Health system governance (HPI 4009)
Tutorial group 1 31-10-2019
Case 1: Health system analysis
Articles and books
It shows, that health systems function in a broader
environment, which consists of: the task
environment and the context. Where the term task
environment refers to the health problems that
should be targeted by a health system, context
signifies other external factors which have an
influence on that system. The Broader context
includes all the cultural, politic, technological,
economy external factors that influence the HS.
Context demographics: there are a lot of older
people. The output forms the context for the task
environment. Example: not enough medicine.
Context examples:
- Economic: GDP influences
- Cultural/politics: USA vs. Europe; EU:
solidarity (cultural; norms and values),
USA: private/do it yourself.
- Political: choices made by politicians.
- Internationalization: globalization: medicine from Japan for example come to NL, Ebola
crisis.
Task environment has an indirect influence; all the different health problems people have and
which should be targeted by a HS.
The intermediate outputs referring to the accomplishment of certain intermediate objectives
that are instrumental to realizing the end goals of the health system. The analytic model also includes a
feedback loop to indicate that outputs can flow back into the health system as new inputs. This may
happen when for example a process is evaluated and needs improvements. In this way an outcome
becomes an input and will follow the route from input to output again.
Conversion: from input to output.
The real purpose of this framework: to provide a means to organize thinking in a comprehensive,
coherent manner that provides a basis for action. Comparison + improve healthcare system.
Duran: Understanding health systems: scope, functions and objectives (2012)
Eventual WHO definition of health system: a health system consists of all organizations, people and
institutions producing actions whose primary intent is to promote, restore or maintain health’. It also
includes: Health services (personal and population based) and the activities to enable their delivery
provided by finance, resource generation and stewardship functions. Stewardship, which includes
activities seeking to influence the positive health impact of other sectors – even though the primary
purpose of those sectors is not to improve health. Example stewardship: BOB campaign.
Personal services are those that are delivered to individuals on a one-to-one basis such as a
surgical operation, a general practice consultation, individual counselling, immunizing a child
or supporting a mother in feeding a child.
Population-based services are those delivered to a group or an entire population; these include
immunization campaigns, warning labels on cigarette packs and workplace health promotion.
This categorization of services depends on the mode of delivery, it is driven by organizational and
managerial concerns. Personal services can include interventions that are curative, preventive and
1
, promotional (delivered to individual but also benefits others e.g. treatment of infectious disease).
Population- based services are preventive and promotional but exclude individual treatment.
Health is influenced by actions of sectors whose primary purpose is other than to produce health
(housing, labour or fiscal policies). Health actions: efforts that influences health determinants that lie
outside the health system. Their primary aim: to promote, preserve or protect health.
Broad definition: Duplessis et al. defined a health system as: “organizations providing health services
(hospital, health care centres, professional officers, and public health services) and also other
networks, sectors, institutions, ministries and organizations which have a definite influence on the
ultimate objective of the system – health. Important in this respect are education, transportation, social
services, housing, the food industry, etc.”
Boundaries:
- No clear view of parts and their interconnections that come together for a purpose.
- If all factors that influence outcomes are included, there are no boundaries and no clarity on
the roles or responsibilities and accountability.
- On the other hand, the very narrow health care definition is unduly limiting, considering
health promotion as outside the boundaries of the health system, for example, would generate
unnecessary fragmentation and may even question the duty of doctors, nurses and health
ministries to incorporate health promotion into their work.
Narrow definition:
Not all factors are included in the healthcare system. For example healthcare promotion: government:
does it excluded.
Not every countries has the same health system, primary intent can differ. Healthcare team (public
health institutions) included, if the government is in charge of it excluded.
Goals and functions of health systems
What should health systems try to achieve?
Main goal: to improve health status of population
The fundamental goals need to be generic (to be applicable to all countries) but specific (all countries
can operationalize to their own circumstances).
Intrinsic and instrumental goals
Health system goals are divided in:
1. Intrinsic goals: goals valued for themselves. Criteria:
a. It is possible to raise the level of attainment of the goal, while holding the level of all
other intrinsic goals constant.
b. Raising the level of attainment of an intrinsic goals is desirable (if not instrumental
goal).
2. Instrumental goals: goals valued for the end result.
a. Effective coverage: the probability that individuals will obtain a health care
intervention if they need it and they will derive benefit from it. The goals improved
health and equity in health can be derived from the concept of effective coverage.
Rich countries have mostly a high effective coverage.
b. Technical efficiency: making the best use of available resources. The means are
specific to a country. How much you have and how much you gain. Healthcare
performance.
