Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
Understanding Health Systems (Part 2)
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From the course by Johns Hopkins University
Understanding and Strengthening Health Systems
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From the lesson
Understanding Organizations and How They Change
Health Systems are human organizations. Organizations have structure, purpose and membership. To remain “Healthy” an organization must adapt to its environment, whether that be funding and policy changes or expectations of its clients. In this module we will focus on diagnosing factors related to the health of organizations and consider strategies to help organizations adapt.
Meet the Instructors
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
So as we talked about it, it's not just enough to be measuring the average levels,
but we also want to be looking at variation.
And particularly, equity or equality.
So one of those most commonly used measures of
equity is called the concentration index.
So let's take a look at how this works.
So I'm going to take one measure of health inequities using children that
are underweight as the measure of health status.
And what you see at the bottom is the percent of the population or
percent of the sample ranked by income, from the poorest to the 25%,
to the 50th and by the time you hit 100, that's the whole population.
And you think of them listed in a row according to how poor they are from
poorest to richest.
And on the top you see what cumulative proportion of that sample includes
children that are underweight.
Now looking at this graph, there is a line that goes diagonally right across,
that 45 degrees.
Now, if things were perfectly equal, if there's a equal probability of
a child having underweight by each income group, you'll follow that line.
So in other words, the poorest 25% of the sample will have
25% of the underweight children, 50%, 50% and so on.
What you see here is the slopes for two different periods of time.
The green one was in 1987 and you see a bit of a bulge that goes above the line.
And then the orange one is in 1994, where the bulge went even further away.
So how do we use this to measure inequity?
Well, what we do for the concentration index is we take that area between
that curve and the 45 degree line.
The green one in 1987 and the orange in 1994,
double that area and that becomes the measure.
The measure goes from minus 1 to plus 1, and
by convention if the concentration index is put at less than 0 when
the variable is higher, are more common among the poor.
So what you see here is, in first case,
it's a number that is going to be less than 1 in 1987 and
then by 1994 it's going to be even larger, but in a negative direction.
So that number is going to be even closer to minus 1.
What you see means that in terms of proportional children that
are underweight, more of them become concentrated among the poor.
So that this particular measure of underweight children has become more
inequitable over time.
Now, that doesn't tell you whether the total number of children are less or more,
because in fact in this program, there are fewer children that were underweight.
They just happened to be more likely among the poor than they were in 1994,
than they were in 1997.
So the concentration index is a common measure.
Here's another view of a concentration curve,
this time showing four different kinds of health services.
This is a study that we did in India back in 2001.
The red diagonal line is the equal line and
what you see here is that the immunizations in outpatients care through
primary healthcare is above the line.
In other words, using those services is more likely to be
used by the poor than by the rich or by wealthier populations.
Whereas on the other hand, outpatient care at the hospital is most likely to be
used among wealthier populations and the inpatient hospital care
is the next one in terms of likely to be used by wealthier patients.
So in this case, you would say that because the benefits in this case of
using these services is a good thing, having a negative concentration index for
use of services is a good thing.
Immunizations and outpatient care through primary
health services would be pro-poor with a concentration indices less than 1.
And the other services would be pro-rich in terms of its distribution of use and
would have concentrations in the indices above 1.
Now there's nothing inevitable about the concentration index and
whether a health system is more pro-poor or not.
Here what we've done is a study showing concentration indices of public
financing of health, but it's sometimes called benefit incidence analysis.
Which looks at all of the public financing in use of health services in a country.
And each one of these bars represents a country in the green.
The brown bars actually represent states in India.
And what you see is a large distribution,
because benefit in this case is a good thing.
You'll see that being above 1 would be pro-rich and
being minus 1 is pro-poor, for taking public funding for health.
And what you see is a large variation, some of which are pro-poor in this
distribution and some of which are pro-rich and even within India,
the average one there is actually shown in yellow-brown.
But even in India, the states show very different levels of equity.
So again, this is a way of looking at inequity across a health system and
you can apply this type of analysis to any kind of indicator where
you have data on both the outcome as well as the distribution among wealth or
incomes of the population.
So let's move on to looking at the actors.
So we've looked at the outcomes, now let's look at the actors.
And this slide shows the same three broad sets of actors, people,
providers and the government.
And now we're showing different kinds of relationships, because again,
health systems is both the parts and their connections.
This one here is more of accountability relationship that shows how political
voice is what links people and their state or the politicians.
Oversight and compacts, the way in which politicians or
the government relates to health providers.
And then client power, people can choose where they go or
they can walk with their feet between providers and people.
So this is just another way of looking at the main actors.
When you think of a health system,
it's important to think of who is the most important sets of actors.
And we like to start off with this question, who produces health?
It's actually a picture of a home.
And it's important to remind us that most health decisions and
most risks about health actually occur in the household.
And they also provide most health services,
most decisions about what kind of care you're going to have.
After households, health services are most frequently provided by shopkeepers and
vendors, quacks, traditional practitioners, private providers,
sometimes in the formally trained sector and public sector providers.
I say this because this is a situation of a typical low and middle income country.
When you think of a health system, people will automatically try to think of
the government providers or the government in the formal providers.
But if you look at where most people get their care, and
this is particularly true for outpatient care or for ambulatory care,
it's first and foremost informal providers in most countries around the world.
Self treatment actually means, in many cases going to the drug shop or
the chemist, or often just an ordinary itinerant vendor, or
other shop keeper, to get your medications and advice.
So again, looking at a systems perspective, don't think of providers
strictly as being the formal providers or just the public sector providers.
