Health Systems Chapter 5

Key Ideas ○ Health systems focus on ways to improve population

health by preventing disease ○ Health care delivery systems focus on medical

services and curative care ○ In high-income countries, health care systems focus

mostly on chronic disease while in low-and middle-income countries they focus on selective primary care

○ As development increases the distribution of health care becomes more important than money spent on health care

Defining Health Systems ○ Health system: collections of organizations,

people, and policies that work to improve population health ○ Inclusion is broadening to nonmedical

determinants of health, like built environment and education systems

○ Health care delivery system: focuses on curative services delivered by clinicians ○ Primary, secondary, tertiary care

Levels of Prevention ○ Primary: preventing disease before it appears

○ Taxation, vaccination, education ○ Secondary: detecting disease early in its course

○ Screening tests ○ Tertiary: providing clinical care to prevent the

spread of disease or added health effects ○ Medical treatment, management programs

Health Care System Features ○ Universality: coverage for everyone in a

population ○ Accessibility: the degree to which people can

receive needed health care services ○ Variation by income, race/ethnicity, geography

○ Comprehensiveness: reasonable costs ○ Portability: ability to move within system ○ Transparency and accountability

Health Care Payments ○ Wide variation across nations ○ Capitated: lump sum for each covered patient

○ Tends to decrease services provided ○ Fixed salary for clinicians ○ Fee-for service: provider bills for specific services

(tests, visits) provided ○ Tends to increase services provided

○ Free market

Health Care Markets ○ Central problem with market-based health care

delivery systems: health care is not a perfect market ○ Difficult to comparison shop ○ Difficult to identify good services ○ Information asymmetry

○ Without downward pressure on prices, prices will rise for a given level of quality ○ Governments generally do better than private

companies at controlling costs in inefficient markets

Health Care Delivery: US vs. Other High Income Countries ○ US is only industrialized nation without universal

health insurance ○ Problems tend to be identified later than in systems

with high primary care coverage ○ More administrative costs for billing

○ US citizens have access to most innovative technology and treatment but no better outcomes and at higher cost than other countries ○ Spends twice as much on health care as next country ○ Ranked 38 in life expectancy

Example: Canadian Health System ○ Funding from federal and provincial governments

○ Payroll, sales, and corporate taxes; premiums; lottery ○ Care delivered by private clinicians who negotiate

payments ○ Coverage throughout Canada for all citizens

○ Some limitations on dental, vision care ○ No private insurance option ○ Little change in health expenditures since 1980s

Health Care Delivery: Middle & Low Income Countries ○ In 1980s UNICEF shifted focus from

disease-specific care to selective primary health care ○ Female education, feeding programs, family

planning ○ Many countries could not fund programs

○ Private FFS systems are most common ○ Can create disparities for the poor within countries

○ Smoking, poor nutrition, inactivity are major issues in middle income countries

Global Health Expenditures