A health system, health care system, or healthcare system, is a set of organizations, institutions and resources whose primary goal is to produce actions for the promotion, restoration or maintenance of health.
There is a wide variety of health systems around the world, with as many histories and organizational structures as there are countries. Implicitly, countries must design and develop health systems in accordance with their needs and resources, although common elements in virtually all health systems are primary healthcare and public health measures.
In certain countries, the orchestration of health system planning is decentralized, with various stakeholders in the market assuming responsibilities. In contrast, in other regions, a collaborative endeavor exists among governmental entities, labor unions, philanthropic organizations, religious institutions, or other organized bodies, aimed at the meticulous provision of healthcare services tailored to the specific needs of their respective populations. Nevertheless, it is noteworthy that the process of healthcare planning is frequently characterized as an evolutionary progression rather than a revolutionary transformation.New Yorker magazine article: "Getting there from here." 26 January 2009
As with other social institutional structures, health systems are likely to reflect the history, culture and economics of the states in which they evolve. These peculiarities bedevil and complicate international comparisons and preclude any universal standard of performance.
Goals According to the World Health Organization (WHO), the directing and coordinating authority for health within the United Nations system, healthcare systems' goals are good health for the citizens, responsiveness to the expectations of the population, and fair means of funding operations. Progress towards them depends on how systems carry out four vital functions: provision of health care services, resource generation, financing, and stewardship.World Health Organization. (2000). World Health Report 2000 – Health systems: improving performance. Geneva, WHO Other dimensions for the evaluation of health systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness.Remarks by Johns Hopkins University President William Brody: "Health Care '08: What's Promised/What's Possible?" 7 September 2007 Also, continuity of health care is a major goal.
Definition The World Health Organization defines health systems as follows: Some authors have developed arguments to expand the concept of health systems, indicating additional dimensions that should be considered: Health systems should not be expressed in terms of their components only, but also of their interrelationships. Health systems should include not only the institutional or supply side of the health system but also the population. Health systems must be seen in terms of their goals, which include not only health improvement, but also equity, responsiveness to legitimate expectations, respect of dignity, and fair financing, among others. Health systems must also be defined in terms of their functions, including the direct provision of services, whether they are medical or public health services, but also "other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce."
Health system frameworks There are many ways to understand health systems. All of them are key to help understand their functions and elements, as well as the relationships between them. These frameworks, besides, can serve as guides to analyze and study specific health systems and their performance, in all their complexity.
The WHO health system framework In 2000, the World Health Organization proposed a clear health system framework in the annual World Health Report. It featured 4 functions (stewardship, creating resources, financing, and delivering services), together with three objectives (responsiveness, fair financial contribution, and health).
In 2007, this initial model evolved towards the most common health system framework to date: the "building blocks" framework. According to this new model, strengthening health systems consisted of improving six building blocks and the interactions between them, with the aim of improving access, coverage, quality and safety, to ultimately achieve improved health, responsiveness, social and financial risk protection, and improved efficiency.
The six building blocks of a health system, in line with this framework, are:
Service delivery: Services being offered, demanded by the population and used. It requires adequate infrastructure and management. Health workforce: Competent and well-performing health professionals, supported by relevant regulations. Health information system: Generation of data about the performance of services and the health status and risks of the population that, in turn, is used for evidence-based decision-making. Medicines, supplies, and vaccines: Medical products that are accessible, safe, and of enough quality, thanks to adequate regulatory systems and supply chains. Health financing: Resources collected and pooled, used to purchase health services that the population uses. Governance and leadership: Stewardship and relationships among authorities, healthcare providers and users that help protect the public interest.
Despite the widespread adoption of this framework, it has also been criticized over the years, due to the apparent segmentation of components, with inadequate emphasis on their relationships, and its limited focus on health services, without enough attention to the community and their role within the health system.
The World Bank model The World Bank, in 2004, published a health system framework that, despite not being as widely adopted by the international community, also had a significant impact: the "Control Knobs" model.
