Health system functions and structure

Health System Functions And Structure
"HS Building Blocks"
Dr. Ahmed-Refat AG Refat (Nov. 2012)

Health System
Functions And Structure
Dr. Ahmed-Refat A.G Refat
Taibah University - Nov. 2012

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Contents
 Definition of Health System
 Health System Goals
 Attributes of a Good Health System
 Health System Functions
 Problems with Health System
 Health System Challenges ( Global Facts)
 Six Health System Building Blocks of Health System
 Ten Essential Public Health Functions

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Definition of
Health System!!

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What is a Health System?
A “system” is an arrangement of parts and their
interconnections that come together for a purpose .

A health system, like any other system, is a set of inter-connected
parts that have to function together to be effective .

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A health system has many parts. In addition to patients, families,
and communities, Ministries of Health, health providers, health
services organizations, pharmaceutical companies, health financing
bodies, and other organizations play important roles.

The interconnections of the health system can be viewed as the
functions and roles played by these parts. These functions include
oversight (e.g., policymaking, regulation), health service provision
(e.g., preventive services, clinical services, health promotion),
financing, and managing resources (e.g., pharmaceuticals, medical
equipment, information).

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A Health System can defined as :
“the combination of resources, organization, financing and management
that culminate in the delivery of health services to the population.”

“all activities whose primary purpose is to promote, restore, and maintain
health.” ( WHO 2000). In recent years, the definition of “purpose” has been
further extended to include the prevention of household poverty due to
illness.

"A health system is the sum total of all the organizations, institutions and
resources whose primary purpose is to improve health.

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A health system consists of all organizations, people and actions whose
primary intent is to promote, restore or maintain health (WHO 2007) .
This includes efforts to influence determinants of health as well as more
direct health-improving activities.
Health System is much broader than the public health service delivery
system that is often the focus of public health officials.
It includes the full range of stakeholders in a health sector, for example,
private for-profit and not-for-profit service providers, health insurance
organizations, public safety legislation, community outreach workers,
patients, and consumers, as well as mothers caring for sick children.

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WHO (2007) also defined health system strengthening, as:
…improving [the] six health system building blocks and managing their
interactions in ways that achieve more equitable and sustained
improvements across health services and health outcomes.

A health system is therefore more than the pyramid of publicly owned
facilities that deliver personal health services. It includes, for example, a
mother caring for a sick child at home; private providers; behaviour
change programmes; vector-control campaigns; health insurance
organizations; occupational health and safety legislation.

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It includes inter-sectoral action by health staff, for example, encouraging
the ministry of education to promote female education, a well known
determinant of better health

A health system needs staff, funds, information, supplies, transport,
communications and overall guidance and direction. And it needs to
provide services that are responsive and financially fair, while treating
people decently.

The ultimate responsibility for the overall performance of a country's health
system lies with government, but good stewardship by regions and
individual health institutions is also vital.

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Health System Goals
Health systems have multiple goals. The World health report 2000 defined
overall health system outcomes or goals as: improving health and health
equity, in ways that are responsive, financially fair, and make the best, or
most efficient, use of available resources.

There are also important intermediate goals: the route from inputs to
health outcomes is through achieving greater access to and coverage for
effective health interventions, without compromising efforts to ensure
provider quality and safety.

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Good Health System
A good health system delivers quality services to all people, when and
where they need them.
The exact configuration of services varies from country to country, but in
all cases requires a forceful financing mechanism; a well-trained and
adequately paid workforce; reliable information on which to base
decisions and policies; well maintained facilities and logistics to deliver
quality medicines and technologies.

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HS Function
The World Health Report 2000 (WHO 2000) identifies the four key
functions of the health system:
(1) stewardship (often referred to as governance or oversight),
(2) financing,
(3) human and physical resources,
and (4) organization and management of service delivery.

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In a 2005 World Health Assembly resolution, WHO member states
committed to develop their health systems to ensure that all people have
access to health services without being subject to financial hardship
paying for them – a goal defined as universal health coverage (WHO
2010).
http://www.who.int/features/factfiles/universal_health_coverage/facts/en/index.ht
ml

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Health System Building Blocks
To achieve their goals, all health systems have to carry out some basic
functions, regardless of how they are organized: they have to provide
services; develop health workers and other key resources; mobilize and
allocate finances, and ensure health system leadership and governance
(also known as stewardship, which is about oversight and guidance of
the whole system).
For the purpose of clearly articulating what WHO will do to help
strengthen health systems, the functions identified in the World health
report 2000 have been broken down into a set of six essential ‘building
blocks’. All are needed to improve outcomes. This is WHO’s health
system framework.

