Summary
HPI4009 Health Systems Governance
Page 1 of 63
,Contents
Case 1 Health systems analysis..............................................................................................................3
Case 2: Governance in healthcare policymaking: actors and institutions............................................12
Case 3: Health policymaking - a matter of evidence or power struggle?.............................................30
Case 4: Perspective on defining health - out with the old, in with the new.........................................39
Case 5: Solidarity.................................................................................................................................50
Page 2 of 63
,Case 1 Health systems analysis
Summary case information
Analytical model based on framework developed by WHO structured as input-output model.
Health systems function in a broader environment:
- Task environment: refers to the health problems that should be targeted by a health system
- Context environment: signifies other external factors which have an influence on that
system
Healthcare demands existing in the task environment = the inputs ⃗
conversion outputs
Outputs:
- Intermediate: accomplishment of certain intermediate objectives that are instrumental to
realizing the end goals of the health system
- Final nature: health system goals
Feedback loop: outputs can flow back into the health system as new inputs.
Literature
1. Dúran A, Kutzin J, Martin-Moreno JM, Travis P. Understanding health systems: scope,
functions and objectives. In: Figueras J, McKee M. Health systems, health, wealth and
societal well-being. Assessing the case for investing in health systems. Berkshire: Open
University Press; 2012: 19-37.
2. Murray CJL, Frenk J. A framework for assessing the performance of health systems. Bulletin
of the World Health Organization, 2000;78(6):717-731.
Learning goals
Health system governance:
- Systematic, patterned way in which decisions are made and implemented
- The way that policymakers try to manage, coordinate or control the activities of healthcare
actors
- The specific mode of production of norms (decision, rules, policies) that can be called co-
production where co-producers are different kinds of actors (private and public).
How things are done
How can a health system- and its boundaries- be defined, and what are the strengths and
limitations of the different definitions?
Health definitions put forward by analysts and organizations vary enormously. At one end of the
spectrum there are narrow definitions that focus medical care, with patients, clear exit and entry
points and services regarding disease, disability, and death. At the other end are broad approaches
that encompass all those determinants that contribute directly or indirectly to health.
Narrow definitions focus on medical care fail to acknowledge other determinants that directly or
indirectly influence health system.
Page 3 of 63
, Duplessis et al, 1989: organizations providing health services (hospital, health care centres,
professional officers, and public health services) and also other networks, sectors, institutions,
ministries and organisations which have a definite influence on the ultimate objective of the system -
health. Important in this respect or education, transportation, social services, housing, the food
industry, etc.
- The all-encompassing definition is problematic (particularly from a policy or management
perspective) because a social system (which includes health systems) is more usually
understood as an arrangement of parts and the interconnections that come together for a
purpose. If we consider that a system includes all factors that have an influence on a given
outcome, then, on the one hand, there are no meaningful boundaries and no clarity on
managerial rules or on responsibilities and accountability.
- On the other hand, the very narrow healthcare definition is unduly limiting, considering
health promotion as outside the boundaries of the health system, for example, we generate
unnecessary fragmentation and may even question the duty of doctors, nurses and health
ministries to incorporate health promotion into their work.
Unsatisfaction with earlier definitions led to WHO definition.
WHO: A health system consists of all organizations, people and institutions producing actions whose
primary intent is to promote, restore or maintain health. This definition is now used by other
organizations, such as the World Bank (2006) and the EU (European Commission 2007).
- Underpinned the Health Systems Assessment Framework (HSAF) designed to enable
review of the performance of health systems against three major societal goals.
Performance= attainment of these goals relative to the resources invested in them
o Fourth goal: efficiency or productivity
Definition therefore includes:
- 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 personal services can include interventions that
are not only curatives but also preventive and promotional.
Page 4 of 63
HPI4009 Health Systems Governance
Page 1 of 63
,Contents
Case 1 Health systems analysis..............................................................................................................3
Case 2: Governance in healthcare policymaking: actors and institutions............................................12
Case 3: Health policymaking - a matter of evidence or power struggle?.............................................30
Case 4: Perspective on defining health - out with the old, in with the new.........................................39
Case 5: Solidarity.................................................................................................................................50
Page 2 of 63
,Case 1 Health systems analysis
Summary case information
Analytical model based on framework developed by WHO structured as input-output model.
Health systems function in a broader environment:
- Task environment: refers to the health problems that should be targeted by a health system
- Context environment: signifies other external factors which have an influence on that
system
Healthcare demands existing in the task environment = the inputs ⃗
conversion outputs
Outputs:
- Intermediate: accomplishment of certain intermediate objectives that are instrumental to
realizing the end goals of the health system
- Final nature: health system goals
Feedback loop: outputs can flow back into the health system as new inputs.
Literature
1. Dúran A, Kutzin J, Martin-Moreno JM, Travis P. Understanding health systems: scope,
functions and objectives. In: Figueras J, McKee M. Health systems, health, wealth and
societal well-being. Assessing the case for investing in health systems. Berkshire: Open
University Press; 2012: 19-37.
2. Murray CJL, Frenk J. A framework for assessing the performance of health systems. Bulletin
of the World Health Organization, 2000;78(6):717-731.
Learning goals
Health system governance:
- Systematic, patterned way in which decisions are made and implemented
- The way that policymakers try to manage, coordinate or control the activities of healthcare
actors
- The specific mode of production of norms (decision, rules, policies) that can be called co-
production where co-producers are different kinds of actors (private and public).
How things are done
How can a health system- and its boundaries- be defined, and what are the strengths and
limitations of the different definitions?
Health definitions put forward by analysts and organizations vary enormously. At one end of the
spectrum there are narrow definitions that focus medical care, with patients, clear exit and entry
points and services regarding disease, disability, and death. At the other end are broad approaches
that encompass all those determinants that contribute directly or indirectly to health.
Narrow definitions focus on medical care fail to acknowledge other determinants that directly or
indirectly influence health system.
Page 3 of 63
, Duplessis et al, 1989: organizations providing health services (hospital, health care centres,
professional officers, and public health services) and also other networks, sectors, institutions,
ministries and organisations which have a definite influence on the ultimate objective of the system -
health. Important in this respect or education, transportation, social services, housing, the food
industry, etc.
- The all-encompassing definition is problematic (particularly from a policy or management
perspective) because a social system (which includes health systems) is more usually
understood as an arrangement of parts and the interconnections that come together for a
purpose. If we consider that a system includes all factors that have an influence on a given
outcome, then, on the one hand, there are no meaningful boundaries and no clarity on
managerial rules or on responsibilities and accountability.
- On the other hand, the very narrow healthcare definition is unduly limiting, considering
health promotion as outside the boundaries of the health system, for example, we generate
unnecessary fragmentation and may even question the duty of doctors, nurses and health
ministries to incorporate health promotion into their work.
Unsatisfaction with earlier definitions led to WHO definition.
WHO: A health system consists of all organizations, people and institutions producing actions whose
primary intent is to promote, restore or maintain health. This definition is now used by other
organizations, such as the World Bank (2006) and the EU (European Commission 2007).
- Underpinned the Health Systems Assessment Framework (HSAF) designed to enable
review of the performance of health systems against three major societal goals.
Performance= attainment of these goals relative to the resources invested in them
o Fourth goal: efficiency or productivity
Definition therefore includes:
- 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 personal services can include interventions that
are not only curatives but also preventive and promotional.
Page 4 of 63
