Health system models-an overview

Health Models And Health System Models

Dr. Ahmed-Refat AG Refat (Nov. 2012) www.SlideShare.net/AhmedRefat

Dr. Ahmed-Refat AG Refat

Taibah University – Nov. 2012

Contents Section One : Health Models

Positive Vs Negative

Preventive Vs Curative

Biomedical Vs social

Section Two: Health Care systems Private vs Public Beveridge, Bismark,Private and Out-of-pocket models

Tired vs Diffuse Care Model

Outpatient Care and Hospitals

Global Health Care Systems UK – Canada, France, Germany, Japan & USA.

Health Models

• Positive Health Model

• Negative Health Model

Determinants

• Biomedical Health Model

• Social Health Model

• Preventive Health Model

• Curative Health Model

Health Models

The positive and negative models

of health

1- The positive model of health

One of the best known of the positive definitions of health is that

of the World Health Organization. In defining health as:

"a state of complete physical, mental and social well-

being and not merely the absence of disease

or infirmity"

the World Health Organization has sought to broaden our view

of the nature of health status and therefore the responsibilities

of those who contribute in different ways to health care.

Merits of The WHO definition of Health

Recognizes the various aspects of health (physical,

mental and emotional)

Draws attention to the fact that health affects every

sphere of life (work, rest and play)

Incorporates a subjective element – how we feel about

our state of health.

Limitations of the WHO' definition

Too idealistic, in the sense that it conceptualizes good

health in such a way that it is unattainable – no one would

ever describe himself or herself as being in ‘a state of

complete physical, mental and social well-being’

All-embracing and undifferentiated, since it seems to

imply that every positive aspect of life is an element of good

health

Too generalized, with too little account being taken of the

differences between individuals.

Health in terms of the capacity

The Ottawa Charter defined health as a resource for doing

things—a capacity, not a state of well-being. According

to this definition, health must be clearly differentiated from

health status, because health has a dynamic potential for

increasing or at least maintaining whatever health status

(place on the spectrum) a person has. Health in this sense is a

means of moving toward the positive end of the health

status spectrum.

Probably more than achieving some degree of health status,

people want health as a resource for doing the things they want

to do. That view of health characterizes the new era of health.

The goal is longevity with good function, and the challenge

to health professionals is not only preventing disease and

overcoming it when it occurs but also helping people to

achieve that goal.

The new concept advanced in the Ottawa Charter—that health

is not a state of well-being but a resource for living—can be

measured in its physical (e.g., body mass index [BMI]), mental

(e.g., cognition), and social health dimensions (e.g., network of

friends and relatives). It also can be measured in terms of

health-related practices (e.g., exercise), because there is

evidence that, as a category of personal characteristics, health-

related practices are important resources for living that carry

great influence for future health

2- The negative model of health The negative model is based on the idea that health is the polar

opposite of disease. On the basis of this model, people are

deemed to be healthy if no trace of disease can be found,

regardless of how they feel or behave.

Conversely, if disease is detected, they are considered to be

unhealthy to varying degrees, regardless of whether or not they

regard themselves as unhealthy.

Thus, unlike positive definitions of health, negative definitions

allow no room for subjectivity. They are essentially objective in

the sense that the presence or absence of disease is

established by scientific investigation.

With the advance of technology for the purposes of screening

and diagnosis, the detection of disease – and therefore the

assessment of health status from the point of view of the

negative model – becomes more sophisticated and relies less

and less on patient reporting.

Which model predominates?? Which model predominates will be determined by a number of factors, including:

. the distribution of power between the various stakeholders, with

academics and some health care practitioners favoring positive definitions and doctors favoring negative definitions

. the stage of development of a health care system, with less

developed, simpler systems tending towards positive definitions and more developed, complex systems tending towards negative definitions

. the particular circumstances of an individual case, with positive

definitions more likely to prevail in community settings and negative definitions more likely to prevail in hospital settings.

Health Models

The Biomedical and Social Models

of Health

1- The biomedical model of health There is a close affinity between the biomedical model and the

negative model of health. The basic idea is that the human

body is a machine made up of a number of parts/organs . As

such, any malfunction (such as disease) is an ‘engineering’

problem which is capable of being tackled by technical means.

The model has its origins in germ theory, which is particularly

associated with the pioneering work of Pasteur and Koch in the

nineteenth century. This, in turn, gave rise to the doctrine of

specific aetiology: for every disease there is a single and

observable cause that can be isolated.