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Health System functions/ building bloc ks:
1. Leadership and governance
2. Health financing
3. Service delivery
4. Human resources for health
5. Medical products, vaccines and technologies
6. Health information systems

This WHO enumeration and definition of the building blocks has been
adopted widely, and now provides a common terminology for discussing
key health system functions.

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The six build ing block s of a he alth system a re:
1- Good health services are those which deliver effective, safe, quality
personal and non-personal health interventions to those who need
them, when and where needed, with minimum waste of resources.
2- A well-performing health workforce is one which works in ways
that are responsive, fair and efficient to achieve the best health
outcomes possible, given available resources and circumstances. I.e.
There are sufficient numbers and mix of staff, fairly distributed; they are
competent, responsive and productive.

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3- A well-functioning health information system is one that ensures
the production, analysis, dissemination and use of reliable and timely
information on health determinants, health systems performance and
health status.

4- A well-functioning health system ensures equitable access to
essential medical products, vaccines and technologies of assured
quality, safety, efficacy and cost-effectiveness, and their scientifically
sound and cost-effective use.

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5- A good health financing system raises adequate funds for health,
in ways that ensure people can use needed services, and are protected
from financial catastrophe or impoverishment associated with having to
pay for them.

6- Leadership and governance involves ensuring strategic policy
frameworks exist and are combined with effective oversight, coalition
building, the provision of appropriate regulations and incentives,
attention to system-design, and accountability

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Building Blocks Interaction

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Health System Actors
1. Public Sector
The public sector, also called the government sector, is a complex group of
actors that includes ministries of health (MOHs), line ministries, and public
servants.

Public health funding comes from a variety of sources such as taxes, social
security payments, and donors .

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The public sector has 11 Essential Public Health Functions (EPHF)
as defined by a WHO study in 41 countries

- EPHF 1 - Monitoring, evaluation, and analysis of health status
- EPHF 2 - Surveillance, research, and control of the risks and threats to public
health
- EPHF 3 - Health promotion
- EPHF 4 - Social participation in health
- EPHF 5 - Development of policies and institutional capacity for public health
planning and management

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- EPHF 6 - Strengthening of public health regulation and enforcement capacity

-EPHF 7 - Evaluation and promotion of equitable access to necessary health

services

- EPHF 8 - Human resources development and training in public health

EPHF 9 - Quality assurance in personal and population-based health services

EPHF 10 - Research in public health

- EPHF 11 - Reduction of the impact of emergencies and disasters on health

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Challenges Facing public health Sector

Public health sectors face many challenges in carrying out their essential
functions. Some are internal, such as lack of financing, insufficient management
skills, and corruption. Others are environmental, such as changing epidemiologic
and demographic trends and emerging diseases, new medical technology,
globalization, and health reform .

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2. Private Sector
Reliance on government health services alone is often insufficient in achieving
improvements in health status indicators such as child mortality or the prevention
of HIV/AIDS. The private sector is a key source of health services, and its
coverage is rapidly expanding. In many developing countries, there is high
utilization of the private sector for essential health services, (IFC 2007).
Therefore, including the private health sector in the HSA provides a more
complete and accurate understanding of a country’s health sector.

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The private health sector is typically described as comprising
“all providers who exist outside of the public sector, whether their aim is
charitable or commercial, and whose aim is to treat illness or prevent disease”

The private health sector comprises both forprofit, commercial entities and
the not-for-profit organizations like nongovernmental organizations (NGOs) and
faith-based organizations (FBOs) that engage in health care.

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There are also a variety of private providers.
1-Formally trained and licensed private providers include doctors, nurses,
midwives, and paramedical staff such as clinical officers and physician
assistants.
 Private pharmacists and drug sellers are often the first-line providers in the
formal health sector that serves people in poor and remote communities.
2-The informal health sector consists of traditional healers, traditional birth
attendants (TBAs), indigenous systems medical providers (ISMPs), and market
drug sellers.

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The informal sector is a significant, although not well documented, source of
health care, particularly for rural and poor populations.

A substantial number of public sector health practitioners in developing countries
also work for private clients during evenings and weekends. These providers
constitute an
important component that spans the public and private sector, and their role
could be an important consideration when assessing service delivery and human
resources.

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3. Communities and Patients
With their focus on the supply side of health care (service provision), the six
building blocks do not always capture the importance of the demand side, which
comprises communities and patients.

The World Health Report 2000 (WHO 2000) recognized the importance of people
as financiers of care, as citizens with a role in health governance, as care
providers, and as consumers.

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Problems with health systems
Problems with health systems are not confined to poor countries. Some rich

countries have large populations without access to care because of inequitable

arrangements for social protection. Others are struggling with escalating costs

because of inefficient use of resources.