Examples:
- Access to care
- Community involvement
- Innovation
2
Tutorial group 1 31-10-2019
Case 1: Health system analysis
Articles and books
It shows, that health systems function in a broader
environment, which consists of: the task
environment and the context. Where the term task
environment refers to the health problems that
should be targeted by a health system, context
signifies other external factors which have an
influence on that system. The Broader context
includes all the cultural, politic, technological,
economy external factors that influence the HS.
Context demographics: there are a lot of older
people. The output forms the context for the task
environment. Example: not enough medicine.
Context examples:
- Economic: GDP influences
- Cultural/politics: USA vs. Europe; EU:
solidarity (cultural; norms and values),
USA: private/do it yourself.
- Political: choices made by politicians.
- Internationalization: globalization: medicine from Japan for example come to NL, Ebola
crisis.
Task environment has an indirect influence; all the different health problems people have and
which should be targeted by a HS.
The intermediate outputs referring to the accomplishment of certain intermediate objectives
that are instrumental to realizing the end goals of the health system. The analytic model also includes a
feedback loop to indicate that outputs can flow back into the health system as new inputs. This may
happen when for example a process is evaluated and needs improvements. In this way an outcome
becomes an input and will follow the route from input to output again.
Conversion: from input to output.
The real purpose of this framework: to provide a means to organize thinking in a comprehensive,
coherent manner that provides a basis for action. Comparison + improve healthcare system.
Duran: Understanding health systems: scope, functions and objectives (2012)
Eventual WHO definition of health system: a health system consists of all organizations, people and
institutions producing actions whose primary intent is to promote, restore or maintain health’. It also
includes: Health services (personal and population based) and the activities to enable their delivery
provided by finance, resource generation and stewardship functions. Stewardship, which includes
activities seeking to influence the positive health impact of other sectors – even though the primary
purpose of those sectors is not to improve health. Example stewardship: BOB campaign.
Personal services are those that are delivered to individuals on a one-to-one basis such as a
surgical operation, a general practice consultation, individual counselling, immunizing a child
or supporting a mother in feeding a child.
Population-based services are those delivered to a group or an entire population; these include
immunization campaigns, warning labels on cigarette packs and workplace health promotion.
This categorization of services depends on the mode of delivery, it is driven by organizational and
managerial concerns. Personal services can include interventions that are curative, preventive and
1
, promotional (delivered to individual but also benefits others e.g. treatment of infectious disease).
Population- based services are preventive and promotional but exclude individual treatment.
Health is influenced by actions of sectors whose primary purpose is other than to produce health
(housing, labour or fiscal policies). Health actions: efforts that influences health determinants that lie
outside the health system. Their primary aim: to promote, preserve or protect health.
Broad definition: Duplessis et al. defined a health system as: “organizations providing health services
(hospital, health care centres, professional officers, and public health services) and also other
networks, sectors, institutions, ministries and organizations which have a definite influence on the
ultimate objective of the system – health. Important in this respect are education, transportation, social
services, housing, the food industry, etc.”
Boundaries:
- No clear view of parts and their interconnections that come together for a purpose.
- If all factors that influence outcomes are included, there are no boundaries and no clarity on
the roles or responsibilities and accountability.
- On the other hand, the very narrow health care definition is unduly limiting, considering
health promotion as outside the boundaries of the health system, for example, would generate
unnecessary fragmentation and may even question the duty of doctors, nurses and health
ministries to incorporate health promotion into their work.
Narrow definition:
Not all factors are included in the healthcare system. For example healthcare promotion: government:
does it excluded.
Not every countries has the same health system, primary intent can differ. Healthcare team (public
health institutions) included, if the government is in charge of it excluded.
Goals and functions of health systems
What should health systems try to achieve?
Main goal: to improve health status of population
The fundamental goals need to be generic (to be applicable to all countries) but specific (all countries
can operationalize to their own circumstances).
Intrinsic and instrumental goals
Health system goals are divided in:
1. Intrinsic goals: goals valued for themselves. Criteria:
a. It is possible to raise the level of attainment of the goal, while holding the level of all
other intrinsic goals constant.
b. Raising the level of attainment of an intrinsic goals is desirable (if not instrumental
goal).
2. Instrumental goals: goals valued for the end result.
a. Effective coverage: the probability that individuals will obtain a health care
intervention if they need it and they will derive benefit from it. The goals improved
health and equity in health can be derived from the concept of effective coverage.
Rich countries have mostly a high effective coverage.
b. Technical efficiency: making the best use of available resources. The means are
specific to a country. How much you have and how much you gain. Healthcare
performance.
Examples:
- Access to care
- Community involvement
- Innovation
2