Against this, however, must be set a number of weaknesses:-

Not everyone exposed to a causative agent will give in to

the disease.

There appear to be many different causative agents

rather than a single one.

2-The Social Model of Health The social model can be seen, in part, as a reaction to the

limitations of the biomedical model. This model is closely linked

with positive definitions of health. In the social model the health

of individuals and communities is seen as the result of complex

and interacting social, economic, environmental and personal

factors.

A person’s optimum state of health is equivalent to the state of

the set of conditions which fulfill or enable a person to work to

fulfill his or her realistic chosen and biological potentials.

Because of the range of its determinants, the potential for

allocating responsibility for ill-health is much greater. In the

case of biomedicine it has been easier to regard ill-health as an

‘act of God’ and therefore nobody’s fault.

By contrast, the social model gives rise to many possibilities for

apportioning blame and has resulted, on the one hand, in

‘victim blaming’ and, on the other, in pointing the finger at

deficiencies in public policy and the behavior of business and

industry.

People are influenced and constrained by the social, economic

and physical environment in which they live and the

organizational setting within which they work.

Thus the failure of governments to provide adequate housing

may result in individual behaviour which is damaging to health

and can also lead directly to an increase in respiratory disease.

In short, the social model sees health primarily as an issue for –

and the responsibility of – society as a whole. Among other

things, this means a collective responsibility for ensuring that

individuals have every opportunity to adopt healthy lifestyles.

By now it should be clear that the positive and

social models of health are more likely to lead to

an approach to health care in which top priority is

given to prevention.

Likewise, application of the principles of the

negative and biomedical models will result in a

curative approach.

Health Models

The Preventive and Curative

Models of Health

A- The Preventive Model of Health Care

Advocates of the preventive model:

. Give pride of place to measures designed to reduce the

incidence and prevalence of ill-health – for example,

promotional campaigns, ensuring that people have access to

the prerequisites for health (adequate housing, satisfactory diet,

etc.), screening, and vaccination and immunization

. Argue for what has come to be called ‘healthy public policy’

which means, in effect, making ‘healthy choices the easier

choices’ – for example, ensuring that healthy food is cheaper

than unhealthy, and creating environments in which it is difficult

to smoke.

. Emphasize the importance of mobilizing a wide range of

agencies such as academic institutions, voluntary organizations

and local authorities, and tapping as many different sources of

expertise as possible, both professional and lay

. See community settings, such as the home, schools and

leisure centres, as the most significant locations for the

provision of health care

. Stress the need for more epidemiological research, to

enhance our understanding of the links between disease

patterns and social factors in health and health care.

There are a number of drawbacks, however.

First, preventive strategies are more difficult to justify because

of the long-term nature of the outcomes and uncertainty

regarding their effectiveness.

For example, the effect of anti-smoking campaigns in primary schools

will not be felt for several years, during which time many other factors

will play a part in influencing people’s smoking behavior

Second,

the collaboration necessary when several professional groups

and agencies are involved in planning and implementing a

preventive programme is extremely difficult to sustain in

practice and can easily lead to a dilution of responsibility.

prevention often raises people’s expectations to such an extent

that some will inevitably be disappointed. This is the case with

people who, despite their healthy lifestyle, getting heart

disease.

B-The curative model of health care

Those who pledge the curative model take as their starting

point the insights provided by the biomedical model and

concentrate on measures designed to cure disease.

. Give pride of place to what are called, in the colourful

language sometimes used in this context, ‘magic bullets’

(wonder drugs, heroic surgery, and other techniques)

. Focus on the treatment of individuals

. Legitimize the central and dominant role played by clinicians

in the health care process

. Regard hospitals as the principal delivery point for health care

Services . place particular emphasis on research into the

biological causes of ill-health and methods for tackling the

malfunctions referred to earlier.

The overwhelming argument in favour of this approach is that

many diseases and conditions can be successfully treated

through the application of science and technology. Moreover, in

so doing, it has made a significant contribution to improving the

health status and well-being of many people.

None the less, it is not without its drawbacks.

For many conditions, particularly those which are currently

major causes of morbidity, such as lung cancer, cures have

remained vague.

In addition, treatment is often very costly in financial terms and

carries with it risks, /‘iatrogenesis’ –

At the same time, the curative approach has made only a

limited contribution to improving the health status of the

population as a whole.