Health outcomes are unacceptably low across much of the developing world, and

the persistence of deep inequities in health status is a problem from which no

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country in the world is exempt. At the centre of this human crisis is a failure of

health systems .

Failing or inadequate health systems are one of the main obstacles to scaling-up

interventions to make achievement of internationally agreed goals such as the

MDGs a realistic prospect.

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Health system challenges: a few facts and figures
• Globally, health is a US$3.5 trillion industry, or equal to 8% of the world's
GDP.
• Large health inequalities persist: even within rich countries such as USA and
Australia, life expectancy still varies across the population by over 20 years.
• Recent essential medicines surveys in 39 mainly low- and low-middle-income
countries found that, while there was wide variation, average availability was
20% in the public sector, and 56% in the private sector.
• Each year, 100 million people are impoverished as a result of health
spending.

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• Extreme shortages of health workers exist in 57 countries; 36 of these are in
Africa.
• In over 60 countries, less than a quarter of deaths are recorded by vital
registration systems.
• An estimated 50% of medical equipment in developing countries is not used,
either because of a lack of spare parts or maintenance, or because health
workers do not know how to use it.
• Private providers are used by poor as well as rich people. For example, in
Bangladesh, around ¾ of health service contacts are with non-public providers.

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• In 2000, less than 1% of publications on Medline were on health services and
systems research.
• Globally, about 20% of all health aid goes to support governments' overall
programmes (i.e. is given as general budget or sector support), while an
estimated 50% of health aid is off budget.
• There has been a rapid increase in global health partnerships. More than 80
now exist, of which WHO houses over 30.

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10 Essential Public Health
Services
http://www.cdc.gov/nphpsp/essentialservices.html

The Essential Public Health Services provide the fundamental framework of
the public health activities that should be undertaken in all communities.

The Core Public Health Functions Steering Committee developed the framework
for the Essential Services in 1994. This steering committee included
representatives from US Public Health Service agencies and other major public
health organizations.

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The Essential Services provide a working definition of public health
and a guiding framework for the responsibilities of local public
health systems.

1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the
community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve
health problems.

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5. Develop policies and plans that support individual and community
health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the
provision of health care when otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and
population-based health services.
10. Research for new insights and innovative solutions to health problems.

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Essential Service #1
Monitor Health Status to Identify Health Problems
 Assessment of statewide health status and its determinants, including the
identification of health threats and the determination of health service needs.
 Analysis of the health of specific groups that are at higher risk for health
threats than the general population.
 Identification of community assets and resources, which support the state
public health system (SPHS) in promoting health and improving quality of life.
 Interpretation and communication of health information to diverse audiences
in different sectors.
 Collaboration in integrating and managing public health related information
systems.

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Diagnose and Investigate Health Problems and Health Hazards

This service includes:
• Epidemiologic investigation of disease outbreaks and patterns of infectious
and chronic diseases, injuries, and other adverse health conditions.
• Population-based screening, case finding, investigation, and the scientific
analysis of health problems.
• Rapid screening, high volume testing, and active infectious disease
epidemiologic investigations.

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Inform, Educate, and Empower People about Health Issues
• Health information, health education, and health promotion activities
designed to reduce health risk and promote better health.
• Health communication plans and activities such as media advocacy and
social marketing.
• Accessible health information and educational resources.
• Health education and promotion program partnerships with schools, faith
communities, work sites, personal care providers, and others to implement and
reinforce health promotion programs and messages.

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Mobilize Partnerships to Identify and Solve Health Problems
• The organization and leadership to convene, facilitate, and collaborate with
statewide partners (including those not typically considered to be health-related)
to identify public health priorities and create effective solutions to solve state and
local health problems.
• The building of a statewide partnership to collaborate in the performance of
public health functions and essential services in an effort to utilize the full range
of available human and material resources to improve the state’s health status.
• Assistance to partners and communities to organize and undertake actions to
improve the health of the state’s communities.

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Develop Policies and Plans that Support Individual and Statewide Health
Efforts

• Systematic health planning that relies on appropriate data, develops and
tracks measurable health objectives, and establishes strategies and actions to
guide community health improvement at the state and local levels.
• Development of legislation, codes, rules, regulations, ordinances, and other
policies to enable performance of the Essential Public Health Services,
supporting individual, community, and state health efforts.
• The process of dialogue, advocacy and debate among groups affected by the
proposed health plans and policies prior to adoption of such plans or policies.

