Write-Up on Healthcare System

8/3/2019 Write-Up on Healthcare System

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COUNTRY PROFILE:

Healthcare System



Table of Contents

1. Healthcare System: An Overview ..................................................................................................... 4

2. Healthcare System by country .......................................................................................................... 4

2.1 Indonesia ................................................................................................................................... 4

2.1.1 Structure of the Health System: ............................................................................................... 4

2.1.2 Health policies and strategies .................................................................................................. 6

2.1.3 Health Information System ...................................................................................................... 7

2.1.3.1 National Health Information Systems (NHIS) ..................................................................... 7

Vision and Mission of NHIS ....................................................................................................... 7

Strength and opportunity ......................................................................................................... 7

Constraints and challenge......................................................................................................... 82.1.3.2 District/City Health Information Systems ..................................................... ..................... 9

2.1.4 Emergency preparedness ......................................................................... ............................... 9

2.2 India ....................................................................................................................................... 10

2.2.1 Health policies and strategies ......................................................................................... 10

2.2.2 Inter-sectoral cooperation .............................................................................................. 11

2.2.3 Organization of the health system .................................................................................. 11

2.2.3.1 National level .............................................................................................................. 11

2.2.3.2 State Level .................................................................................. ................................ 11

2.2.3.3 Regional Level ............................ ................................................................................. 12

2.2.3.4 District level ................................................................................................................ 12

2.2.3.5 Sub-divisional/Taluka level .......................................................................................... 12

2.2.3.6 Community level ......................................................................................................... 12

2.2.3.7 PHC level..................................................................................................................... 13

2.2.3.8 Sub-centre level .......................................................................................................... 13

2.2.4 Health information system .................................................................................................... 13

Census ....................................................................................................................................... 13

Civil Registration System ............................................................................ ................................ 13

Sample Registration System ........................................................................... ............................ 13

National Sample Surveys ........................... ................................................................................. 14

Service statistics ................................ ......................................................................................... 14



2.2.5 Community action .......................................................................................................... 14

2.2.6 Health research and technology...................................................................................... 15

2.3 Thailand ................................................................................................................................. 15

2.3.1 Health policies and strategies ......................................................................................... 15

2.3.2 Inter-sectoral cooperation .............................................................................................. 16

2.3.3 Organization of the health system .................................................................................. 16

2.3.4 Managerial process ......................................................................................................... 18

Compliance of goals and strategy of the superior administrative units ....................................... 18

The compatibility with the regional problems and the capacity of the responsible administrative

units ........................................................................................................................................... 18

The best utilization of the existing resources ....................................................... ....................... 18

2.3.5 Health information system ............................................................................................. 19

Communitybased surveys......................................................................................................... 19

Institutionbased reports ........................................................................................................... 19

2.3.6 Community action .......................................................................................................... 20

2.3.7 Emergency preparedness ................................................................................................ 22

2.3.8 Health research and technology...................................................................................... 23

2.4 Vietnam .............................................................................................................................. 23

2.4.1 Organization of Healthcare System ................................................................................. 24

2.4.2 Development of Health Systems ..................................................................................... 25

2.4.3 Health systems financing ................................................................................................ 26

2.4.4 Health information system ............................................................................................. 26

2.5 China ...................................................................................................................................... 26

2.5.1 Development of Healthcare System .................................................................................... 27

2.6 UAE ........................................................................................................................................ 28

2.6.1 Development of healthcare system................................................................................. 28

2.6.1 Organization of Health System ........................................................................................ 29

2.6.2 Partnerships ................................................................................... ................................ 29

2.6.3 Financing ...................................................................................... .................................. 29

2.6.4 Healthcare Services and Ministrys Responsibilities ......................................................... 29

List of Figures



Figure 1: Structure of Healthcare Systems in Indonesia ............................................................................ 5

List of Tables

Table 1: Link Between Political and Health Structure ............................................................................... 9

1. Healthcare System: An Overview

Health care systems are designed to meet the health care needs of target populations. There are a wide

variety of health care systems around the world. In some countries, the health care system planning is

distributed among market participants, whereas in others planning is made more centrally among

governments, trade unions, charities, religious, or other co-ordinated bodies to deliver planned health

care services targeted to the populations they serve.

2. Healthcare System by country

2.1 Indonesia

2.1.1 Structure of the Health System:

There are 33 provinces and each province is sub-divided into districts and each district into sub-districts.

As decentralization had been already implemented, the 349 regencies and 91 municipalities are now the

key of administrative units.

Each sub-district in Indonesia has at least one health centre headed by a doctor, usually supported by

two or three sub-centres, the majority of which are headed by nurses. Health centres mainly provide

eight programs. Most of the health centres are equipped with four-wheel drive vehicles or motorboats



to serve as mobile health centres and provide services to underserved populations in urban and remote

rural areas.

At the village level, the integrated Family Health Post provides preventive and promotive services. These

health posts are established and managed by the community with the assistance of health canter staff.

To improve maternal and child health, midwives are being deployed to the villages.

The Decentralization Policy has been implemented in Indonesia, with the implementation of Act No.

22/1999 regarding Regional Governance and Act No. 25/1999 regarding the financial equality between

Central and Regional government. With the implementation of the aforementioned Acts, the

government system in Indonesia has been changed from Centralized to Decentralized type of

government, which provides regional autonomy. In the Act No. 22/1999, there have been three levels

of regional autonomy, i.e., Province, District, and City regional autonomy.

Figure 1: Structure of Healthcare Systems in Indonesia

In line with Province government responsibility, Broader Decentralization has been given to District and

City levels. Regional government has also been given the authority of support = perbantuan or

medebewind. This has an implication that regional development has to be performed by District/City,

while the development at Province level is limited only to those, which have not been covered by

District/City, and Inter-district/Inter-city. Meanwhile, the Central government has to perform the role of

policy formulation, standards and providing guidance to Province and District/City government levels.



Government Act on Health No. 23/1992 has stated that Health Systems should be implemented by the

community with government as facilitator. Private sectors will perform an active role, so that

government will act in the provision of guidance and supervision.

2.1.2

Health policies and strategies

The creation of Healthy Indonesia 2010 forces the Ministry of Health and Social Welfare to forge

collaborative relationships with others. As health is a shared responsibility, the Ministry of Health and

Social Welfare must involve all strata of the community, all related government departments and

agencies, and the private sector. In the effort to achieve Healthy Indonesia 2010,the Ministry of

Health and Social Welfare must also be proactive and forward-thinking.

The Healthy Indonesia 2010 goals are:

y To initiate and lead a health orientation of the national development

y To maintain and enhance individual, family, and public health along with improving the

environment

y To maintain and enhance quality, accessible, and affordable health services

y To promote public self-reliance in achieving government health

While the Ministry of Health and Social Welfare was redefining the new Vision and Mission, two new

fundamental Acts were enacted, namely Act No. 22/1999 on Local Governance and Act No. 25/1999 on

Financial Balance Between Central Government and Local Governments. The two Acts are a reference

for the implementation of decentralization policy in Indonesia, which give provinces and districts a large

autonomy to manage their own home affairs except defense, monetary and fiscal, foreign affairs, justice, and religion.

Based on the new Vision and Mission of National Health Development and in line with the

decentralization policy, it is agreed that there are four paramount issues to serve as the pillars in

formulating a Strategy for National Health Development. These are:

Initiating health-oriented national development

Professionalism

Community Managed Healthcare Programme (JPKM)

Decentralization

The identification of these four elements as pillars of the Strategy for National Health Development does

not mean that other programmes should not be supported. All programmes and plans of potential

assistance to the Ministry of Health and Social Welfare in achieving the new Vision and Mission should

be continued, even though these four pillars have the highest priority.



2.1.3 Health Information System

2.1.3.1 National Health Information Systems (NHIS)

National health information systems reforms has been indicated by the development of a new NHIS

policy and strategy included in the Ministry of Health decree No. 468/MENKES-KESOS/SK/V/2001, dated25 May 2001, which has been amended by decree No. 511/MENKES/SK/V/2002, dated 24 May 2002.

