Introduction to Health Systems & Health Services Systems

Introduction to Health Systems & Health Services Systems

Borwornsom Leerapan, MD PhD

MGMG 548: Health Service Systems and Health Systems

CMMU, Mahidol University May 18, 2014

Pix source: ra.mahidol.ac.th

MGMG 548 •  Major issues in the organization of a health services system •  The role of values in the development of health care policy •  Methods for assessing the health status of populations •  Analysis of need for, access to and use of services; current supply

and distribution of health resources •  Analysis of health care costs and expenditures •  Sociopolitical, economic, and moral/ethical issues confronting the

public health and medical care system •  Trends in service provision, human resources, financing and health

services organization, and implications for the public’s health.

Course Description

Source Prattana Punnakitikashem. PhD; Pix source: online.wsj.com

Format

Pix source: online.wsj.com

F/U

Mini-lecture

DiscussionQ&A

Wrapup

To-do list

Course Website

Course Calendar

Week Date Topic 1 May 18, 2014 Overview of health & health services

Systems 2 May 25, 2014 Systems thinking & the building blocks of

health systems 3 June 1, 2014 Healthcare quality 4 June 8, 2014 Healthcare efficiency 5 June 15, 2014 Health equity 6 June 22, 2014 Social determinants of health 7 June 29, 2014 Mid-term exam

Course Calendar

Week Date Topic 8 July 6, 2014 Ambulatory care and primary healthcare 9 July 13, 2014 Chronic care 10 July 20, 2014 Long-term care 11 July 27, 2014 Emergency care 12 August 3, 2014 Palliative care 13 August 10, 2014 Care for certain diseases and populations:

travel clinic 14 August 17, 2014 Student presentations of final papers

Required reading: •  Selected readings available via the course website. •  In addition, there is a recommended textbook for this course.

–  The Institute of Medicine (2001). Crossing the quality chasm: a new health system for the 21st century. Committee on Quality Health Care in America, Institute of Medicine. Washington, D.C.: National Academy Press.

Learning Materials

Source: nap.edu

Optional textbook/resource: •  Garwande, A. (2002). Complications: a surgeon's notes on an imperfect

science. New York, NY: Picador Press. •  Roberts, M. J., Hsiao, W., Berman, P., & Reich, M. R. (2004). Getting health

reform right: a guide to improving performance and equity. New York, USA: Oxford University Press.

•  Aday, L. A., Begley, C. E., Lairson, D. R., & Balkrishnan, R. (2013). Evaluating the healthcare system: effectiveness, efficiency, and equity. Chicago, IL: Health Administration Press.

•  Wibulpolprasert, S., Sirilak, S., Ekachampaka, P., & Wattanamano, N. (2011). Thailand health profile 2008-2010. Bangkok; The War Veterans Organization of Thailand Press.

Learning Materials

Up and Down the Ladder of Abstraction

Abstract: •  Concepts

•  Theories •  Principles

•  Strategies

Concrete: •  Case studies •  Data, Evidence

•  Analysis, Synthesis

•  Presentations

1.  Pre-test 2.  Concepts of health and health determinants 3.  Health systems vs. Health services systems 4.  Desirable characteristics of health services systems 5.  Case study and discussion –  Healthcare managers vs. policy/systems analysts.

Outline for Today


Pretest (in-class exam, no grade)


Considering the provided VDO presentation, please give your best answers to these two following questions: 1.  What “health systems issues” are dominated in the

provided VDO presentation? (Please describe.) 2.  As a (future) administrators in your healthcare

organizations, what could you do to address such issues? (Elaborate more on what, why, and how.)

(30 min)

Pre-test Exam

Concepts of Health & Health Determinants


WHO definition of Health:

“Heath”

Source: reamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Thailand’s Definition of Health:

“Heath”

Source: Statute on National Health System B.E. 2552 (2009)

Health & Health Determinants

Figure source: Thailand Health Profile 2012

Health Systems & Health Services Systems


“System”

Source: Scheerens and Bosker 1997; Pix source: system humanrevod.wordpress.com

“CIPO” Model

“Health System”

Source: who’s World Health Report (2000)

“Health System”

Pix source: WHO’s framework for action. (2007)

•  “The Six Building Blocks” and their interconnections

“Health System”

Pix source: WHO’s framework for action. (2007)

Social Determinants of Health

Pix source: greenpeace.org; twirlit.com; who.int/bulletin; cha-amcity.go.th

•  Health is not merely the absence of disease or infirmity. •  Health promotion and disease prevention •  Health promotion strategies have to go beyond health services

sector.

