Health Systems International

8/13/2019 Health Systems International

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HEALTH SYSTEMS and SERVICES: A Global & Developing Country perspective

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Population and International HealthPIH 30 - Health Systems International

Prof Ruair BrughaDept Epidemiology and Public Health Medicine


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RCSI Medical Graduate profile

The RCSI doctor:

4.3 Understands the characteristics of a range of healthsystems and population health responses and the meritsand problems associated with each.

4.3.1 Understands the principles, values and strategiesthat underpin the population health and different health systemsapproaches to controlling the major burden of disease in wealthyand poor countries

4.3.2 Understands how health systems and services areorganised, financed, managed, staffed and delivered in onesown country and the main models used in other high, middle and

low-income countries.


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Health Systems: Learning

Outcomes students will be able to

1. Explain, with examples, the inter-sectoral nature of health

systems, including the broader actions that contribute to health The basic primary health care interventions that benefit populations

most

2. Define what is meant by the health system and list itsgoals, components and levels

3. Discuss the origins and global variations in health systems

4. Explain Patient referral pathways through the differentlevels of the health system

Primary (health) care Secondary (hospital) care Tertiary(specialist) care

5. Describe global health worker distribution and responsesto the health workforce crisis

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Millennium

Development Goals

1: Eradicate extreme poverty and hunger2: Achieve universal primary education

3: Promote gender equality and empower women

4: Reduce child mortality5: Improve maternal health

6: Combat HIV/AIDS, malaria and other diseases

7: Ensure environmental sustainability

8: Develop a Global Partnership for Development

See http://www.un.org/millenniumgoals/pdf/mdgs_glance_factsheet.pdf

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Impact of AIDS in 1990sand then?

Lifeexpectancy

atb

irth,

total(years)

Botswana 1960

Life expectancy progress from 1960 to 2010

Botswana 2001

66 years

1990

51 years

2000

?56 years

2007

What is the triple burden of AIDS on the health system?

?

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Anti retrovirals in 2000s


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MDG 4: reduce child mortality by 2/3rds,

1990-2015

What 3 interventions will prevent most deaths?6


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Health action goes beyond

Health Services water, food, work,

sex, travel, cooking

investment in health, theeconomy and an equitablesociety as well as

investing in health services

environmental problems need to betackled because they impact on health

the health system is about more than just health services or health is tooimportant to be left to doctors alone

Q?What are the causes of the high burden of HIV and AIDS in southern

Africa? What population measures will prevent HIV?7


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Example: Maternal Health

MDG 5: reduce maternal mortality ratio by three quarters (1990-2015)

Safe Motherhood strategy components?: Community education

Antenatal care: e.g. nutritional supplements, blood pressure andinfectious disease screening,

Post partum care Skilled assistance at delivery

Interventions to manage obstetric complications & emergencies

What else . . . .?

1. Transport ! in many poor countries, facilities for managingcomplications exist but people cannot reach them

2. Trained health workers often lost to rich countries, e.g. Ireland

3. New technologies mobile phones

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From health services to health

systems definitions

1. the resources, organisation, financing and management that go

into the delivery of health services to the population

2. the means whereby programmes and interventions areplanned and delivered

3. the institutions and individuals that combine to determinehow goods and services are delivered, whose principalintended function is to improve human health

Apart from meeting the health & health care needs ofpopulations, what is the other big role of Health Services ?

they employ people !

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Health

Systems components

1. Health Services types, levels, target groups

Preventive and curativepersonal health services

Primary, secondary and tertiary services (appropriate levels of care)

Services for specific population groups, e.g. children, mental illness,People living with AIDS, disability, etc.

2. Resources needed Trained staff, commodities (drugs), facilities (hospitals and clinics)

3. a) Organisation and b) Stewardship

a) Ministries of health, private sector, voluntary sector

b) Planning, Management, Regulation, Legislation

4. Financing mechanisms Tax, insurance, user (patient) fees . . . . more later

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How health systems evolved

around the world

Pre-colonial Informal traditional systems in Africa

Herbalists Spiritualists / fetish priests

Formal traditional systems in Asia Ayurvedic medicine

Homeopathy (also popular in Europe and USA)

1.There are more formally trained Ayurveds and Homeopathists in India thanAllopaths (MB BS doctors)

2.Healers are the first port of call for 50% who seek care for HIV and sexuallytransmitted diseases in Africa