Although the NHIS Policy and Strategy has been developed in support of Decentralization on health to

achieve Healthy Indonesia by the year 2010, current condition shows that constraints and classical

problems have been chronically identified.

Below are the elaboration of vision and mission of NHIS, strength and opportunity, and constraints or

challenges (SWOT analysis) of the current NHIS.

Vision and Mission of NHIS

The vision of NHIS is to support the achievement of Healthy Indonesia by the year 2010. Healthy

Indonesia achievement will be accelerated with the provision of accurate, updated and timely

presentation of information. Reliable and valid information in other word is a prerequisite for the

achievement of Healthy Indonesia 2010. Motto of NHIS VISION is RELIABLE HEALTH INFORMATION 2010.

To support the above vision, the following MISSION of NHIS has been formulated:

The development of data management, which includes data collection, storage and retrieval,

and analysis The development of Data Bank, Health Profiles, and presentations of information for different

purposes

The development of networking/sharing information among different data and information

users

The development of methods for the use of data and information for action purposes

Strength and opportunity

The strength and opportunity that will contribute to the development of NHIS are:

Firstly, the strength to support the development of a comprehensive NHIS includes the provision of

adequate health infrastructures have been provided by government from national down to sub-district

level, different HIS for different purposes have been developed, the initiatives of HIS developed by the

unit for local purposes, and the rapid development of Information Technology.



Secondly, there are opportunities which consider will accelerate the development of HIS, which includes

Regional Autonomy Implementation which will consider HIS as an important support for the health

provider in convincing other health related sectors of its usefulness for decision makers. Structural

streamlining organization and empowering professional/functional health personnel, will allow the

maximum utilization of HIS personnel. Independency policy of regional health unit with the obligation to

provide the quality health services to the community will have to use evidence-based information for

decision making purposes.

Considering the aforementioned strengths and opportunities, the development strategy of NHIS consists

of the following:

The integration of existing HIS

The streamlining of current procedure and mechanism of reporting and recording systems

The empowerment of regional capacity relating to HIS

The development of HIS human resources, taken into consideration the rapid advance of

Information Technology and maintenance of equipment

The provision of adequate information for decision makers and community

For example, at the peripheral level of health management i.e. Health Centre level, apart from

illustrating current health problem or situation, information should perform its usefulness as action

oriented, which also involve situation analysis for the implementation of programme activity or prompt

action to recover the health problems within the area of responsibility.

At the District/Municipality health level, apart from health services delivery monitoring, HIS will also

include resources mobilization or relocation, as well as local health system planning and health

management improvement

In line with the development of HIS, the improvement of data management should also include

integrating data collection, reporting, and use of the information for improving health services

effectiveness and efficiency through better management at District/Municipality under decentralized

settings.

Constraints and challenge

Some constraints identified regarding the development of NHIS includes fragmented HIS i.e. different

HIS for different programme purposes, lack of regional capacity, minimum use of information for

management purposes, minimum use of information by community, minimum usage of Information

Technology. These constraints have been more burden to the fact that financial support for the

implementation and maintenance of HIS facility and equipment are considered as the least priority in

the budgetary line items and provision of an adequate and dedicated HIS personnel is in fact not an

evidence in most units either at the point of services or health management level.



2.1.3.2District/City Health Information Systems The objective of HIS is to co-ordinate and provide planning and management support to the service

delivery levels (Design and Implementation of HIS, WHO 2000)

The most important issue in which the Central Health Systems level can be situated are whether thesystem in the country is Centralized or Decentralized; government or private sector-managed

systems horizontally and vertically managed health services systems. For example: budgeting and

decisions on financial allocation will be made at the national level in a centralized system, while it will be

delegated to the district/city level in decentralized systems. In a country with a predominantly private

sector managed health systems, most of listed health functions are perform by private institutions,

while the government only has a regulatory role, setting policies, and making legislation. In a health

systems managed mainly through vertically organized health programmes, the manager has taken over

responsibilities in resource management and supervision of the line managers.

Health Information Systems, in which District Health Report is one of its important elements, have to be

developed in line with decentralization policy on health.

2.1.4 Emergency preparedness

Indonesia is located in an area of the world that experiences regular natural disasters, such as

earthquakes, tsunamis, floods, severe droughts and volcanic eruptions. Since the Indonesian

archipelago forms a part of the Pacific Ring of Fire, it is prone to earthquakes and volcanic eruptions. The

government has since last year been putting 10 of its 129 active volcanoes on alert status.

In recent years, political, economic, religious and social crises have led to complex emergency situationsin several provinces, notably Maluku, North Maluku, NTT (West Timor), Aceh, Sulawesi, Papua and

Kalimantan. These civil disturbances have contributed to an increasing number of emergencies in

Indonesia in recent years. Both, natural and man-made disasters have resulted in increased mortality

and morbidity, as well as a growing population of displaced people.

The Government of the Republic of Indonesia established a coordinating body, called BAKORNAS at

central level, and SATKORLAK at provincial level, for response to both natural and man-made disasters.

For Emergency Response and Preparedness, there is well defined political structure linked with the

health system, as given below:

Table 1: Link Between Political and Health Structure

Political Structure Health Structure

Level Position Level Position



Central (Pusat) Government of

Indonesia(Pemerintah

Indonesia)

Ministry of Health

(Departemen

Kesehatan)

Minister of Health (Mentri

Kesehatan)

Provincial

(Propinsi)

Governor= Gubernur Provincial Health Office

(Dinas KesehatanPropinsi)

Head of Provincial Health

Office (Kepala DinasKesehatan Propinsi)

District /

Municipality

(Kabupaten)

Head of District /

Major= Bupati /

Walikota

District Health Office

(Dinas Kesehatan

Kabupaten)

Head of District Health Office

(Kepala Dinas Kesehatan

Kabupaten)

Subdistrict

(Kecamatan)

Head of Subdistrict=

Camat

Health Center

(PUSKESMAS)

Head of HealthCenter (Kepala

PUSKESMAS)

Source: WHO

2.2 India

2.2.1 Health policies and strategies

Anemia and malnutrition among women and children respectively has led to serious problems of macro

and micro nutrition capacities. Moreover, the public health expenditure over the years has been less in

India due to which out-of-pocket expenditure is more. As a result of all this, a realistic strategy was

planned before making the NHP of 2002 according to the current needs of the people. The main goal of

NHP 2002 is to evolve a policy structure to reduce the inequalities and to see that public health services

are acceptable to the disadvantaged sections of the people.

The main objective of this policy is to achieve an acceptable standard of good health among the general

population of the country. The approach would be to increase access to the decentralized public health

system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the

existing institutions. Overriding importance would be given to ensuring a more equitable access to

health services across the social and geographical expanse of the country. Emphasis will be given to

increasing the aggregate public health investment through a substantially increased contribution by the

Central Government.

Emphasis will be laid on rational use of drugs within the allopathic system. Increased access to tried and

tested systems of traditional medicine will be ensured. Within these broad objectives NHP 2002 shall

achieve the goals of eradicating Polio and Yaws by 2005, eliminate leprosy by 2005, eliminate kala azar

by 2010, eliminate lymphatic filariasis by 2015, achieve a zero level growth of HIV/AIDS by 2007, reduce

mortality on account of TB, Malaria and other vector borne diseases by 2010, reduce prevalence of

blindness by 0.5 percent by 2010, reduce IMR to 30/1000 and MMR to 100/100,000 by 2010, increaseutilization of public health facilities from less than 20 to more than 75 percent by 2010, and establish an

integrated system of surveillance.

The public health administration at the State level is to render effective service delivery. The

contribution of the private sector in providing health services would be much enhanced, particularly for

the population group, which can afford to pay for services. Priority will be given to preventive and first-

line curative initiatives at the primary health level through increased sectoral share of allocation.