Stakeholders in Thai Health System

Pix source: www.nationalhealth.or.th

Desirable Characteristics of Health Services Systems


Goals of Health Services System

Source: Modified from WHO (2000) and Marc J Roberts et al. (2003)

Health

•  A great health services system should be: 1.  Equitable 2.  Efficient 3.  Safe 4.  Timely 5.  Effective 6.  Patient-centered

Desirable Health Services System

Source: Adapted from IOM (2001)

“STEEEP”

Quality

•  Equity: – Equality of opportunity to access to healthcare

services, regardless of race, gender, age, religion, geographic location, socioeconomic status

– “Equal services for equal needs, and unequal services for unequal needs”

1. Equitable Health Services

Pix source: www.stephenharrington-online.com

What is Your Theory of Justice?

Pix source: hp-lexicon.org/wizards; helenicproducts.com

•  How would you fairly cut this cake into two pieces for each of the twins?

Theory of Justice

Source: John Rawls. The Theory of Justice (1971, 2001): Pix source: irwinbartlet.wordpress.com

– Fair decisions should be made from “the original position” where no one knows what burdens or benefits he or she might receive once “the veil of ignorance” is lifted.

•  John Rawls: “Justice as Fairness”

Equity vs. Equality

Pix source: twicsy.com/i/TwC76c

•  Equity means equality of opportunity (“justice as fairness”). •  Equality is not always justice.

Equality Equity

•  It is very difficult to measure “health equity”. •  Equitable health services could be used as its proxy

measures, particularly measures of the “accessibility to health services”: –  Physical accessibility –  Psychological accessibility –  Financial accessibility –  Information accessibility

Equitable Health Services

Source: WHO/Europe (2007)

•  Efficiency: – Efficient health services means a system that utilize

health resources (drugs, human resources, budgets) in a cost-effective fashion, with utility maximization and waste reduction.

2. Efficient Health Services

Source: Modified from IOM (2001)

Efficiency of Thai Healthcare?

“31.2% of diabetes patients and 50.3% of hypertension patients are not diagnosed. Only 28.5% and 20.9% of cases have been diagnosed, treated and brought under control.”

Figure source: Kanchanachitra .et al. (2010)

•  Two approaches to improve efficiency: 1.  Technical efficiency 2.  Allocative efficiency

Technical vs. Allocative Efficiency

•  Quality: – “Quality is in the eye of the beholder.” – Nonetheless, all health services should be “safe,

timely, effective, patient-centered”.

3. Quality Health Services

Source: Adapted from IOM (2001)

•  Safety: – By design, a system that prevents medical error and

avoid iatrogenic injuries.

Quality as Safety

Source: Modified from IOM (2001); Pix source: thieme-connect.de/ejournals; tumblr.com

Quality as Safety

Source: amazon.com, matichonbook.com

(Disclaimer: Obviously, this is partly my self-advertisement!)

•  Timeliness: – Reducing waiting time of both health providers and

consumers, which sometimes lead to injuries and harms.

Quality as Timeliness

Source: Modified from IOM (2001); Pix source: toonpool.com/cartoons.jpg

•  Effectiveness:

–  Delivery of evidence-based health services to all people who likely will benefit from such services (“avoid underuse”) and provide no services that have no evidence of benefits or that could be harmful (“avoid overuse and misuse”).

Quality as Effectiveness

Source: Modified from IOM (2001); Pix source: www.rch.org.au/clinicalguide

•  Patient-centeredness: –  A system that respects the patient’s rights. –  Be responsive to personal beliefs ่ and value of individuals. –  Open an opportunity for patients (and families) and

clinicians to make mutual decisions on their health interventions

–  Not a disease-centered system –  Not a provider-centered system

Quality as Patient-Centeredness

Source: Modified from IOM (2001); Pix source: blog.skylight.com/patient-centric

Ø Learning about health systems: “Experience, not explanation.”

Picture source: commonsenseatheism.com; variety.thaiza.com

Adult Learning

EXPERIENCE

What Level of Our Learning?

•  Why Wisdom

•  How Knowledge

•  What, Who, When, Where Information

•  Number, Text, Picture, Sound, etc. Data

Q& A Discussions
