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https://twitter.com/KeystoneHPSR
Building the HPSR Community Building HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Health System and Health Policy Frameworks- 1
KEYSTONE
What is a health system?
• A health system is the sum total of all the organizations, institutions and resources whose primary purpose is to improve health
• A well functioning health system responds to a population’s needs and expectations by:– improving the health status of individuals, families and communities – defending the population against what threatens its health– protecting people against the financial consequences of ill-health– providing equitable access to people-centred care
www.who.int
KEYSTONE
What is Policy?“Whatever governments choose to do
or not to do” Dye 1984
“… the manner in which problems get conceptualized and brought to government; institutions formulate alternatives and select solutions; and solutions get implemented, evaluated and revised” Sabatier 1999
“Decisions (in the public and private sector)… taken by those with responsibility for a given area, e.g. health, education, environment or trade” Buse et al. 2005
Decisions with a Purpose
KEYSTONE
1. SYSTEM FUNCTIONS
Systems defined on basis of their utility, problems mainly relate to efficiency
Decisions are concentrated, flow in one direction
Policy content not problematized
E.g. WHO ‘building blocks’
International
National
Subnational
Local
ARENA
Systems Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems
Outputs
Outcomes
Policy Decisions
KEYSTONE
Three key goals (WHO – WHR 2000)
1) Improvement in health : ‘health status of the entire population ..over people’s whole life cycle, taking account of both premature mortality and disability.’
2) Responsiveness: ‘how the system performs relative to non-health aspects, meeting a population’s expectations of how it should be treated by providers of prevention, care or non-personal services’– Respect for persons: confidentiality, autonomy– Client orientation: prompt attention, amenities, choice
3. Health System Goals
KEYSTONE
3) Fair financing : ‘the risks each household faces due to the costs of the health system are distributed according to ability to pay rather than to the risk of illness: a fairly financed system ensures financial protection for everyone..’– Unexpected costs: reduce out of pocket payment (OOP)– Contribution to total costs: richer households contribute
proportionally more than poorer households (progressive)
4) Now combined as ‘universal health coverage’: “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost”. (WHA 2005 58.33)
3. Health System Goals
KEYSTONE
Systems ‘Software’Ideas and interests, Values
and normsRelationships and power,
Systems ‘Hardware’Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems
International
National
Subnational
Local
ARENA2. COMPLEX SYSTEMS
Decisions are diffused through the system, focus on non-linear relationships
‘Software’ critical to health systems performance
Problems (and solutions) are related to (understanding) complexity
See Frenk 1994, de Savigny and Adam 2009
KEYSTONE
A health system
Health• Beyond sickness
– mental & physical health– social wellbeing
• Beyond the individual– actors/agents promoting
health & wellbeing– domestic/national AND
international factors impacting on health and HS agents
A complex adaptive system• A set of interacting elements• More than the sum of the
parts
• Acts in ways that are not fully predictable e.g. feedback loops
• Influenced by history • Self-organising • Resistant to change
KEYSTONE
COLLECTIVE MEDIATOR
HEALTH CARE PROVIDERS
ORGANISATION
POPULATION
ORGANISATION
RESOURCE GENERATORS
OTHER SECTORS
Basis for eligibility
Degree of control
Degree of control
Degree of control
Taxes, Demands for services
Services with health effects
Subsidies, Information, Ideologies
Potential personnel, money, data
Schemes for interpreting human experience
Human resources, Payment mechanisms, Scientific information, Technology
Formal health servicesCommunity participation
Frenk, 1994
Competition for responsibilities and resources
KEYSTONE
Systems ‘Software’Ideas and interests, Values and norms Relationships
and power,
Systems ‘Hardware’Human Resources, Finance, Medicines & technology, Organizational structure, Service infrastructure, Information systems
International
National
Subnational
Local
ARENA3. SOCIAL CONSTRUCTION
Policy and systems are shaped by particular politics, culture, discourse (and not others)
Policy (and systems) can be problematized
Suggests solutions within and beyond health systems
(Sheikh et al. 2011)
KEYSTONE
People Centred Health Systems
1. Putting people’s voices and needs first
2. People-centredness in service delivery
3. Relationships matter: health systems as social institutions
4. Values drive people-centred health systems
KEYSTONE
1. PUTTING PEOPLE’S
VOICES & NEEDS FIRST
How can people’s voices influence shaping the health
systems to serve public interest?