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Enforce Laws and Regulations that Protect Health and Ensure Safety
• The review, evaluation, and revision of laws (laws refers to all laws,
regulations, statutes, ordinances, and codes) designed to protect health and
ensure safety to assure that they reflect current scientific knowledge and best
practices for achieving compliance.
• Education of persons and entities in the regulated environment and persons
and entities that enforce laws designed to protect health and ensure safety.
• Enforcement activities of public health concern, including, but not limited to,
enforcement of clean air and potable water standards; regulation of health care
facilities; safety inspections of workplaces; review of new drug, biological, and
medical device applications; activities occurring during emergency safety seat
usage, and childhood immunizations. …etc..

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Link People to Needed Personal Health Services and Assure the Provision
of Health Care When Otherwise Unavailable
 Assessment of access to and availability of quality personal health services for the
state’s population.
 Assurances that access is available in a coordinated system of quality care which
includes outreach services to link populations to preventive and curative care, medical
services, case management, enabling social and mental health services, culturally
and linguistically appropriate services, and health care quality review programs.
 Partnership with public, private, and voluntary sectors to provide populations with a
coordinated system of health care.
 Development of a continuous improvement process to assure the equitable
distribution of resources for those in greatest need.

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Assure a Competent Public and Personal Health Care Workforce
• Education, training, development, and assessment of health professionals--
including partners, volunteers and other lay community health workers--to meet
statewide needs for public and personal health services.
• Efficient processes for credentialing technical and professional health
personnel.
• Adoption of continuous quality improvement and life-long learning programs.
• Partnerships with professional workforce development programs to assure
relevant learning experiences for all participants.
• Continuing education in management, cultural competence, and leadership
development programs.

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Evaluate Effectiveness, Accessibility, and Quality of Personal and
Population-Based Health Services
• Evaluation and critical review of health programs, based on analyses of
health status and service utilization data, are conducted to determine program
effectiveness and to provide information necessary for allocating resources and
reshaping programs for improved efficiency, effectiveness, and quality.

• Assessment of and quality improvement in the State Public Health System’s
performance and capacity.

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Research for New Insights and Innovative Solutions to Health Problems
• A full continuum of research ranging from field-based efforts to foster
improvements in public health practice to formal scientific research.
• Linkage with research institutions and other institutions of higher learning.
• Internal capacity to mount timely epidemiologic and economic analyses and
conduct needed health services research.

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Public Health Agency of Canada:
Six Essential Activities Of Public health
1. Health protection: This includes ensuring that water, air and food are safe,
maintaining the regulatory framework for the control of infectious disease and
protection from environmental threats, as well as advising on food and drug
safety regulations.
2. Health surveillance: The ongoing, systematic use of routinely collected
health data for the purpose of tracking and forecasting health events or
health determinants. It includes
i. The collection and storage of relevant data
ii. The integration, analysis, and interpretation of these data

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iii. The production of tracking and forecasting products with the
interpreted data
iv. Publication and dissemination of those products
v. Provision of expertise to those developing or contributing to
surveillance systems, including risk surveillance.
vi. The information produced by surveillance is used in planning
services and prevention programmes.
3. Disease and injury prevention: The investigation, contact tracing, and
development of preventive and control measures to reduce the risk of
infectious disease emergence and outbreaks as well as the promotion of
safe, healthy lifestyles to reduce preventable illness and injuries.
4. Population health assessment: Understanding the health of communities
or specific populations, as well as the factors that underlie good health or
pose potential risks, to produce better policies and services.

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5. Health promotion: Preventing disease, encouraging safe behaviours, and
improving health through public policy, community-based interventions,
active public participation, and advocacy or action on environmental and
socio-economic determinants of health.
6. Emergency preparedness and response: Planning for natural disasters
(e.g., floods, earthquakes, fires, dangerous infectious disease) and man-
made disasters (e.g., those involving explosives, chemicals, radioactive
substances, or biological threats and social disruption).

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Cited References
WHO Health System Web Pages
http://www.who.int/healthsystems/en/
http://www. who.int/healthsystems/topics/en/

WHO- 2012 : World Health Report

http://www. who.int/healthinfo/EN_W HS2012_Full.pdf
The World health report 2000 : health system s : improving performance
http://www.who.int/whr/2000/en/whr00_en.pdf

WHO- Health System Performance
http://www. who.int/health-systems-performance/

Monitoring the building blocks of health system s: a handbook of indicators and their measurement strategies. © World Health Organization 2010
http://www. who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf
THE HEALTH S YSTEM ASS ESSMENT APPROACH: A HOW-TO MANUAL
Version 2.0 September 2012
http://www.healthsystem s2020.org/ content/re source/detail/528/

USAI D- Health system 2020

http://www.healthsystems2020.org/

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