National health Accounts and Health statistics by 2005 show increase in the expenditure by government

as a percentage of GDP from the existing 0.9 percent to 2 percent by 2010, increase share of central

grant to constitute at least 25 percent of total spending by 2010, increase State sector health spending

from 5.5 percent to 7 percent of the budget by 2005 and further increase it by 8 percent by 2010. The

policy places great reliance on the strengthening of primary health structure for the attaining of

improved public health outcomes on an equitable basis.

2.2.2 Inter-sectoral cooperation

Inter-sectoral cooperation is very much for the betterment of health services in India. Public health

mainly depends on adequate nutrition, safe drinking water, sanitation, a clean environment, primary

education, etc., which are all interconnected. There is a need for policies to be interrelated. The Expert

committee on Public Health System (Bajaj committee) 1996 has rightly emphasized the need for

coordination with other sectors for better health outcomes. It has suggested for two committees to be

set up, i.e., cabinet committee on health and committee of secretaries chaired by cabinet secretary

comprising all departments concerned with activities influencing health outcomes, like education,sanitation, drinking water, environment, nutrition, etc.

2.2.3 Organization of the health system

The healthcare services organization in the country extends from the national level to village level.

From the total organization structure, we can slice the structure of healthcare system at national, state,

district, community, PHC and sub-centre levels.

2.2.3.1 National level

The organization at the national level consists of the Union Ministry of Health and Family Welfare. TheMinistry has three departments, viz. Health, Family Welfare, and Indian System of Medicine and

Homeopathy, headed by two Secretaries, one for Health and Family Welfare and the other for ISM and

H. The department of Health is supported by a technical wing, the Directorate General of Health

Services, headed by Director General of Health Services (DGHS).

2.2.3.2 State Level

The organization at State level is under the State Department of Health and Family Welfare in each State

headed by Minister and with a Secretariat under the charge of Secretary/Commissioner (Health and

Family Welfare) belonging to the cadre of Indian Administrative Service (IAS). By and large, the

organizational Structure adopted by the State is in conformity with the pattern of the Central

Government. The State Directorate of Health Services, as the technical wing, is an attached office of theState Department of Health and Family Welfare and is headed by a Director of Health Services.

However, the organizational structure of the State Directorate of Health Services is not uniform

throughout the country. For example, in some states, the Programme Officers below the rank of

Director of Health Services are called Additional Director of Health Services, while in other states they

are called Joint/Deputy Director, Health Services. But regardless of the job title, each programme officer

below the Director of Health Services deals with one or more subject(s). Every State Directorate has

supportive categories comprising of both technical and administrative staff.



The area of medical education which was integrated with the Directorate of Health Services at the State,

has once again shown a tendency of maintaining a separate identity as Directorate of Medical Education

and Research. This Directorate is under the charge of Director of Medical Education, who is answerable

directly to the Health Secretary/Commissioner of the State. Some states have created the posts of

Director (Ayurveda) and Director (Homeopathy). These officers enjoy a larger autonomy in day-to-day

work, although sometimes they still fall under the Directorate of Health Services of the State.

2.2.3.3 Regional Level

In the state of Bihar, Madhya Pradesh, Uttar Pradesh, Andhra Pradesh, Karnataka and others, zonal or

regional or divisional set-ups have been created between the State Directorate of Health Services and

District Health Administration. Each regional/zonal set-up covers three to five districts and acts under

authority delegated by the State Directorate of Health Services. The status of officers/in-charge of such

regional/zonal organizations differs, but they are known as Additional/Joint/Deputy Directors of Health

Services in different States.

2.2.3.4 District level

In the recent past, states have reorganized their health services structures in order to bring all

healthcare programmes in a district under unified control. The district level structure of health services

is a middle level management organization and it is a l ink between the State as well as regional structure

on one side and the peripheral level structures such as PHC as well as sub-centre on the other side. It

receives information from the State level and transmits the same to the periphery by suitable

modifications to meet the local needs. In doing so, it adopts the functions of a manager and brings out

various issues of general, organizational and administrative types in relation to the management of

health services. The district officer with the overall control is designated as the Chief Medical and

Health Officer (CM & HO) or as the District Medical and Health Officer (DM & HO). These officers are

popularly known as DMOs or CMOs, and are overall in-charge of the health and family welfareprogrammes in the district. They are responsible for implementing the programmes according to

policies laid down and finalized at higher levels, i.e. State and Centre. These DMOs/CMOs are assisted

by Dy. CMOs and programme officers. The number of such officers, their specialization, and status in

the cadre of State Civil Medical Services differ from the State to State. Due to this, the span of control

and hierarchy of reporting of these programme officers vary from state to state.

2.2.3.5 Sub-divisional/Taluka level

At the Taluka level, healthcare services are rendered through the office of Assistant District Health and

Family Welfare Officer (ADHO). Some specialties are made available at the taluka hospital. The ADHO is

assisted by Medical Officers of Health, Lady Medical Officers and Medical Officers of general hospital.

These hospitals are being gradually converted into Community Health Centres (CHCs).

2.2.3.6 Community level

For a successful primary healthcare programme, effective referral support is to be provided. For this

purpose one Community Health Centre (CHC) has been established for every 80,000 to 1, 20,000

population, and this centre provides the basic specialty services in general medicine, pediatrics, surgery,

obstetrics and gynecology. The CHCs are established by upgrading the sub-district/taluka hospitals or



some of the block level Primary Health Centres (PHCs) or by creating a new centre wherever absolutely

needed.

2.2.3.7 PHC level

At present there is one Primary Health Centre covering about 30,000 (20,000 in hilly, desert and difficult

terrains) or more population. Many rural dispensaries have been upgraded to create these PHCs. Each

PHC has one medical officer, two health assistants one male and one female, and the health workers

and supporting staff. For strengthening preventive and promotive aspects of healthcare, a post of

Community Health Officer (CHO) was proposed to be provided at each new PHC, but most states did not

take it up.

2.2.3.8 Sub-centre level

The most peripheral health institutional facility is the sub-centre manned by one male and one female

multi-purpose health worker. At present, in most places there is one sub-centre for about 5,000

populations (3,000 in hilly and desert areas and in difficult terrain).

The 73rd and 74th constitutional amendments have given the powers to the local bodies in some states

of India. In the process, different states have adopted different stakeholders for the benefit of health

services, with the help of community participation, which gives stress on safe drinking water and

sanitation at village level. The Panchayats are given the power to look after the welfare of the people.

2.2.4 Health information system

Census

The census in India is a decennial activity, which pools tremendous resources, and huge data pertaining

to many facets of population is generated. The census in India started on regular basis from the year

1891 and last one was conducted in the year 2001. The data represents the situation as on 1st March

(except 1971 census when it was 1st April). It normally provides age and sex structure and spatial

distribution of population. In addition, it also provides information on some socio-economic factors.

Occasionally some additional information is also obtained like mortality, disability, etc. Among all

sources of information, census information reaches maximum accuracy.

CivilRegistration System

It is a continuous permanent systematic activity of enlisting vital events countrywide. Considering its

utmost importance, this activity is given legal status through a special Act, Birth and Death Registration

Act 1969. Authorities like local registrar, Registrar General under the act in different areas like rural,

urban have been designated from various sectors. Normally, the local registrar is from local self-

government or from health department. General apathy leads to gross under-registration from time to

time and differs from place to place. There is often a considerable time lag between collection of dataand its compilation and publication. The data collected from urban area are comparatively of better

quality than from rural area.