You want to look at the full set of providers.
Now are there other health system actors?
Well of course there are or we wouldn't be asking.
So here's a list on this slide of a number of range of actors.
If you think of governments, there are of course multiple levels, local and
national.
There are other kinds of financing organizations.
They could be insurance or other kinds of agencies that finance or subsidize care.
There often are regulatory agencies that are arms length,
they're part of governments.
And then of course there's a whole set of people that provide the drugs and
the equipment and those that are involved with selling them.
There's a whole group of organizations around medical information and
health information systems.
You've got a lot of other philanthropic and faith-based organizations and
other organizations related to citizens groups, or community organizations,
consumer groups.
And then of course there's us, the people who are academics and
those that are involved with international organizations,
that can get involved with any kind of these functions in a health system.
So when you're thinking of a health system set of actors,
you want to start off with people and then thinking of the other main actors.
But don't just think of the common sets of public providers and
government oversight or government regulators.
There really are a broad set of actors and depending on where you are,
they have different amounts of influence.
Let's move on to the key functions of the health system.
I'm going to break them down into these functions of service delivery,
financing, managing inputs and then oversight.
When you think of health services, they can be organized in many,
many different ways.
You can organize them according to point of care, where do you deliver them,
whether they be hospitals or clinics, or other kinds of public health agencies.
You can think of them as an administrative structure, whether they'd be at the local,
county, district, or national level.
You can think of them as organizing around the management unit.
It might be a particular ward in a hospital,
or a district health management team, or you could be organizing by profession.
You could have sets of community health workers, or doctors, or nurses, or
you could organize them around community organization.
In international health we often have priority disease programs which
are organized around particular diseases.
For AIDS control, TB, malaria, or around child health, family health,
reproductive sexual health and the like.
More and more we're interested in trying to have patient or
family-centered types of care that's more concerned about the broader sense
of social and health conditions of a person,
rather than a particular disease or a supply side structure.
But all of these services have to be thought of, not just in terms of cure and
rehabilitation, but also health prevention and promotion, when you're
thinking about important functions and service delivery in a health system.
If you think about health financing,
you can break this down into at least three different kinds.
One is how do you raise revenues?
How do you get money for them?
It might be through taxes.
It might be through premiums.
It might be through different kinds of subsidies.
But different ways in which you raise revenues is important for
what you can do in a health system.
Both the amounts and how you raise them.
How do you pool the resources?
How do you put them together for insurance?
Do you actually try to provide financial protection by pooling resources?
And then of course, how do you allocate the money?
How do you pay your doctors?
How do you buy things?
Has an important influence on how the providers or
other actors in a health system will behave.
The mechanism of paying is hugely important.
But this is another specialized area for other study and analysis, but
important to see that this is a function that's intimately related to the other
functions of service delivery, input management and of course, oversight.
So what is oversight?
Well, oversight broadly means to watch over the health sector,
at least oversight in the health sector.
And you may want to see, well,
how does a government actually provide oversight in the health sector?
Immediately we think of the traditional regulation.
Here, I've got the Organization of Economic Cooperation Development,
the OECD measures.
Which is the instruments by which governments place requirements on
enterprises, citizens, government, etc., etc.
And you can see that the lines get very small because really,
this is quite boring and it's sort of what we expect.
This is the red tape and the paperwork.
This is very important, however.
But there are other ways to think of regulation as well.
And you want to think of it broadly in terms of how do you make policy?
How do you establish and enforce laws and regulation?
Well, okay.
This sounds like traditional approaches and yes, they are, and they're needed.
But there are other ways.
Public disclosure, or naming and shaming, or trying to provide evidence and
have people or performing.
Professional self-regulation is very common around the world, whether it be by
hospitals or providers, or whether it would be the doctors or nurses,
physiotherapists, professions trying to set up regulation for how they work.
Increasingly we're seeing this in groups of informally trained providers,
patent medical vendors, or
village doctors forming associations to try to have some kind of self-regulation,
often commercial interests, but sometimes over quality of care issues as well.
Do not forget that you have consumer advocates, consumer organizations.
You have independent media, or
you can explicitly put in third parties to be independent monitors.
These are ways in which you can provide regulation or
oversight in the health sector.
Increasingly though, we're finding that particularly in low and middle income
countries, that you have to go beyond just thinking of the formal regulations.
And you need to be thinking of both informal and formal rules of the game or
institutions, that affect how people behave.
They affect performance, but they affect all those different actors that we talked
about, behave, incentives matters.
So local institutions, they need to go beyond simply government and
often they need to involve bringing different groups together, whether they be
the consumer groups, or the professional organizations, or the media.
So that increasingly, we've got something that's called co-production, or
co-production and regulation, that may be more important and may be more effective
than just simply relying on government trying to enforce laws and rules, or
other regulations that they've had difficulty enforcing.
So you often need to bring the different groups together.
Sometimes the consumers, the providers,
as well as maybe some of the producers of drugs and materials, or
professional organizations, in ways to find rules that work in local settings.
So increasingly, the co-production models and innovations and how these work is
becoming a more important way of trying to influence the rules of the game,
how the health system performs.
So in this section what we've done is really describe the health system.
We can think of it in terms of its purpose, health outcomes,
financial protection, trust in this health system.
Can think of it as its many actors, including people and
the different providers, different kinds of state and other intermediaries.
And then of course its functions.
All of these are important parts that fit together in a health system.
In this next section, we're going to be talking about system thinking,
which is really the practice of thinking of how one thing leads to another.
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