This is reflected, in part, in the increasing demand for health

services.

Models of Health Care System

According to Delivery Methods

According to

Funding Methods

Health System According to Funding Types

All healthcare systems occupy a distinct place on the “public

versus private” continuum in terms of the financing and delivery of

healthcare . Although distinctions blur, most systems tend to

predominantly hold a (a) “national health service model,” (b)

“entrepreneurial model,” or (c) “mandated insurance model.”

A• Under a national health service (e.g. the United Kingdom

and Spain), universal coverage is publicly financed through

taxation. Healthcare delivery occurs via mostly public

mechanisms; hospitals are publicly owned, and medical

services are primarily delivered by government-salaried

physicians .

B• In an entrepreneurial model of healthcare (e.g. the United

States), people voluntarily purchase employment-based or individual

insurance, and the healthcare delivery mechanisms (providers and

healthcare facilities) exist largely in the private sector. Financing can

come from both private and public sources . Consumerist-

commercial-capitalist

C• Between these two extremes lies the mandated insurance

model, in which compulsory universal coverage is publicly

financed and health care is delivered by both public and private

entities . Within this category, systems can be further classified as

following a national health insurance/single-payer model (e.g.

Sweden) or a multi-payer health insurance model that relies on

sickness funds to provide universal health coverage (e.g. Germany

and France) .

Another Classification

Health Systems Based on the Sources of Funding

Based on the source of their funding, three main models of

national healthcare systems can be distinguished:

1. the Beveridge model,

2. the Bismarck model

3. the Private Insurance model

1-The Beveridge Model "Public Model" - “Socialized Medicine Model”

The Beveridge "public" model was inspired by the William Beveridge

Report for social insurance presented in the English Parliament in 1942.

Funding is based mainly on taxation and is characterized by a centrally

organized National Health Service where the services are provided by

mainly public health providers (hospitals, community GPs, specialists and

public health services).

In this model, healthcare budgets compete with other spending priorities.

The countries using this model, beside United Kingdom, are Ireland, Sweden,

Norway, Finland, Denmark, Spain, Portugal, Italy, Greece, Canada and

Australia.

Characteristics: Healthcare is provided and financed by the government,

through tax payments

There are no medical bills

Medical treatment is a public service

Providers can be government employees

Lows costs b/c the government controls costs as the sole

2-The Bismarck Model "Mixed Model" - “Sickness Funds”

The Bismarck „mixed” model was inspired by the 1883 Germany

Social Legislation and National Health Insurance Plan for workers

introduced by Otto von Bismark, the Chancellor of Germany. Funds

are provided mainly by premium-financed social/mandatory insurance

and, beside Germany, is found in countries such as France,

Switzerland, Japan, Central and South East European (CSEE)

countries and Former Soviet Union (FSU) countries. Also Japan has

a premium-based mandatory insurance funds system. This model

results in a mix of private and public providers, and allows more

flexible spending on healthcare.

Characteristics: Providers and payers are private

Private insurance plans – financed jointly by employers and

employees through payroll deduction

The plans cover everyone and do not make a profit

Tight regulation of medical services and fees (cost control)

3-The Private Insurance Model

The „private” insurance model is also known as the model of

„independent customer”. Funding of the system is based on

premiums, paid into private insurance companies, and in its pure form

actually exists only in the USA.

In this system, the funding is predominantly private, with the

exception of social care through Medicare and Medicaid. The great

majority of providers in this model belong to the private sector.

Out-of-Pocket Model 4-(!)

There is also a 4th type of health system ( No System !!!!) called

" the out-of-pocket-model!!!

Only the developed, industrialized countries -- perhaps 40 of

the world's 200 countries -- have established health care systems.

Most of the nations on the planet are too poor and too disorganized to

provide any kind of mass medical care. The basic rule in such

countries is that the rich get medical care; the poor stay sick or die.

In rural regions of Africa, India, China and South America, hundreds

of millions of people go their whole lives without ever seeing a doctor.

They may have access, though, to a village healer using home-

brewed remedies that may or not be effective against disease.

Characteristics:

Only the rich get medical care; the poor stay sick or die

Most medical care is paid for by the patient, out-of-pocket

No insurance or government plan

What is the best System?

All models of health care systems are imperfect and there is

no a odel which is the best and broadly accepted and

recommended. There are big differences among countries in

relation to the goals, structure, organization, finance and the

other characteristics of the health care systems.