SampleRegistration System

In 1964-65, Government of India introduced Sample Registration System for improving reliability of data

pertaining to vital events and also to have urban and rural break-up. Population covered was 61,12,000

in 1998. Although initiated on pilot basis, it covered 2,235 urban sampling units and 4,436 rural



sampling units selected. A Government servant, usually a teacher, is selected and trained to function as

enumerator. A baseline survey of sample unit is conducted to obtain information about usual resident

population of the same sampling areas. The enumeration of birth and deaths is continuously carried out

pertaining to resident population by him for his area. Every six months, an official supervisor makes a

visit and independently checks all the households in the area of enumerator. Thus, it functions as a

continuous process and which is superimposed by periodic retrospective surveys. Unmatched or

partially matched events after verification are added and final estimates are worked out. Sometimes,

additional information is also collected through sub samples. Presently, this is supposed to be most

accurate data source providing information about birth rate, death rate, age specific death rates, Infant

Mortality Rate, age and sex composition, and seasonal and spatial variations in these statistics. It has

been decided now to collect data pertaining to causes of deaths on regular basis. Sample Registration

System provides information by states and for the country.

National Sample Surveys

National Sample Survey Organization regularly conducts nation-wide surveys collecting information

regarding social, economical, demographic, industrial and agricultural conditions. The organization has

many wings. One wing shoulders responsibilities like designing the sample survey, improving quality of

data, etc. Another wing consists of well trained full time personnel who actually conduct surveys. Theorganization also obtains support from State statistical organizations. Normally, the surveys collect

multi sectoral information. The surveys are conducted in the form of rounds stretched over a specific

period, generally one year. The first round was carried in the year 1951 and 55th round in the year

1999-2000. The organization has published extensive information through 456 reports. Sometimes,

special information directly pertaining to health is also collected.

Service statistics

Information generated from Sub Centre level and above is also fed into the health information system

on specifically designed reporting formats submitted monthly. The health and family welfare

information is compiled at district level and submitted to State level from where it goes to central level

(GoI).

Ministry of Health and Family Welfare brings out two publications yearly (there is backlog currently)

Family Welfare Yearbook and Health Information Yearbook. These yearbooks compile all information

available from various sources and present by districts, states and country. However, most of the

information pertains to services provided by public sector.

In addition, all India surveys are also conducted such as National Family Health Survey (I & II have been

done so far), RCH survey, etc.

India has national disease surveillance. The surveillance exists only for polio and HIV/AIDS and it has

been effective in getting information. However, there is a need for a strong disease surveillance network

in the whole country for better information on diseases and better health initiatives.

2.2.5 Community action

A considerable change has happened in the last two decades towards implementation of the

government's action plans through the institutions of civil society and NGOs. It is to be recognized that



widespread debate on various public health issues has, in fact, been initiated and sustained by NGOs

and other members of the civil society. Also, an increasing contribution is being made by such

institutions in the delivery of different components of public health services. Certain disease control

programmes require close interaction with the beneficiaries for regular administration of drugs, periodic

carrying out of pathological tests, dissemination of information regarding disease control, and other

general health information.

2.2.6 Health research and technology

Research in the private sector has assumed some significance only in the last decade. In our country,

where the aggregate annual health expenditure is of the order of Rs. 80, 000 corers, the expenditure on

research, in both public and private sectors in 1998-99, was only of the order of Rs. 1150 corers. It would

be reasonable to infer that with such low expenditure on research, it is virtually impossible to make any

dramatic break-through within the country, by way of new molecules and vaccines; also, without a

minimal backup of applied and operational research, it would be difficult to assess whether the health

expenditure in the country is being incurred through optimal applications and appropriate public health

strategies.

2.3 Thailand

2.3.1 Health policies and strategies

The MOPH is authorized and responsible for the strengthening of the public health and hygiene,

preventing and controlling diseases and recovering the energy-level of the population. It has established

its goals and a 3-year strategy for pursuing the goals so that the subordinating agencies adhere to the

principal goals and their strategy is in operation according to estimates of the public health budget

required for achieving the goals.

The followings are the target of MOPHs policies:

y To improve the organization structure, culture and the operation procedure in order to have

good administrative system and to become a learning organization of public health

y To develop and provide mechanism in facilitating the involvement of all concerned parties in

monitoring the public health system as a whole.

y To increase the capability of the medicines, public health and biology of health, in order to be on

the front line of world competition.

The middle-term goals of the MOPHs services are following:

y The important public health problems in different age groups of the population are to be

lowered.

y The people have health security with standard and quality health services, and to encourage

people to take part in taking care of health and the public health environment.

y The healthcare products and services are to be of the quality and up to the standard of

international requirement.

y To have good governance in the public health administration

The MOPHs strategies in pursuing the goals according to the policies are:



y Improving the sanitation behavior of the people and to prevent and control diseases with

involvement of all concerned parties.

y To increase the varieties and capacity of the research, including bio-medicines, development,

transfer, applications of technology and knowledge

y To develop the system of health security and public health services to be holistically efficient

with equal quality services for all.y To promote peoples involvement in developing public health, managing public health

environment accordingly and efficiently.

y To encourage innovations, develop mechanism of facilitating innovations of health products and

services, which make use of domestic resources to further enhance the Thai traditional wisdom

so that the products and services are of better quality and meet the international standard.

y To develop and improve the systems and procedures of operations of public health

management to make them better and more efficient.

The devising of the public health strategic plan: The strategic plan is very important for the result-

oriented management (or Management by Objectives). Therefore, the strategic plan will be designed

carefully in order to conform to the desired goal and the strategy of achieving the goal of the superior

operation unit, so as to achieve the goal successfully.

2.3.2 Inter-sectoral cooperation

Change in policy, organization structure, and the ways to allocate the budget have been achieved both

at the central and the provincial administrations to facilitate these result-oriented functions of

administration. It has helped to increase the efficiency in deploying the allocated budget and have good

outcomes for the people and the country as a whole.

According to the principle of MBO, the MOPH has adjusted its paradigm regarding the public health

management by allowing different operation units to have higher working flexibility while maintaining

the connectivity among the related units so as to maintain the coherency of the whole organization atthe same time ensuring that the line of command of ministry -> department -> division/province is still

valid.

The new perspective of the MOPH stipulates that each subordinating unit to study the impacts of the

superior units strategy in order to adhere to it as the direction for guiding its operation in pursuing a

common goal.

2.3.3 Organization of the health system

The organizational structure at the central level of the MOPH consists mainly of the Office of Permanent

Secretary of MOPH and 3 task clusters, described below:

The Office of Permanent Secretary of MOPH is responsible for the drafting of policies, plans, and

supervising, monitoring and appraising the outcomes of the operation units of the Ministry. It

also administers to ensure that the execution is in line with the law, undertakes legislation of

laws regarding the health establishments and other related affairs and is also responsible for the

production and development of public health personnel.

The Task Cluster for the development of medicines is responsible for the development of

medical science, the therapeutics and recovery of potency, development and transfers of



medical knowledge and technology for therapy and recovery of health. The cluster is also

responsible for establishing healthcare standard, and developing alternative medicines for the

provision of quality public health services to the public for the purpose of good mental and

physical health of the people. The Task Cluster comprises 3 departments - the Department of

Health, the Department of the Development of Thai Medicines and Alternative Medicines and

the Department of Mental Health.

The Task Cluster for development of Public Health is responsible for the development of public

health science for promoting health, controlling and preventing diseases, research and

development of knowledge and technology, transfer of knowledge for promoting health and

controlling and preventing diseases for the purpose of good mental and physical health of the

people. It comprises 2 departments - the Department of Disease Control and the Department of

Health.

The Task Cluster of Health Service Support is responsible for supporting the public health service

providing units, the systems and mechanism facilitating public health service provision and the

public health system. They are also responsible for administering the protection of consumers of

healthcare services and drug products for the purposes that the general people can take care of

their health efficiently and receive standard and quality health services and products. The

Cluster consists of 3 departments - the Department of Service Support, the Department of Medical Science and the Food and Drug Administration.

