Lecture 1 – Introduction to health systems
Pre-modern states – epidemics and hospitals ran as religious charity (state: quarantine)
Modern states – French revolution & industrial revolution
- Emergence of welfare states (responsibility of the state for population health measures
and healthcare services)
- Scientific development (sanitation, hygiene, vaccination, antibiotics)
- Focus on ‘healthcare’ rather than ‘the health of people’
Crumbling welfare states – health reform!
- Population growth & ageing
- Higher level of chronic diseases and disability
- Increased availability of technology
- Rising expectation of the public
All lead to increasing healthcare costs – unable to cope with the cost of care
Solution: health reform! Innovation!
Health systems around the globe evolve within their own situations and technologies.
Consequently, different health systems emerge
State responsibility for health
• Countries responded differently
o Political, social, economic and technologic context
o Historical developments, national & global
o Scope of the responsibility
o Different actors, structures and processes
• Notable examples from health finance
o Germany, Bismarck – social health insurance with income based contribution
from wages (progressive – earning more is paying more)
o UK, Beveridge – tax based financing, equitable access, national health system
(NHS) (as a result, health care will be free for the citizens, when they need it)
▪ Sweden as well
Currently, none of the countries around the globe have the same health systems. We want to
gain insights into the different components of these systems and compare them.
1. If you want to measure health system performance, one has to define the health system
and what it does. Also, to benchmark.
a. Input → process → outputs (e.g. amount of operations performed) → outcomes
(health gain, effectiveness, efficiency)
2. define concepts, draw borders and assign responsibilities. There are several frameworks
for different purposes. An example is the framework from Murray & Frenk (2000)!
Mid 20th century – there was a focus on the biomedical paradigm of health (focus on the disease,
rather than health). However, within this paradigm one focuses on the fact that, when one is
free of disease, one is healthy. But this is not always the case!
, • Early 80s – WHO strategy: “Health for all” – the attainment by all people of the highest
possible level of health
o Not the absence of disease; health is a state of complete physicial, mental and
social well-being and not merely the absence of disease or infirmity
o ‘for all’ – equity !
o ‘for all’ – responsibility of all sectors, not only the health sector
Education is the most important factor that influences health! Even more than income
Ottawa Charter for Health promotion:
- Health is not merely a product of health services
- Recognition of prerequisites (peace, shelter, basic food) for health and the role of non-
health sectors on health (education, transportation – it has not the main goal to make
people healthier, but it is an important outcome). So all the other sectors beside the
health sector is important for ones health / public health
o Socio-economic determinants of health
Public health - “the science and art of preventing disease, prolonging life and promoting health
through the organised efforts of society”
• Public’s health (health of the public)
• Public health services
o Public vs private insurance
o Public vs private hospital
• Public health services
o Population based health services
Health system – “all organisations, people and actions whose primary intent is to promote,
restore or maintain health”. Everything we do to make people healthier.
• Primary intent criteria – boundaries of the health system. Personal medical, non-
personal health services & intersectoral action (when the health system takes the lead,
but does not do everything. Collaboration with other sectors, such as the tobacco tax –
the minister of Health asks the minister of finance to execute this tax. Second, the
minister of health is the one who inspects the quality of water, but the maintenance of
the water quality is the responsibility of the local authorities)
If you are using public health as the whole public’s health, then the health system falls
underneath it.
Public health – WHO – health for all! Everything that relates to a society’s health is a part of
public health! Therefore, health systems can be seen as a part/component of public health.
Health system pyramid.
• Objectives of health systems
o Health gain – are we living longer and healthier lives?
o Equity
o Responsiveness
o Effectiveness and efficiency
• Functions of health systems
,Equity vs equality – picture with the box. The need of the smaller person is different than the
need of the bigger person when it comes to the boxes. Therefore, the smaller person gets three
boxes and the bigger one just one. The same when you say that you give everybody five GP
visits a year (equality), but it can be that people have different needs. One person for example
needs one visit a month due to diabetes, and the other does not need any GP visits at all (equity).
Responsiveness – enhancing the responsiveness of the health system to the legitimate
expectations of the population. How are they feeling with the health gain, and how are they
feeling with the outcome? Is the population happy with the healthcare services? Are their
expectations met? It could be that some of the expectations are not able to meet.
Effectiveness vs efficiency – outcome vs process. For example with vaccines. They are not
efficient within all the parts of the world. The effectiveness of a vaccine can be decreased in
countries like Africa, as it is hard to keep the vaccines cooled during the trip to the people in
need. Effectiveness is about reaching the target/goal (in this case the health outcomes), whereas
efficiency is about the resources you are using (time, money, manpower etc). if you want to be
effective, you allocate your resources to reach maximum outcome (doing the right thing). If
you want to be efficient, you allocate them in the most convenient way (doing it the right way).