These differences are influenced by history, traditions,

socio-cultural, economic, political and other factors. But,

regardless of all present differences, there are same common

characteristics, typical for all organized health care systems

Health Care Delivery System

There is no perfect healthcare delivery system for a country.

Some models seem to work better than others but each has its own

advantages and drawbacks.

Broadly, healthcare delivery models could be classified under

tiered system or diffuse system.

a- The Tiered System

The tiered system is made up of regionalized systems of healthcare

delivery divided into Primary care, Secondary care and Tertiary

care. Such a pyramidal system is more common in UK and in HMOs

(Health Maintenance Organizations) in US.

a- Primary care Refers to the activities concerned with prevention and treatment of

common medical problems in outpatient setting. Care is delivered by

primary care practitioners (PCPs) in the US or general practitioners

(GPs) in the UK. A PCP could be responsible for 2000-3000 patients

and is responsible for managing patient’s overall care.

b- Secondary care

Concerns with treatment of disorders requiring specialist

opinion or hospitalization. The patients are usually referred from

Primary care and the physicians are affiliated to a hospital or a

group practice.

c- Tertiary care

Provides medical and/or surgical management of complex

disorders in an inpatient setting and usually requiring

collaboration between multiple specialties. These are super-

specialized standalone hospitals or specialty departments in a

multi-specialty hospital.

Self Care ( Nonprofessional care ):

Self care is nonprofessional care. It is performed within the

family, and the population group counts from one to 10 persons.

Self-care implies largely unorganized health activities and health-

related decision-making carried out by individuals, families,

neighbors, friends and workmates. These include the maintenance of

health, prevention of disease, self-diagnosis, self-treatment, including

self-medication, and self-applied follow- up care and social support to

the sick and weak members of the family after contact with the health

services

b- Diffuse System In the diffuse system there is no such division. In this system patients

can directly approach specialists without consulting GPs or PCPs

first. The boundaries between GPs, internists, family practitioners and

pediatricians are blurred. Many internal medicine specialists provide

primary care, many family practitioners provide secondary care.

The diffuse system is the relatively more common in United States. It

is a diamond type of system with most hospitals providing a mix of

multi-specialty secondary and tertiary services. The stress is on

getting the latest technology and advanced clinical care closer to

Outpatient Care

Outpatient care is very important part of the health care system

representing the first contact of the consumer with the

professional health care and the first step of a continuous

health care.

Such kind of services and institutions might be a part of the

hospital, community health center or certain polyclinic

and dispensaries In-patient care and institutions

In-patient/hospital care means admission into hospital or other

stationary health organization, including diagnosis, treatment

and rehabilitation, with in-patient care and treatment of the most

severely ill patients who cannot be treated in ambulatory-

polyclinic institutions or at home.

Hospitals are institutions whose primary function is to provide

diagnostic and therapeutic medical, nursing, and other

professional services for patients in need of care for medical

conditions. Hospitals have at least six beds, an organized staff

of physicians, and continuing nursing services under the

direction of registered nurses. The WHO considers an

establishment a hospital if it is permanently staffed by at least

one physician, can offer in-patient

accommodation, and can provide active medical and nursing

care .

Classification of hospitals

Hospitals are classified in several ways: length of stay, type of

service, and type of control or ownership, as well as size of the

hospital

Length of stay is divided into acute care (short term) and

chronic care (long term). Acute care (of short duration or

episodic) is a synonym for short term. Chronic care (or long

duration) is a synonym for long term hospitals.

Types of service denote whether the hospital is „general” or

„special”.

A third classification divides hospitals by type of control or

ownership: for profit (investor owned), or not for profit,

governmental (federal, state, local, or hospital authority),

religious or voluntary organizations.

International

Health Care Systems

GREAT BRITAIN Insured :100% of population insured

Spending:7.5% of GDP

Funding

— Single payer system funded by general revenues

(National Health System); operates on huge deficit

Private Insurance

— 10% of Britons have private health insurance

— Similar to coverage by NHS, but gives patients access to

higher quality of care and reduce waiting times

Physician Compensations

— Most providers are government employees

Physician Choice

— Patients have very little provider choice

Copayment/Deductibles

— No deductibles

— Almost no copayments (prescription drugs)

Waiting Times

— Huge problem

Benefits Covered

— Offers comprehensive coverage

— Terminally ill patients may be denied treatment

CANADA Insured

— Single payer system – 100% insured

— Each province must make insurance:

Universal (available to all)

Comprehensive (covers all necessary hospital

visits)

Portable (individuals remain covered when

moving to another province)

Accessible (no financial barriers, such as

deductible or copayments)

Funding

— Federal government uses revenue to provide a block

grant to the provinces (finances 16% of healthcare)

— The remainder is funded by provincial taxes (personal

and corporate income taxes)

Spending

— 9% of GDP

Private Insurance

— At one time all private insurance was prohibited;

changed in 2005

— Many private clinics now offer services on the black

market

Physician Compensation

— Physicians work in private practice

— Paid on a fee-for-service basis

— These fees are set by a centralized agency; makes

wages fairly low

Physician Choice

— Referrals are required for all specialist services except

the ED

— Generally no copayments or deductibles

— Some provinces do charge insurance premiums

Waiting Times

— Long waiting lists

— Many travel to the U.S. for healthcare

FRANCE • Insured

– About 99% of population covered

• Cost

– 3rd

most expensive health care system

– 11% of GDP

• Funding

– 13.55% payroll tax (employers pay 12.8%, individuals

pay 0.75%)

– 5.25% general social contribution tax on income

– Taxes on tobacco, alcohol and pharmaceutical company

revenues

• Private Insurance

– “more than 92% of French residents have

complementary private insurance”

– These funds are loosely regulated (less than U.S.); the

only requirement is renewability

– These benefits are not equally distributed (creates a two-

tiered system)

• Physician Compensation

– Providers paid by national health insurance system

based on a centrally planned fee schedule – fees are

based on an upfront treatment lump sum (similar to

DRGs in US)

– However, doctors can charge whatever they want

– The patient or the private insurance makes up the

difference

– Medical school is free

– Legal system is fairly tort averse

• Physician Choice

– Fair amount of choice in the doctors they choose

• Copayment/Deductible

– 10% to 40% copayments

• Waiting Times

– Very little waiting lists/times

• Technology

– Government does not reimburse new technologies very

generously

– Little incentive to make capital investments in medical

technology

GERMANY • Insured

– 99.6% of population – sickness funds

– Those with higher incomes can buy private insurance

– The federal gov. decides the global budget and which

procedures to include in the benefit package

• Funding

– Sickness funds are financed through a payroll tax (avg.

15% of income)

– The tax is split between the employer and employee

• Private insurance

– 9% of Germans have supplemental insurance; covers

items not paid for by the sickness funds

– Only middle- and upper-class can opt out of sickness

• Physician Compensation

– Reimbursement set through negotiation with the

sickness funds

– Providers have little negotiating power

– Very low compensation

– Significant reimbursement caps and budget restrictions

— Almost no copayments or deductibles

Technology

— Low technology compared to U.S.

Waiting Times

— WHO reported that “waiting lists and explicit rationing

decisions are virtually unknown”

Benefits Covered

— There is an extensive benefit package which even

includes sick pay (70% to 90% of pay) for up to 78

JAPAN Insured

— Universal health insurance based around a mandatory,

employment-based insurance

— “The Employee Health Insurance Program” requires that

all companies with 700 or more employees to provide

workers with health insurance

— Small business workers join a government-run small

business national health insurance plan

— The self-employed and the retired are covered by

Citizens Insurance Program administered by municipal

governments

— Not as high as U.S.; average household spends $2300

per year on out-of-pocket costs

— Japans have a healthy lifestyle – lower incidence of

disease

Funding

— 8.5% (large business) or an 8.2% (small business)

payroll tax

— Payroll taxes are split almost evenly between employer

and employee

— Those who are self-employed or retired must pay a self-

employment tax

Private Insurance

— Very rare for Japanese to use this; less than 1%

Physician Compensation

— Hospital physicians are salaried

— Non-hospital physicians are paid on a fee-for-service

— Hospitals and clinics are privately owned but the

government sets the fee schedule

Physician Choice

— No restrictions on physician or hospital choice

— No referral requirements

— Copayments are 10% to 30%

— Capped at $677 per month for the average family

Technology

— High levels of technology; comparable to U.S.