• Back to PHC approach: equality, rights, health as socio-economic issue
• Confronting disproportionate power balances
• Participation Participatory governance
2. PEOPLE-CENTREDNESS IN SERVICE DELIVERY
Putting people first in terms of how services are designed and delivered,
not merely orienting services on basis of diseases, or for
convenience of clinicians
• Quality and safety of care• “Longitudinality”, closeness to
communities, responsiveness to users’ views, requirements
• Capacity building as enhancing capabilities for responsiveness
KEYSTONE
3. HEALTH SYSTEMS AS SOCIAL INSTITUTIONS
Health systems actors – administrators, providers, users, researchers – are linked through
relationships
• Systems thrive on trust, dialogue between actors,
• System change goes beyond altering rules & resources, to managing relationships effectively
4. VALUES DRIVE PEOPLE-CENTREDNESS
Decision-making should be informed by people-centred values:
justice, respect, inclusiveness
• Values define system culture and influence perfomance
• Procedural justice complements distributional justice, in a people-centred system
KEYSTONE
The Health Policy “Triangle”
CONTENT
ACTORS
• as individuals•as members of groups
PROCESSCONTEXT
(Walt and Gilson 1994)
KEYSTONE
Types of Policies
• Distributive / redistributive: concerned with the distribution of new resources or with changing the distribution of existing resources
• Regulatory: concerned with the control of individual and organization activities
• Constituent: concerned with setting up and re-organizing institutions
From Lowi (1972)
KEYSTONE
Top-down and Bottom-up policy
Top Down
• Policy-making and implementation are distinct
• Focus on execution of policy-makers’ intentions
• Starts with a statement of intent
• Implementation with clear lines of authority and enforcement of norms
Bottom Up
• No clear separation between policymaking, implementation
• Subordinate actors (e.g. service providers) also seen as decision-makers
• Starts with a statement of behavior in the ‘field’
• Implementation seen as relationships between actors
KEYSTONE
Policy Actors
Governments
Lawmakers Executive Judiciary
Ministries and bureaucracy
Institutions, firms and organizations
Technical and professional bodies
Donor agencies
Civil society and interest groups
‘Networks’
‘Street level bureaucrats’
Laity / electorate
Multilateral / bilateral organizations
NON-STATE
STATE
Open Access PolicyKEYSTONE commits itself to the principle of open access to knowledge. In keeping with this, we strongly support open access and use of materials that we created for the course. While some of the material is in fact original, we have drawn from the large body of knowledge already available under open licenses that promote sharing and dissemination. In keeping with this spirit, we hereby provide all our materials (wherever they are already not copyrighted elsewhere as indicated) under Creative Commons Attribution-NonCommercial 4.0 International License. To view a copy of this license visit http://creativecommons.org/licenses/by-nc/4.0/ This work is ‘Open Access,’ published under a creative commons license which means that you are free to copy, distribute, display, and use the materials as long as you clearly attribute the work to the KEYSTONE course (suggested attribution: Copyright KEYSTONE Health Policy & Systems Research Initiative, Public Health Foundation of India and KEYSTONE Partners, 2015), that you do not use this work for any commercial gain in any form and that you in no way alter, transform or build on the work outside of its use in normal academic scholarship without express permission of the author and the publisher of this volume. Furthermore, for any reuse or distribution, you must make clear to others the license terms of this work. This means that you can:
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