The organizational structure of the regional agencies which are under the administration of the Office

of Permanent Secretary of MOPH, consist of Provincial Public Health Offices, hospitals, Ampur Public

Health Offices, the PCUs and the community clinics. The above agencies are the major healthcare

service providers who help the people promote health, control and prevent diseases, and provide

medical treatment and recover health. They utilize the knowledge and technology that have been

developed and transferred from the technical Department and adjust and apply them appropriately

according to the specific requirements of their regions. The organizational relationship between the

technical Department at the centre and the regional public health operation agencies is basically staff

relationship in which the centre provides support to the regional agencies, but does not command.

For healthcare at the primary level, there are the PCUs providing the services within the scope of

Tambol and village. They are responsible for arranging a suitable aggregate of health services for the

rural people in their responsibility areas which normally have 1,000 5,000 people. There are fulltime

public health personnel stationed at the public health units such as Sanitation Officers, Midwife Nurses

and Technical Nurses. In addition, Dental Officers, Technical Nurses and Public Health Officers are also

working there. Ampur Public Health Offices are responsible for the assistance, supports, supervision,

monitoring and appraisal of their accomplishments.

On the aspect of decentralization of the authority of the public health administration, the Constitution

of the Kingdom, 1997, the section 78 stipulates that the government is to decentralize its authority to

empower the regional authorities to make them self-reliant and make their own decisions regarding the

regional affairs through the legislation of acts, plan and procedure of achieving the goal of the

decentralization within 4 years (2001-04). In case the regional organizations are not ready to assume

their new role within 4 years, the decentralization period is expanded to 10 years (2001-10). The

regional organizations are stipulated to prepare themselves for the decentralization while the central

government is stipulated to provide administrative assistance, and intellectual and technical supports

for decentralization purpose. The Steering Committee of the Decentralization has also been established



for the purpose of forming the policy and procedure of the decentralization. The Steering Committee

has so far drafted up two major plans:

The Master Plan of Decentralization which shapes the vision, the mindset and the direction of

decentralizing the authority to the regional organizations. It also determines the tasks and

operations that are to be assigned to the regional organizations. Some parts of the public health

affairs are parts of the tasks and operations that are to be distributed out.

The Reformation Plan of Decentralization requires the establishment of specialized committee

for the respective provinces, like the Regional Health Committee for the public health affairs.

The MOPH, in an effort to actualize the decentralization of the public health administrative authority to

regional organizations, has designated the Regional Health Committees in 43 provinces. These regional

committees are responsible for the coordination in forming policy, drafting plans of regional public

health development, plans of resource requirement, and also planning budgeting and personnel. They

are also responsible for defining the criteria and allocating the resources, supervising and inspecting and

defining the criteria for appraising the outcomes of the regional public health administration. Currently,

the committees are in the process of determining the forms and procedure of operation.

2.3.4 Managerial process

For the result-oriented management, the strategic plans are instrumental in the administration and

operation of each department. The process of administration is described below:

Compliance of goals and strategy of the superior administrative units

While the MBO allows each administrative unit to have more flexibility, they also need to accomplish

the goals and comply with the strategy of the superior administrative units. As a result, each

administrative unit is restrained by the goals and strategy of the superior units; each has the freedom on

how to achieve the goals but not what to be achieved. The consequence is that each unit will work in

concert towards a common goal set by the top management.

The compatibility with the regional problems and the capacity of the responsible

administrative units

In forming the strategic plans of the MBO administration, not only the compliance to the superiors goal

is required but also the compatibility of the strategic plan with the regional problems and the capacity of

the responsible administrative units. Therefore the data and information of the regional problems and

the capacity of the responsible administrative units are required to be incorporated in forming the

strategic plan in order that the subordinate units are able to comply with the superiors goals and

strategy in solving their problems.

The best utilization of the existing resources

The MBO management will compare the budget utilization and the results achieved in order to see the

efficiency of each administrative unit. The same result achieved does not mean the same efficiency but

if it is achieved with lower budget, then it is definitely better efficiency. As an effect, the MBO will

stimulate collectively the administrative units to best utilize their existing resources.



To provide the accountability of the success and failure of the administration, the MBO practice requires

that in appraising the administrative results the factors for success or failure are identified so that the

weakness can be amended and obstacles can be overcome in the next endeavors. One particular set of

success indicators cannot be applied to different levels of different administrative functions; the correct

performance appraisal of the personnel cannot be achieved this way.


For the improvement of the management information system, the MOPH has been developing and

improving the centralized database for collecting and storing data in a common database in order to

provide necessary information for the managerial decisions and for other purposes. For example, the

data storage system has been improved to be an Electronic Individual Records system which collects

data at the points of data generation. The MOPH has resolved to develop 3 levels of database i.e. the

database for the PCUs or Tambol Health Centres, the database for the hospitals and database for the

provincial public health administrations. The collected data (in operative units) also may be utilized by

the data collecting units in order to improve the data quality. Furthermore, the MOPH has put efforts

into developing the National Public Health Data Centre for the purpose of keeping data for themanagerial decision-makings. Currently, the Ministry Operation Centre (MOC) is operational in which

important data such as the policy indicators of the government and of the MOPH and the principal

indicators (KPI) of each fiscal year are kept for the purpose of following up the progress and appraising

the performance of the work for which the budgets have been allocated.

The health information system is divided into 2 groups, namely, the community-based information

system, in which data is obtained usually from surveys, and the institution-based information system of

which most data are from the reporting system. The details of the two groups of information system are

as follows:

Communitybased surveys

They provide data which are difficult to collect within normal operation processes. Since the data

generated from the normal operation process are in the form of report for those people, who have

come to receive services at the healthcare centres, information from the people, who have not gone to

the healthcare centres, will not be recorded. On the other hand, the health report systems normally

cover the data of the health services provided within the government establishments (under MOPH),

while those of the private health establishments are not available. In addition to this, community-based

surveys provide more and better quality of data for assessing the coverage of healthcare services than

the data from the normal operation process and also more varieties of data like incomes and

expenditures of households etc.

Institutionbased reports

These are from two major groups of data sources - one is from the agencies under the MOPH and

another is from the agencies not under the MOPH. The agencies under the MOPH are PCUs,

regional/general hospitals, and community hospitals. The main data sources from agencies which are

not under the MOPH, include the Bureau of Registration. It keeps record of births and deaths of

population. The collected data is analyzed and processed to produce some important ratios which can

be used to indicate the efficiency, quality and justice in providing healthcare services.



The data from the private health establishments and other independent organizations are made

available through the co-operation of those private and independent parties, who have helped in

collecting data for MOPH through filling in report forms and replying survey forms. Some data from the

above co-operation are not mandatory to send, but some data are mandatory to be submitted to the

MOPH, under the law.

The current data kept by the MOPH database system for the purposes of a following-up progress,

performance appraisal and for managerial decision making, could be classified into 3 categories: (i)

Health status data (ii) Health Resource data and (iii) Health Service data.

y Health status data: these are the data necessary for health administration and for evaluating

the performance of the public health system. They need to be collected regularly. Some

examples of such data are illness and death cases by gender and age groups, the causes of

deaths, nutrition status of the children, mental health, the situation of the dental health and so

on. These data are fundamental for the purposes of planning public health development and can

be viewed in different perspectives such as region-wise, district-wise, ampur-wise and province-

wise.

y Health resource data: they are data of human resource, allocated budgets, health

establishments and health equipments. They are useful in assessing the coverage of health

services that government has provided to the people and the adequacy of the health resources.

They are necessary data that must be collected regularly. They are arranged to show details at

different levels like province and their respective health establishment.

y Health service data: they are the data of health services received and the accessibility of health

services like the out-patient data, in-patient data, hospital bed occupancy rate, average length

of over-night stay, the coverage of health insurance, health education activities, immunization,

provision of medical services, food and environment, school sanitation and family planning.These data are used to appraise the performance of the public health personnel at the

community level and assess the efficiency in providing health services.