Indicators:
- Health gain
o QALY/DALY (combination of mortality and morbidity)
o life expectancy at birth
- Equity
o World map of money/disease (90/10 ratio – global level).
o Uninsured adults
o Life expectancy at birth by race and sex in the USA
- Responsiveness
o health rate (individual)
o patient satisfaction
o satisfaction of the health workforce
- Effectiveness and efficiency
o Cost-effectiveness analysis & cost-benefit analysis & ICER.
o The amount of health you are gaining by the amount of expenditure
o Comparison among countries. How good are you in caring for your diabetes
patients?
Equitable health finance:
- Rich funds the poor
- Young funds the old
- Healthy funds the sick
➔ But what about the ones who smoke, don’t bother to cook healthy? This is the other side
of the coin. But there are a lot of external factors of influence
, Functions of the health system:
• Stewardship – defining the strategic directions for the health system (minister of
health). Sets the rules, implements them and monitors them. Sub-functions are priority
setting, legislation and regulation, steering (steering the boat where it is going towards,
whilst the others are rowing the boat) and administration and management
o Priority setting – closely linked to policy making. Finite resources are
insufficient to meet all the needs in health. In order to determine your priorities,
you first need to decide your priorities
o Legislation and regulation
o Steering – steering the boat, not rowing!
o Administration and management
➔ How can the minister of Health (MoH) fulfil these functions? In the Netherlands, the
minister of Health has quite a distant position. They are not actually steering the boat
anymore, but they are watching the boats from the shore. Are all the boats doing what
they have to do, and are they going in the right direction
• Financing
o Revenue collection
o Fund pooling
o Purchasing
• Resource generation
o Human resources – education, licensing
o Physical resources – buildings, equipment, technology
o Knowledge
o Providers
• Provision
o Personal
o Non-personal
Health services – specialized care, primary care service (personal and primary care),
population based disease prevention, population based health promotion, population based
health protection
- Travel health interventions – personal disease prevention (malaria tablets you get based
on the area you travel to. People at risk)
Health providers – formal/informal, western/traditional, public/private/NGO, special
hospitals.
- higher income countries with strong health systems tend to have more structured and
less diverse service providers
Pre-modern states – epidemics and hospitals ran as religious charity (state: quarantine)
Modern states – French revolution & industrial revolution
- Emergence of welfare states (responsibility of the state for population health measures
and healthcare services)
- Scientific development (sanitation, hygiene, vaccination, antibiotics)
- Focus on ‘healthcare’ rather than ‘the health of people’
Crumbling welfare states – health reform!
- Population growth & ageing
- Higher level of chronic diseases and disability
- Increased availability of technology
- Rising expectation of the public
All lead to increasing healthcare costs – unable to cope with the cost of care
Solution: health reform! Innovation!
Health systems around the globe evolve within their own situations and technologies.
Consequently, different health systems emerge
State responsibility for health
• Countries responded differently
o Political, social, economic and technologic context
o Historical developments, national & global
o Scope of the responsibility
o Different actors, structures and processes
• Notable examples from health finance
o Germany, Bismarck – social health insurance with income based contribution
from wages (progressive – earning more is paying more)
o UK, Beveridge – tax based financing, equitable access, national health system
(NHS) (as a result, health care will be free for the citizens, when they need it)
▪ Sweden as well
Currently, none of the countries around the globe have the same health systems. We want to
gain insights into the different components of these systems and compare them.
1. If you want to measure health system performance, one has to define the health system
and what it does. Also, to benchmark.
a. Input → process → outputs (e.g. amount of operations performed) → outcomes
(health gain, effectiveness, efficiency)
2. define concepts, draw borders and assign responsibilities. There are several frameworks
for different purposes. An example is the framework from Murray & Frenk (2000)!
Mid 20th century – there was a focus on the biomedical paradigm of health (focus on the disease,
rather than health). However, within this paradigm one focuses on the fact that, when one is
free of disease, one is healthy. But this is not always the case!
