health system?
 A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.

 Formal health services, including the professional delivery of personal medical attention, are clearly within these boundaries.

 Actions by traditional healers, and all use of medication, whether prescribed by a provider or not.

 Public health activities such as health promotion and disease prevention, and other health enhancing interventions like road and environmental safety improvement, are also part of the system.

 Beyond the boundaries of this definition are those activities whose primary purpose is something other than health – education, for example – even if these activities have a secondary, health-enhancing benefit. Hence, the general education system is outside the boundaries, but specifically health-related education is included.

 Nearly all the information available about health systems refers only to the provision of and investment in, health services: that is, the health care system, including preventive, curative and palliative interventions, whether directed to individuals or to populations.

 In most countries, these health care services account for the great bulk of employment, expenditure and activity.

 Nonetheless, efforts are needed to quantify and assess these activities which matters a lot for health system and to estimate their relative cost and effectiveness (consequences in contributing to the goals of the system.

 To take one example, in the United States between 1966 and 1979 the introduction of a variety of safety features in automobile design (laminated windshields, collapsible steering columns, interior padding, lap and shoulder belts, side marker lights, head restraints, leak resistant fuel systems, stronger bumpers, increased side door strength and better brakes) helped reduce the vehicle accident fatality rate per mile travelled by 40%.

 Only three of these innovations added more than $10 to the price of a car and in total they accounted for only 2% of the average price increase during 1975–1979.  From 1975 to 1998, seat belts saved an estimated 112 000 lives in the United States and total traffic fatalities continued to fall.

 The potential health gains were even greater: in 1998 alone, 9000 people died because they did not use their belts.
 The potential savings are very large: road traffic accidents in low and middle income countries.

 Health systems today represent one of the largest sectors in the world economy.  Global spending on health care was about $2985 billion (thousand million) in 1997, or almost 8% of world gross domestic product (GDP)  The International Labour Organisation estimates that there were about 35 million health workers worldwide a decade ago, while employment in health services now is likely to be substantially higher.

 These figures reflect how what was for thousands of years a basic, private relationship – in which one person with an illness was looked after by family members or religious caregivers, or sometimes paid a professional healer to treat him or her – has expanded over the past two centuries into the complex network of activities that now comprise a health system.

 More than simple growth, the creation of modern health systems has involved increasing differentiation and specialization of skills and activities.

 It has also involved an immense shift in the economic burden of ill-health. Until recently, most of that burden took the form of lost productivity, as people died young or became and remained too sick to work at full strength.

 The cost of health care accounted for only a small part of the economic loss, because such care was relatively cheap and largely ineffective.  Productivity losses are still substantial, especially in the poorest countries, but success in prolonging life and reducing disability has meant that more and more of the burden is borne by health systems.

 This includes the cost of pharmaceutical products – for controlling diabetes, hypertension, and heart disease, for example – that allow people to stay active and productive.

 The resources devoted to health systems are very unequally distributed, and not at all in proportion to the distribution of health problems.

 Low and middle income countries account for only 18% of world income and 11% of global health spending ($250 billion or 4% of GDP in those countries).
 Yet 84% of the world’s population live in these countries, and they bear 93% of the world’s disease burden.

 These countries face many difficult challenges in meeting the health needs of their populations, mobilizing sufficient financing in an equitable and affordable manner, and securing value for scarce resources.

What do health systems do?
 For rich and poor alike, health needs today are very different from those of 100 or even 50 years ago.

 There are growing expectations of access to health care in some form and growing demands for measures to protect the sick and their families, against the financial costs of ill-health.

 People also now turn to health systems for help with a much wider variety of problems than before – not just for the relief of pain and treatment of physical limitations and emotional disorders but for advice on diet, child-rearing and sexual behaviour that they used to seek from other sources.

     

Patients and populations Providers Consumers of nonprescription medications and Recipients of health-related information Recipients of advice Contributors for paying for health system

 It matters very much how the system treats people’s health needs and how it raises revenues from them, including how much protection it offers them from financial risk.

 But it also matters how it responds to their expectations. In particular, people have a right to expect that the health system will treat them with individual dignity. So far as possible, their needs should be promptly attended to, without long delays in waiting for diagnosis and treatment – not only for better health outcomes but also to respect the value of people’s time.

 Patients also often expect confidentiality, and to be involved in choices about their own health, including where and from whom they receive care. They should not always be expected passively to receive services determined by the provider alone.

 In summary, we may say that health systems have a responsibility not just to improve people’s health but to protect them against the financial cost of illness and to treat them with dignity.

Objectives of Health Systems
 Health systems thus have three fundamental objectives:
 Improving the health of the population  Responding to people’s expectations  Providing financial protection against the costs of ill-health

 Because better health is the most important objective of a health system and because health status is worse in poor populations, one might assume that for a low-income country, improving health is all matters.