The disease Surveillance System monitors the spread-out of the communicable diseases. Individual

cases of each disease are reported together with locations and their time of occurrence. These data are

maintained mainly for the purpose of controlling diseases from spreading out, monitoring the disease

and mitigating them in time. Within this data system, data are transferred up from tambol to province

and then to the MOPH. There are two major goals for keeping this system (i) they are used as a

systematic process of disease prevention and control within a region or overlapping areas among

regions and (ii) they are used as a system of planning and appraising system, which are currently the

most important objectives of the Disease Surveillance System.

2.3.6 Community action

The public health problems, however, cannot be solved by relying either on the efforts of the

government or of private enterprises alone. The encouragement of the co-operation and involvement of

the people and communities are necessary in realizing the mission of Good Health for All. This could

be achieved through educating them in order to enable them to look after their health properly.



For evolving a strategy for developing primary public health services, Thailand has been encouraging and

developing different forms of involvement of people on public health issues, especially for the rural

communities, such as conducting health instructions, establishing public health volunteer units and

encouragement for forming of health groups or societies like the exercise groups. At the same time,

there have been many organizations that people have established by themselves to promote good

health within their communities, both in urban and rural areas, under the leaderships of people from

both public and private sectors. There are many aspects of public health in which these independent

organizations have been involved like the development of healthcare services and the protection of

consumers. Some examples of these independent organizations are the Family Planning Association, the

Association of the Development of the People and Communities, Association of Rural Doctors

Foundation and the Village Doctors Foundation. The MOPH has seen the strategic importance in these

peoples involvements in public health affairs and has provided supports in various forms like the

material supplies, equipment, places, man-power and budget. Till date, there have been many

complimentable accomplishments made by these independent organization, for example, family

planning, the provision of clean water and sanitation in districts, the development of community

hospitals and government clinics, the dissipation of knowledge and information about health to the

people, the revitalizing of the Thai herbs and Thai traditional medicines by encouraging hospitals to use

herbs in healing disease and recovering health.

During the period 200006, National Public Health Act was drafted which stipulates the establishment of

the National Health Committee. The Committee will comprise equal number of representatives from the

government, intellectuals and general people representing all walks of life. Further, the Act also

stipulates to have National Health Assembly meting to be held at least once a year. This Assembly will

provide a forum for the general people throughout the country to express their opinions on the

requirements of the public health system development. It also stipulates the establishment of a public

health research institute for which the MOPH is to allocate 3 percent of the public health budget. The

purpose of establishment of such institute is to develop the knowledge of public health and the wisdom

required for policy initiative, health administration and operation. However, the most important mission

is to promote awareness about health service.

The wind of development, changes and reformation is now blowing everywhere in the Thai society and

has its impact on all the systems, especially the system of government administration, which is steering

towards a decentralization of authority. There is, of course, no exception for the public health

administrative system, especially when the Reformation Acts of 1999 has been declared effective and

has stipulated to share the administrative authority with the regional agencies. Along with that, regional

committees of public health are being set up. They consist of representatives from the local authorities,

professional administrators, representatives from the general people, and other qualified persons for

the purposes of jointly managing the transition, and to ensure that the decentralization is in line with

the pre-set policy and up to the standard. The regional committees of public health are also responsible

for the co-ordination of public health administration within the region. The designation of delegates

from the general people from all walks of life is very critical in encouraging the involvement of general

people in the public health system development.

The factors that motivate peoples involvement in public health affairs are now in the declaration in the

Constitution 1997, which is a constitution by the people and for the people. It has opened up

opportunities for the general people to get actively involved into the development processes and also in

solving various important and complicated problems of the country. Therefore, the scope of work and

activities in which people will have direct involvement, is expected to increase in the near future.



2.3.7 Emergency preparedness

As stipulated in the National Development Plan of Economy and Society Issue 9 (2002 2006), the

MOPH has resolved to develop emergency medical service system in the rural areas all over the country.

It also has a policy of encouraging the involvement of the local people in this development. This rural

emergency medical service system development has been listed as one of the top 4 policies of the

MOPH. For this purpose, Narentorn Centre, the centre for administrating the emergency medical

services system of MOPH, has been established in 2002.

The details of the work of the emergency medical services system are as follows:

y Emergency case detection

y Emergency reporting

y The field operation of the emergency medical service team

y Basic life support

y Advanced life support

y On scene care providing

y Transportation and care in transit

y Transfer to definitive care

On the preparedness of the medical and public health system for the cases of nation-wide health crisis,

all levels of the countrys administration right from the government agencies, the public organizations,

regional agencies and the private organizations, have prepared themselves for crisis with respective

crisis responsibilities and co-ordination requirements. The major co-coordinating agencies in cases of

crisis, are the followings:

The Administrative Centre of Medical and Health Emergency Preparedness - stationed in the MOPH,

chaired by the Permanent Secretary of MOPH has the following responsibilities before, during and afteremergencies:

y Administrating the operation system and providing support for the preparedness of the medical

and health emergency, as has been planned.

y Coordinating the government agencies, other agencies and private organizations concerned in

the cases of emergency, for helping people and providing them with emergency medical and

health services

y Preparing reports, proposing recommendations, identifying problems and obstacles and other

relevant issues to the Subcommittee of Medical and Health Emergency Preparedness, which is

chaired by the Permanent Secretary of MOPH, for the purpose of improving the crisis

management system and being well prepared for the upcoming emergency

The Operative Centre of Medical and Health Emergency Preparedness: for the purpose of coordinating

the emergency operations within the region (provincial level), has the Provincial Public Health doctor, as

the chairman and has the following responsibilities:



y To coordinate the operation in emergency cases according to the pre-set plan of medical and

health emergency preparedness

y To coordinate the emergency operation and to coordinate with other concerned agencies,

public or private, both within or outside the country, for emergency aids, in cases of crisis.

y To coordinate with concerned agencies and organizations to be alert and prepared for possible

emergency cases all the time by conducting drill following the pre-set plan of medical and healthemergency preparedness.

y To procure the resources necessary for medical and health emergency, so as to keep it current

with up-to-date technology and well prepared for emergency.

y Preparing reports, proposing recommendations, identifying problems and obstacles, and other

relevant issues to the centre-director of the Administrative Centre of Medical and Health

Emergency Preparedness, for the purpose of improving the crisis management system and be

well prepared for any emergency.

2.3.8 Health research and technology

Thailand has developed its own facilities for researches in the field of health. A health research centre,

under the MOPH, has been set up for this purpose. The academic and research activities in the researchcentre are also used to provide the medium and mechanism for developing research collaboration

network with other researchers from the general society. These academic and research collaboration

networks help in evolving the knowledge and technology regarding the public health affairs. The

research centre has established the following goals to achieve:

Q uality research outputs which can be used as alternative solutions to the public health

development issues in order to meet Thai peoples health requirements.

Efficient operation mechanism and performance are also recognized by concerned parties in

helping the development of public health system forwards.

Developing ever-learning network of the people in public health affairs, for the purpose of

providing the momentum of public health system development and extending the public healthbenefits to more people.

Development of fellowship network of public health researchers and institutes which is capable

of conducting quality research, and is efficient and transparent in operation, for the long-lasting

academic support of the public health system.

The Health System Research Institute (HSRI) has drafted a 3-year (2002-04) plan of research for the

purpose of responding to various public health system reformation requirements. As a result, the

research projects which are relevant to the reformation are under way. They have the followings

research features:

The knowledge and skills for defining the roles and functions of public health jobs and the

structure and architecture of the public health system during the transition period.

The development of instrument and mechanism for administering the new public health system

under the various constraints of the country.

The development of adequate and qualified intellectual and researching personnel for analysis

work and for the purpose of providing feedback data to the new public health system.

2.4 Vietnam



The Vietnam Heath System was established on September 2, 1945. The development of the Vietnam

health system can be divided into 3 periods: (1) 1945-1954; (2) 1954-1975 and (3) 1975 till now.

2.4.1 Organization of Healthcare System

The Vietnam health system was established at four levels: Commune, District, Provincial, and National.

The Ministry of Health is the national authority with regards to the provision of health services.