Waiting Times

— Significant problem at the best hospitals b/c they cannot

charge higher prices

Comparison of Global Healthcare by Rand Corporation

UNIVERSAL LAWS OF HEALTHCARE SYSTEMS

No matter how good the healthcare in a particular country

people will complain about it

No matter how much money is spent on healthcare, the

doctors and hospitals will argue that it is not enough

The last reform always failed

- Tsung-mei Cheng,

an American economist

5 MYTHS ABOUT HEALTH CARE

AROUND THE WORLD

1. It’s all socialized medicine out there

Many countries provide universal coverage

using private providers, hospitals and insurance

2. Overseas, care is rationed through limited choices or long

lines – some truth.

3. Foreign health systems are inefficient, bloated

bureaucracies

4. Cost control stifles innovation

False. This pressure to control cost can

generate innovation

5. Health insurance companies have to be cruel

Insurance plans in other countries accept all

applicants

Cannot deny on the presence of a preexisting

condition

Cannot cancel as long as you pay your

premium

U.S. HEALTHCARE: COST DRIVERS

Drugs and devices

Defensive medicine

Demands

— Patient related

— Physician related---? Fee for service!

Administrative costs

Market driven healthcare

COST MANAGEMENT

Evidence based medicine

Use of protocol and guidelines

Reduction of administrative costs

Managing demand

Management of chronic diseases

Promotion of healthier living

Tort Reform

In United States, the healthcare administration is largely

outside the governmental control. This leaves hospital

capacity regulation, residency seat allocation and

coordination of care in the hands of private entities.

The physician groups control the policy, occupational

standards and entry requirements for licensing. So their

professional interests and favor for technology and inpatient

capacity also led to expansion of hospital facilities.

Over the last few decades, the healthcare has

increasingly been delivered at hospitals rather than physician

offices. With emerging consumer driven healthcare models

and advanced surgical techniques, there is a gradual shift

towards Ambulatory Clinics. This will introduce newer models

of healthcare delivery.

The United States has a unique system of health

care delivery.

The US health care delivery system is complex

and massive.

In contrast to the United States, most

developed countries have national health

insurance programs

referred to as “universal access”

• provide routine and basic health care

• run by the government and financed

through general taxes.

All Americans are not “entitled” to routine

and basic health care services.

187.4 million Americans have private health

insurance coverage,

Health insurance can be bought from:

1,000 health insurance companies

70 BlueCross/BlueShield plans

The managed care sector includes

approximately: 540 licensed health maintenance

organizations (HMOs) 925 preferred provider

organizations (PPOs)

Vulnerable Populations

Particularly the poor, uninsured, minorities

and immigrants

live in disadvantaged communities and

receive care from “safety net” providers.

Vulnerable Populations

Safety nets are not secure

Provider type and availability vary

Some individuals give up care and seek

hospital emergency services if nearby

Characteristics Of The U.S. Health Care System

No Central Governing Agency;

Little Integration and Coordination

Technology-Driven and Focuses on Acute

High on cost, Unequal in Access, and Average in

Outcomes

Imperfect Market Conditions

Government as Subsidiary to the Private Sector

No Central Governing Agency;

Little Integration and Coordination

The US system is different from other

developed countries

It is not centrally-controlled

• Central systems are less complex, less

costly

Has different payment, insurance, and

delivery mechanisms

Health care is financed both publicly and

privately

Technology-Driven and Focuses on Acute Care

What is good about USA system? US is responsible for more than 53% of Drug Research

Dollars

Best Medical Education and Training in the World

Eight of the top 10 medical Advances in the past 20 years was

developed in the US

Nobel Prizes in Medicine have been awarded to more

Americans than to researchers in all other countries combined

Eight of the 10 top-selling drugs are made in the US

We have the highest breast, colon, and prostate cancer

survival rates in the world

Cited References

1. WHO. Measurement of Levels of Health. Geneva, Switzerland: WHO; 1957. 2. World Health Organization (WHO), European Regional Office. Ottawa Charter

for Health Promotion. Copenhagen, Denmark: WHO; 1986. 3. Lester Breslow, Health Measurement in the Third Era of Health. Am J Public

Health. January; 96(1): 17–19. 2006 4. Elizabeth A. www.ololcollege.edu 5. HEALTH SYSTEMS AND THEIR EVIDENCE BASED DEVELOPMENT. VESNA

BJEGOVI] AND DON^O DONEV(editor). Hans Jacobs Publishing Comany2004 6. Roger Ottewill and Ann Wall . Models of health and health care. Crwon

7. Sibu Saha, HEALTHCARE MODELS ACROSS THE GLOBE A COMPARATIVE ANALYSIS. Harvard University

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