 Concern for non-health outcomes of the health system – for fairly sharing the burden of paying for health so that no one is exposed to great financial risks and attending to people’s expectations about how they are to be treated, would then be luxuries.

 But, this is not true. This view is taken mistaken for several reasons.  Poor people need financial protection as much as or more than the well off since even small absolute risks may have catastrophic consequences for them.  And the poor are just as entitled to respectful treatment as the rich, even if less can be done for them materially.

 Moreover, pursuing the objectives of responsiveness and financial protection does not necessarily take substantial resources away from activities to improve health.  Much improvement in how a health system performs with respect to these responsibilities may often be had at little or no cost.

 So, all three objectives matter in every country, independently of how rich or poor it is or how its health system is organized.

 Better ways of achieving these objectives, are similarly relevant for all countries and health systems, although the specific implications for policy will vary according to income level and the cultural and organizational features of the system.

Functions of Health Systems
 Functions of the health system are as follows:
    Financing Management of non-financial resources Delivery of services Stewardship (oversight)

 Responsibilities for the first three sets of functions – financing, management of inputs and service delivery are shared between private and public sector.

Financing
    Revenue generation Risk pooling Allocation of resources purchasing

Management of non-financial inputs
       Human resources Knowledge and software Pharmaceuticals Consumables Medical equipment Buildings Supplies

Service delivery
       Public health services Clinical services Outpatients services Inpatients services Diagnostic services Therapeutic services Rehabilitative services

Oversight
 Oversight function is largely a responsibility of the State.  The concept of oversight goes beyond the conventional idea of regulation – setting and enforcing rules – to other functions such as developing policy and providing strategic direction to the health system.

examples
      Policy setting Regulation and setting standards Providing incentives Developing partnerships Providing information and advocacy Monitoring and evaluation

 The financial costs of strengthening oversight are small and the benefits are considerable.  Oversight activities are a prerequisite to improving quality, equity and being able to use health insurance or strategic purchasing of health services.

 Oversight roles are the development of partnerships or networks among health service providers and financiers and the strategic use of incentives to promote the public policy objectives.

 Acquiring and disseminating information about performance, quality or pricing is another oversight function.  Using information through monitoring and evaluation for programme strengthening

 The distinctions between some of these functions may be somewhat arbitrary because the functions are often closely related.  Example - People’s demand healthy deliveries, which creates markets for more particular services such as fetal ultrasound testing, and products perhaps new drugs.

 Oversight function influence each of the other actors and functions. The management of inputs is tied to the types of services delivered; how they are paid for affects their quality, quantity and distribution.

Outcomes of Health System
 The health system has three types of outcomes:
 Health status  Financial status  Consumer responsiveness

Health status
 Measures of health status:
     Mortality Nutrition Fertility Illness Disability

Financial protection
 The financial protection is a measure of the financial loss due to illness, which include direct costs of health care and indirect costs of health care.  The concern is not about how costs affect access but also the risk of loss of income and assets.  Financial protection is particularly important to the poor as the costs of ill health push people into poverty and deepen the levels of poverty.

Consumer responsiveness
 The consumer responsiveness of the health system is measured by how satisfied the public is with various aspects of health services.  It also includes consideration of whether health services treat people with respect and whether they are provided with protection against malpractice and explotiation.

 Here, again the poor are just as concerned with dignity and with being treated respectfully by the health system as are those who are wealthier and more powerful.

Intermediate objectives
 How can India’s health system meet its fundamental objectives in an equitable, effective, accountable and affordable manner?  This question raises a second order of objectives relevant for the health system.

 This level of intermediate objectives may include the following parameters:
     Equity Quality Costs Consumer choices Provider autonomy

Equity
 Some minimum of health care should be accessible to all citizens in accordance with their needs, at least in services publicly financed.

Quality
 Health services should provide the optimum combination of good outcomes – good health, financial protection, and consumer satisfaction, with costs minimized for a given level of output.

 Another way of stating this is that quality of health services should be optimized which can be considered in terms of technical quality of services (how well the interventions provided work), managerial quality (how well outputs are maximized given the level of inputs), and perception of quality (how well patients are satisfied with services).

Costs
 At macro level, the health expenditure should consume an appropriate proportion of GDP. At micro level, the patients should be financially protected.

Consumer choice
 The clients should have a sufficient of providers in both public sector and private sector for their treatment and services.

Provider autonomy
 Doctors and health providers should have the maximum freedom compatible with the attainment of the other health system objectives.

 The overall levels of health systems outcomes are important but the distribution of the results among different geographic areas and populations, and particularly for various vulnerable groups such as poor, scheduled castes, scheduled tribes, women and young.

Assignment 1
1. Define health systems and what are the major objective of health system?
2. Describe the Health System of India including its actors, functions and outcomes. 3. Analyze systems outcomes – health status; financial status, and consumer responsiveness based on evidence gathered from secondary data sources.

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