Provincial and District Health authorities and the Commune Peoples Committee are responsible for the

development and implementation of health strategies in Vietnam.

Despite having a strong central level, local government plays an important role in the provision of many

services including health. Administration of health services is the responsibility of a health bureau at

provincial and district level. The provincial health bureau administers provincial facilities and oversees

the delivery of healthcare through district hospitals and communal health centres.

Over the past few decades Vietnam centralized model has changed to a more decentralized one. The

Ministry of Health is responsible for developing national strategies and programmes as well as for thefunctioning (budget and manpower allocation) for the national institutions. The central level also plays a

supervisory role for the national institutions and the Provincial level.

At the Provincial level the Provincial Peoples Committee is responsible for manpower, budgeting and

policy and planning. maternal and child health, family planning and control of communicable diseases

(Tuberculosis, Leprosy, Trachoma). Management at the two lower levels is done by the District and

Commune Peoples Committees. At the District levels similar preventative services are offered. In

addition mobile units may exist for delivery of healthcare in remote areas. At the Commune level,

healthcare delivered by the Commune Health Station is focused on hygiene, vaccinations, antenatal

care, safe delivery and health education.

Despite trying to devolve care to lower levels of the health system, care is mainly provided in hospitals.

In Hanoi National Hospitals exist for each type of condition, e.g. National Cancer Hospital, National

Hospital of Endocrinology, etc. In cities health care is delivered mainly through hospitals (specialized or

general) in the public sector or private clinics. Each Province has a Provincial hospital and the level of

facility below this is a Health Centre in the Districts.

There are a total of 903 Hospitals in Vietnam and 6.2 doctors per 100,000 population.

The pharmacy system was also established at the same four levels. The pharmacy system includes

National pharmacy companies and factories, provincial pharmacy companies and factories, district

pharmacy stores or distribution company and pharmacy stores at communes which provide

pharmaceutical products for communities.

The health system is a combination of ideas, policies, guidelines, methods, resources and actions with

the objectives of promoting, rehabilitating, maintaining and enhancing health. Health system is a

combination of human resources, organizations and management institutions which relates to health

service delivery. Health system includes not only government health units but also others subjects who

involve in providing services and financing for health care.



2.4.2 Development of Health Systems

Health systems are systems including networks of preventive medicine services delivery, primary health

care, medical care and rehabilitation, drug production, distribution and supplies, etc., (from commune

health centers to district health centers , provincial and national health centers).

The objectives of building health systems are to build the health systems modernly, fully in order to

ensure equity, effectiveness and development; to build health systems to meet the increasing needs on

health care; to build health systems in order to decrease morbidity and mortality rates, to increase life

expectancy, to improve quality of life and reach or go beyond all the objectives in the health care

policies and plans.

The tendency of health systems development is increasing socialization in which government health

care plays the main role, meeting the needs on good quality health care services, having health systems

which are appropriate to national economic and social conditions and ensuring equity and effectiveness

in providing and using health services.

Health systems are also defined as economic systems that are concerned with human health. According

to this definition, health systems include economic units, economic agents and institutions that interactcoherently; adapting and adjusting to the social and physical environment. There are seven principal

components of Health Systems, including:

Primary health service delivery system

Health workforce

Leadership and governance to assure quality

Health systems financing

Supplying medical products and technologies

Health systems information

Households

Each health system is analyzed and, evaluated on seven dimensions: Output, Stability, Fairness,

Efficiency, Protection, Freedom, and Innovation.

Primary health service delivery system uses health staff, infrastructure, drugs, health devices, etc., as

inputs to provide health services. In primary health services delivery system, two important concepts

focused are impact and reach. Impact is defined as the effect of treatment on the treated while

reach is the ability to bring more people into treatment and thus Population Benefit=Reach ´ Impact.

There is a tradeoff between reach and impact in any budget, which means one must choose whether to

enlarge reach or to improve impact. It is usually difficult to achieve impact and reach along the

last mile of a health system. For example it is not easy for poor people or people in the remote areas,

who are considered to be the last mile to access and get effective health services. Thus, health

services delivery should think about the last mile to ensure the quality and coverage of health

services. In order to evaluate or diagnose the syndromes of dysfunction of health services delivery

systems, performance metrics are used to measure the levels of performance such as stewardship,

financial equity, responsiveness to peoples non-medical expectations (dignity and respect), equity (Fair

delivery to rich and poor; delivery without barriers). Understanding agents incentives helps treat the

diseases of the system.



Health workforce includes all health workers (people who work in the field of health care). They may

have formal training in medical schools at different levels: doctors, nurses, pharmacists, public health

workers, etc., or do not have formal training such as untrained midwives and traditional healers. If plans

for health workforce development are not appropriate and thus lead to health worker shortage or

worker imbalance, other health systems can not run effectively.

Leadership and governance to assure quality: According to Avedis Donabedian of the University of

Michigan, health system quality is evaluated on three aspects:

Structure

Process

Outcome

These three aspects relate to the arrangement of units, agents and institutions and thus make the

differences on the services quality (public goods and private goods). Service quality (public and private

services) is also determined base on the incentives of services providers and users. There are some

classic syndromes of poor quality in health systems, including:

Insufficient training

Insufficient oversight

Uninformed Patients

2.4.3 Health systems financing

Health insurance is popular in developed countries. Expenses for an insurance company to pay its own

staffs often count for 20 to 30 percent of the premium. According to the on the law of large numbers, a

good insurance market has to have at least 10,000 customers to effectively spread risk. One incentive of

insurance providers is to cherry pick which is choosing customers with low risk or offering high premium

to customers with high risk, and thus destabilize the market, such as adverse selection. Besides that,incentive of insurance customers is over-utilization and thus increases health care expenses.


Health information system is an important component in health systems. Types of health information

follow types of decisions for different systems: Primary health delivery, Health workforce, Q uality and

governance, Financing, Supply chain.

Decisions that require support are:

y Decisions for primary health care: information for Primary health worker decisions and Health

district supervisor decisions

y Decisions for workforce: Information for Decisions at Schools and Decisions at Ministry

y Decisions on quality: feedbacks from patients and inspectors

y Decisions in f inancing: frequency and medical spending.

y Decisions on supply

2.5 China



2.5.1 Development of Healthcare System

The development of a health-care system depends on a countrys economic, political, social and cultural

background. Because of Chinas transformation over the last 20 years from a socialist economy to a

market economy, Chinas healthcare services have been converted from social and public goods to

market goods without government planning or intervention. Differences in economic growth and in

financing, organization and resources between urban and rural regions have made China a country with

two health-care systems.

The urban system has more resources and is better organized, but is faced with major financing and

organization issues and concerns about cost-containment, whereas the rural system lacks resources and

is not well organized, and difficulty of access causes concern.

The two key control points in health-care reform are:

y Organization of Health system

y Healthcare financing

They are interrelated and require coordination for health-care services to function efficiently and

equitably.

In China, however, the financing and administration of health services are segmented:

The Ministry of Labor and Social Security, which is responsible for the urban health insurance sector.

The Ministry of Health for the rural sector

The Ministry of Civic Affairs, which is responsible for poor urban and rural households.

The Ministry of Health is therefore in a weak position to lead the necessary reform of the health-care

system at the central government level. In towns, decentralized health insurance organizations managehealth-care financing for at least half the population, and this structure can be built on to expand and

reinforce the financing and delivery of health services at the local level.

In rural areas, however, such facilities are lacking. Numerous rural health insurance experiments were

launched to restore the cooperative medical system of the early 1960s, with support from UNICEF,

WHO, the World Bank and other international organizations. Virtually none of these systems was

sustained after the experiments ended, for several reasons:

y Insufficient support from the local or central government meant that farmers were essentially

self-insured on a voluntary basis, resulting in financial hardship

y The central government prohibits imposing additional taxes on farmers. Local officials were

worried that insurance premiums could be interpreted as an additional tax

y Low insurance premiums resulted in limited benefit coverage, in terms of low reimbursement

rates (2030%) for both outpatient and inpatient services

y The services of village doctors and township hospitals are inferior in quality to those received in

county or urban hospitals, so farmers preferred to travel to urban areas

y Farmers were distrustful of the local government insurance fund management and worried that

their insurance premiums might be diverted to other uses.