In this framework, its authors suggested that action could be taken in five different dimensions or control knobs of the health system: financing, payment, organization, regulation, and behavior. Depending on how these knobs where turned, they would have an effect on the efficiency, quality, and access of the system. Improved performance at this level would help improve health status, customer satisfaction and risk protection, the three performance goals of the health system.
Financial resources
There are generally five primary methods of funding health systems:"Regional Overview of Social Health Insurance in South-East Asia , World Health Organization. And . Retrieved 18 August 2006.
general taxation to the state, county or municipality national health insurance voluntary or private health insurance out-of-pocket payments donations to charities
+Healthcare modelsUniversalNon-universalSingle payerMulti-payerMulti-payerNo insuranceSingle providerBeveridge model, Semashko modelMultiple ProvidersNational Health InsuranceBismarck modelPrivate health insuranceOut-of-pocket Most countries' systems feature a mix of all five models. One studyGlied, Sherry A. "Health Care Financing, Efficiency, and Equity." National Bureau of Economic Research, March 2008. Accessed 20 March 2008. based on data from the OECD concluded that all types of health care finance "are compatible with" an efficient health system. The study also found no relationship between financing and cost control. Another study examining single payer and multi payer systems in OECD countries found that single payer systems have significantly less hospital beds per 100,000 people than in multi payer systems.
The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a social insurance program, or from private insurance companies. It may be obtained on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case premiums or taxes protect the insured from high or unexpected health care expenses.
Through the calculation of the comprehensive cost of healthcare expenditures, it becomes feasible to construct a standard financial framework, which may involve mechanisms like monthly premiums or annual taxes. This ensures the availability of funds to cover the healthcare benefits delineated in the insurance agreement. Typically, the administration of these benefits is overseen by a government agency, a nonprofit health fund, or a commercial corporation.How Private Insurance Works: A Primer by Gary Claxton, Institution for Health Care Research and Policy, Georgetown University, on behalf of the Henry J. Kaiser Family Foundation
Many commercial health insurers control their costs by restricting the benefits provided, by such means as deductibles, copayments, co-insurance, policy exclusions, and total coverage limits. They will also severely restrict or refuse coverage of pre-existing conditions. Many government systems also have co-payment arrangements but express exclusions are rare or limited because of political pressure. The larger insurance systems may also negotiate fees with providers.
Many forms of social insurance systems control their costs by using the bargaining power of the community they are intended to serve to control costs in the health care delivery system. They may attempt to do so by, for example, negotiating drug prices directly with pharmaceutical companies, negotiating standard fees with the medical profession, or reducing unnecessary health care costs. Social systems sometimes feature contributions related to earnings as part of a system to deliver universal health care, which may or may not also involve the use of commercial and non-commercial insurers. Essentially the wealthier users pay proportionately more into the system to cover the needs of the poorer users who therefore contribute proportionately less. There are usually caps on the contributions of the wealthy and minimum payments that must be made by the insured (often in the form of a minimum contribution, similar to a deductible in commercial insurance models).
In addition to these traditional health care financing methods, some lower income countries and development partners are also implementing non-traditional or innovative financing mechanisms for scaling up delivery and sustainability of health care, such as micro-contributions, public-private partnerships, and market-based financial transaction taxes. For example, as of June 2011, Unitaid had collected more than one billion dollars from 29 member countries, including several from Africa, through an air ticket solidarity levy to expand access to care and treatment for HIV/AIDS, tuberculosis and malaria in 94 countries.UNITAID. Republic of Guinea Introduces Air Solidarity Levy to Fight AIDS, TB and Malaria. Geneva, 30 June 2011. Accessed 5 July 2011.
Payment models In most countries, wage costs for healthcare practitioners are estimated to represent between 65% and 80% of renewable health system expenditures.Saltman RB, Von Otter C. Implementing Planned Markets in Health Care: Balancing Social and Economic Responsibility. Buckingham: Open University Press 1995. There are three ways to pay medical practitioners: fee for service, capitation, and salary. There has been growing interest in blending elements of these systems.
Fee-for-service Fee-for-service arrangements pay general practitioners (GPs) based on the service. They are even more widely used for specialists working in ambulatory care.
There are two ways to set fee levels: By individual practitioners.