, • Early 80s – WHO strategy: “Health for all” – the attainment by all people of the highest
possible level of health
o Not the absence of disease; health is a state of complete physicial, mental and
social well-being and not merely the absence of disease or infirmity
o ‘for all’ – equity !
o ‘for all’ – responsibility of all sectors, not only the health sector
Education is the most important factor that influences health! Even more than income
Ottawa Charter for Health promotion:
- Health is not merely a product of health services
- Recognition of prerequisites (peace, shelter, basic food) for health and the role of non-
health sectors on health (education, transportation – it has not the main goal to make
people healthier, but it is an important outcome). So all the other sectors beside the
health sector is important for ones health / public health
o Socio-economic determinants of health
Public health - “the science and art of preventing disease, prolonging life and promoting health
through the organised efforts of society”
• Public’s health (health of the public)
• Public health services
o Public vs private insurance
o Public vs private hospital
• Public health services
o Population based health services
Health system – “all organisations, people and actions whose primary intent is to promote,
restore or maintain health”. Everything we do to make people healthier.
• Primary intent criteria – boundaries of the health system. Personal medical, non-
personal health services & intersectoral action (when the health system takes the lead,
but does not do everything. Collaboration with other sectors, such as the tobacco tax –
the minister of Health asks the minister of finance to execute this tax. Second, the
minister of health is the one who inspects the quality of water, but the maintenance of
the water quality is the responsibility of the local authorities)
If you are using public health as the whole public’s health, then the health system falls
underneath it.
Public health – WHO – health for all! Everything that relates to a society’s health is a part of
public health! Therefore, health systems can be seen as a part/component of public health.
Health system pyramid.
• Objectives of health systems
o Health gain – are we living longer and healthier lives?
o Equity
o Responsiveness
o Effectiveness and efficiency
• Functions of health systems
,Equity vs equality – picture with the box. The need of the smaller person is different than the
need of the bigger person when it comes to the boxes. Therefore, the smaller person gets three
boxes and the bigger one just one. The same when you say that you give everybody five GP
visits a year (equality), but it can be that people have different needs. One person for example
needs one visit a month due to diabetes, and the other does not need any GP visits at all (equity).
Responsiveness – enhancing the responsiveness of the health system to the legitimate
expectations of the population. How are they feeling with the health gain, and how are they
feeling with the outcome? Is the population happy with the healthcare services? Are their
expectations met? It could be that some of the expectations are not able to meet.
Effectiveness vs efficiency – outcome vs process. For example with vaccines. They are not
efficient within all the parts of the world. The effectiveness of a vaccine can be decreased in
countries like Africa, as it is hard to keep the vaccines cooled during the trip to the people in
need. Effectiveness is about reaching the target/goal (in this case the health outcomes), whereas
efficiency is about the resources you are using (time, money, manpower etc). if you want to be
effective, you allocate your resources to reach maximum outcome (doing the right thing). If
you want to be efficient, you allocate them in the most convenient way (doing it the right way).
Indicators:
- Health gain
o QALY/DALY (combination of mortality and morbidity)
o life expectancy at birth
- Equity
o World map of money/disease (90/10 ratio – global level).
o Uninsured adults
o Life expectancy at birth by race and sex in the USA
- Responsiveness
o health rate (individual)
o patient satisfaction
o satisfaction of the health workforce
- Effectiveness and efficiency
o Cost-effectiveness analysis & cost-benefit analysis & ICER.
o The amount of health you are gaining by the amount of expenditure
o Comparison among countries. How good are you in caring for your diabetes
patients?
Equitable health finance:
- Rich funds the poor
- Young funds the old
- Healthy funds the sick
➔ But what about the ones who smoke, don’t bother to cook healthy? This is the other side
of the coin. But there are a lot of external factors of influence
, Functions of the health system:
• Stewardship – defining the strategic directions for the health system (minister of
health). Sets the rules, implements them and monitors them. Sub-functions are priority
setting, legislation and regulation, steering (steering the boat where it is going towards,
whilst the others are rowing the boat) and administration and management
o Priority setting – closely linked to policy making. Finite resources are
insufficient to meet all the needs in health. In order to determine your priorities,
you first need to decide your priorities
o Legislation and regulation
o Steering – steering the boat, not rowing!
o Administration and management
➔ How can the minister of Health (MoH) fulfil these functions? In the Netherlands, the
minister of Health has quite a distant position. They are not actually steering the boat
anymore, but they are watching the boats from the shore. Are all the boats doing what
they have to do, and are they going in the right direction
• Financing
o Revenue collection
o Fund pooling
o Purchasing
• Resource generation
o Human resources – education, licensing
o Physical resources – buildings, equipment, technology
o Knowledge
o Providers
• Provision
o Personal
o Non-personal
Health services – specialized care, primary care service (personal and primary care),
population based disease prevention, population based health promotion, population based
health protection
- Travel health interventions – personal disease prevention (malaria tablets you get based
on the area you travel to. People at risk)
Health providers – formal/informal, western/traditional, public/private/NGO, special
hospitals.
- higher income countries with strong health systems tend to have more structured and
less diverse service providers