A new cooperative medical system under the Ministry of Health should organize a primary care service

to use village doctors in a referral system. This could require financial incentives, such as capitation

payments or prepaid services. The budget currently provided by the central and provincial authorities is

not sufficient to cover a large uninsured population or to provide health promotion and disease

prevention activities.

Because the central government has routine budgetary allocation, it may not be easy to shift monies to

the health sector. One major untapped financial source is cigarette taxation, which contributes about

10% of central government revenue. The overall tax rate on cigarettes is relatively low: about 40% of the

retail price, compared with the international median tax rate of about 66%. Portions of an additional

tobacco tax which could improve the health of the population by reducing cigarette consumption

could be earmarked for health-care insurance funds and health promotion and disease prevention for

rural or low-income families. Tobacco taxes have successfully been used for health-care financing in, for

example, Australia, Thailand and some states of the USA. The economic benefits of additional revenues

from tobacco taxation for the central government and health care for the Chinese population greatly

outweigh the negative economic impact on the tobacco industry and tobacco farmers.

During the last two years, especially following the outbreaks of severe acute respiratory syndrome

(SARS), the Chinese Government has recognized the importance of investing in health; improving health-

care services has become a key element in economic development plans. The long-term goal of the

Chinese Government is to make China a moderate well-being (Xiao Kon) society. By reforming the

financing and organization of health care, China can establish a system that provides health protection

(in terms of improved access to and utilization of services) and social protection (in terms of reduced

poverty caused by illness) for its population.

2.6 UAE

The UAE has a developing health care system, and comprehensive health programs are being adopted tomeet the needs of the UAE society. Health care infrastructure has kept pace with other health care

developments to ensure that adequate services are provided in the Emirates.

For a young country that started off with rudimentary healthcare, the UAE has made significant progress

in attaining world-class infrastructure in the health sector. Major public healthcare service providers are

the Ministry of Health, The Abu Dhabi Health Authority, the Dubai Health Authority, and the UAE Army

Directorate of Medical Services. The private sector is also a major player in healthcare services.

Medical and healthcare facilities in the UAE are expected to increase in the coming decade to

accommodate a rapidly growing population which is currently 4.5 million and expected to reach 5.3

million in 2010. It is also expected that in the coming decade the UAE will have more than 10,000

patient beds. Dubai Healthcare City alone comprises of 9 hospitals and 1100 beds and due to be fully

operational in 2017.

2.6.1 Development of healthcare system

The UAE has a comprehensive, government-funded health service and a rapidly developing private

health sector that delivers a high standard of healthcare to the population. In many parts of the UAE

health care delivery is undergoing a significant transformation.



Most of the infectious diseases like malaria, measles and poliomyelitis that were once endemic in the

UAE have been eradicated, while pre-natal and post-natal care is on par with the world's most

developed countries: the new-born (neonate) mortality rate has been reduced to 5.54 per 1000 and

infant mortality to 7.7 per 1000. Maternal mortality rates have dropped to 0.01 for every 100,000.

As a consequence of this high standard of care at all stages of the health care system, life expectancy at

birth in the UAE, at 78.3 years, has reached levels similar to those in Europe and North America. To date,

health care in the UAE has, by and large, been funded by the Government. As with other sectors, this

emphasis is evolving and public-private partnerships are becoming more important.

Public policy focuses on developing organizational and legal frameworks based on best practice, to

upgrade the private and public sector health service capabilities. In addition, public policy action will set

priorities for health services development within the sector.

2.6.1 Organization of Health System

The public healthcare services are run by different authorities: The Health Authority-Abu Dhabi, the

Dubai Health Authority, the Ministry of Health and the Armed Forces and Police Medical Services. Eachentity has its separate autonomous operation authority and run independent of each other. The Health

Authority-Abu Dhabi (HAAD) was established in 2001by a royal decree by the ruler of Abu Dhabi with a

mandate to manage all the Ministry of Health hospitals and PHCs within the Emirate of Abu Dhabi. The

aim of the HAAD is to upgrade and operate all of the Emirate of Abu Dhabi hospitals according to

accredited international standards. In 2007 HAAD announced its plan to invest US$ 400 million in

projects to improve healthcare provision in the Emirate of Abu Dhabi.

2.6.2 Partnerships

The UAE is working with leading global institutions to develop its health care system. The UAE seeks to

become a major center for world-class health care in the Middle East, for its own residents, as well asthose in the region. A number of the partnerships are with US-based institutions:

y The Harvard Medical School Dubai Center (HMSDC) is a joint project of Harvard University and

the Dubai Health Care City (DHCC).

y The Cleveland Clinic Abu Dhabi is in development and will be a world-class specialty hospital and

clinic.

y The Johns Hopkins Medical School manages health care systems in Abu Dhabi, including the

469-bed Tawam Hospital.

2.6.3 Financing

In June of 2006 a health insurance scheme was implanted based on a presidential decree, making it

compulsory for employers and business owners in the Emirate of Abu Dhabi to provide health insurance

for their expatriate employees and their families. In May of 2006, the National Health Insurance

Company (Daman) in partnership with Munich RE Group, created to provide affordable health insurance

schemes to all residents of Abu Dhabi, started operations.

2.6.4 Healthcare Services andMinistrysResponsibilities



The Ministry of Health (MOH) has federal responsibilities over the healthcare services in the UAE

including managing the Northern Emirates healthcare system (the northern Emirates include Ras Al

Khaimah, Ajman, Umm al Q aiwain, Shargah and Fujairah). Approximately five percent of the MOH

budget is spent on medical machines, tools, and supplies. Currently MOH operates 13 hospitals with

2100 beds and 61 PHCs distributed throughout the Northern Emirates. MOH has started the

construction of a 500-bed referral hospital, which will service the population of the Northern Emirates.

The MOH also announced that it will be implementing a mandatory health insurance scheme for the

Northern Emirates as part of a proposed federal insurance law.

Dubai Department of Healthcare and Medical Services (DOHMS) were established in 1972 by the Ruler

of Dubai to provide healthcare services in the Emirate of Dubai. DOHMS manages four hospitals, with

1504 beds and 20 PHCs & peripheral clinics distributed throughout the Emirate of Dubai. On June 2007

the Dubai Health Authority (DHA) was created following a Royal Decree mandating better healthcare

services and facilities within the Emirate of Dubai to the benefit of all UAE nationals, residents and

visitors. DHA implementation will be undertaken in phases and will take around four years to complete.

In the meantime the DOHMS will continue to provide medical services. The DHA transition team is

working closely with the Health Insurance Committee on future financing arrangements for a national

health insurance scheme for the emirate of Dubai.

The private sector is also developing steadily to become an important partner in providing

comprehensive healthcare to the people in the UAE. Currently, there are more than 25 privately owned

hospitals with 1000 plus beds and several more are coming up. The American Hospital, New Medical

Centre, Al Zahra Hospital, Welcare Hospital, Belhoul Apollo Hospital, Zulekha Hospital, Emirates

Hospital, Al Noor Hospital, and others are some of the established private hospitals. Apart from the

large private hospitals, patients also have the option to visit private polyclinics that house several

specialties under one roof.

Gulf Diagnostic Center and Dubai London Clinic are leading private polyclinic with about 50,000

registered patients. Moreover, there are 1019 privately owned clinics, covering all specialties. Recentdevelopments indicate that the private sector is likely to expand and play a bigger role in the healthcare

industry, particularly because of the new health insurance schemes and the aim of the UAE government

now to treat highly complex operations within the country, rather than sending patients abroad for

treatment.

Documents

Write-Up on Healthcare System