3.80% of people in Africa continue to visit traditional healers because ofphysical, mental and social ill health (see Wikipedia on traditional medicine)

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From colonial health to

Primary Health Care

Health Services in Africa + much of Asia

Hospital focus no formal primary care service Urban concentration cities prioritised rural areas neglected

Focused on needs of elite few

Primary Health Care Principles (Alma Ata 1978) Universal accessibility and coverage

Community participation

Intersectoral action for health

Appropriate (evidence-based) interventions

Affordability and Sustainable systems

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Health System Structure:

primary care

Aim of Primary Health Care:

to provide care as close to the community as possible, but safely & effectively

Primary Care: 1st level of formal care within the health system

- Ireland: GP, District Nurse, Pharmacist (Primary Care team, esp in UK)

- Africa:

Community health post, village health worker, traditional birthattendant

- India: Rural areas: informally trained private provider practicing a mix of

allopathy, homeopathy and ayurvedic medicine

Urban areas: privately for profit GP trained in allopathy, orhomeopathy or Ayurvedic medicine

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* Referral system in

Ireland and the UK

The GP (General Practitioner) = gate keeper to

The Hospital

County or district (secondary care)

Regional, voluntary & national specialist (tertiary care)

Level of hospital care depends on

Complexity of case and need for specialist investigation

and specialist care Access (financial and physical)

* Student Notes Page include hyperlinks to Wikipedia for explanations of terms

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Referral system in

India & Africa

Rural Africa and India

Functioning public district hospital + district management are key

primary care services rudimentary patients directly access district hospital

In a functioning system, cases requiring emergency care and major surgeryare referred to district hospital + more complex cases referred onwards

district management of preventive, treatment and care services

Urban Africa and India:

Mix of public sector and private sector

private specialists working in small private hospitals and clinics large tertiary public hospitals providing basic and even primary care as

well as tertiary specialties

mixed public private practice common (e.g. Drs work in public sector in themorning and refer patients to their afternoon private clinics)

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16http://www.gapminder.org/


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Human Resources for

Health: a framework

1. Capacity

Basic and in-service training appropriate to disease burden

To produce knowledge, skills, competencies, attitudes

2. Remuneration and other incentives

Financial: salary, pension, personal and family allowances Non-financial incentives: access to training

3. Organisational environment Availability of facilities, drugs, equipment to deliver services

Management / leadership

Hongoro & Normand17


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COST-Africa: a case study

1. RCSI is partnering with the College of Surgeons of East, Central and Southern Africa(COSECSA) to train doctors to be specialist surgeons in 10 African countries on-linesimulation methods and exams overseen by RCSI.

Hypothesis: training African doctors as surgeons in-situ will meanthey will continue to practice in these countries.

Problem: salary levels at 10% of Europe + US levels

Doctors not employed at district hospitals ($) + doctors emigrate

2. Response: train non-medics (clinical officers 3 yrs training) to do major surgery COST-Africa: an EU-funded cluster randomised controlled trial (RCT) to measure the

health impact and cost-effectiveness of training clinical officers to do major surgery atthe district level in Malawi and Zambia: 2011-15

Potential to save thousands of lives / ten thousands of DALYs

New roles for surgeons as: (i) specialists, (ii) trainers, (iii) quality assurers

a population approach to health workforce planning based on good evidence18


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1. Ethical international recruitment Avoid active recruitment from countries facing critical shortages

Ireland recruited its nurses mainly from Philippines and India andnow doctors from India and Pakistan is this ethical ?

2. Health workforce development and health

systems sustainability Member states should train and retain a health workforceappropriate to its needs HWs central to health systems Ireland is good at training, but not at retaining its doctors and nurses

3. Fair treatment of migrant health personnel Health workers have rights, including rights to emigrate, Rights to accurate information, and to equal treatment

researchable issues being researched by RCSI in 2011-15

Global Code on the international

recruitment of Health Personnel


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4. International cooperation

Destination countries encouraged to collaborate with sourcecountries to maximise mutual benefits Ireland (donors, practitioners and researchers) collaborating with

African countries but what about our main source countries?? Support training, technology and skills transfer best practice is to

support in-country training: RCSI COSECSA, COST, Medical Schools

5. Support to developing countries Technical assistance and financial support (as above)

6. + 7 Data gathering, reporting, research Establish effective health personnel information systems Research programmes Share information and Report on implementation internationally

Global Code on the international

recruitment of Health Personnel

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