Comparative Health Systems Study Guide Flashcards
Health System
all activities whose primary purpose is to promote, restore, or maintain health and disease prevention, enviornmental safety.
What does a health system include?
health services, traditional healers, home care, all use of medication, health promotion and disease prevention, environmental safety.
Is education part of the health system?
No! It supports its purpose, but is not part of it
Americans consider the health system as
hospitals and clinics
What do other countries consider the health system as?
Health process in the entire country.
Health CARE system
The provision of and investment in health services.
Can be preventive, curative, or palliative
Proximate health factors
health system, healht behavior, psycosocial factors
Intermediate health factors
educaiton, occupation, income, ethnicity, environment, food, working conditions
Structural health factors
socioeconomic and political context
What is the #1 thing you can do to improve maternal and child health?
focus on female education… 50% of decline in U5MR is due to female education
Wealth and its connection to health
wealthier countries on average have individuals with longer life expectancy
income and survival are strongly correlated
It helps to a certain point w/ regards to increased life expectancy, but isnt everything
What is NOT captured in life expectancy numbers?
Quality of Life
What led to an improvement in health before modern medicine, and to what degree?
sanitation, germ theory, handwashing, birth spacing, housing improvements
IMR dropped from high 190s/1000 live births in 1900 to 30s/1000 prior to penecillian, all without drugs
What are the 3 goals of any health system?
1) Improve the health of the population and its distribution
2) Respond to people’s non-health expectations (customer service)
3) provide financial protection against the costs of ill health
What other goals should a health system encompass?
- Equitable provision of services
- Efficient provision of services
- should function as social institutions that communicate government’s committments to their citizens.
Why does health care need government intervention
Capital markets need perfect competition and information to function freely - health care has market failures that prevent optimal function without oversight
What are the marekt failures of health systems that create imperfect competition?
- Externalities
- Adverse Selection
- Moral Hazard
- Agency/Information Assymertry
- Monopolies
What is the government’s role in healthcare ?
AS health is a basic right of most countries’ citizenship, governments must ensure access to essential health care and quality of care, given that the market ISNT perfect
Government’s roles range by region and level of income
What is the role of government in the health system in SSA?
the government is often the payor and provider of health care… there isnt health insurance.
What % of all health spending runs through the government in the US?
45%
What is the role of the government in Canada, the UK, and France?
they are the main payor of health care and are sometimes the employer of physicians
What are the WHO building blocks of health?
She Helps Inmate Manage Fine Lines
Service Delivery Health workforce Information Medical products, vaccines, technologies Financing Leadership/Governmance
What are the goals relative to the WHO building blocks?
and IRIS
Improved Health (level and equity)
Responsiveness
Social and Financial Risk Protection
Improved Efficiency
Service Delivery
Offer safe, effective, quality personal and non-personal health interventions to those who need them, who and where needed, with a minimum waste of resources
Health Workforsce
works in ways that are responsive, fair, and efficient to achieve the best health outcomes possible, given available resources and circumstances.
Must be sufficient in numbers and mix of staff, and be fairly distributed; should be competent, responsive and productive.
Information
HIS must ensure the production, analysis, dissemination, and use of reliable and timely info on health determinants, health systems performance, and health status.
Medical Products, Vaccines, and Techonoliges
Must have equitable access to these. Must be of assured quality, safety, efficacy, and cost effectiveness, and should be scientifically sound and cost-effective in use.
Financing
system must raise adequate funds for health, in ways that ensure people can use needed services, and are protectd from financial catastrophe or impoverishment assoiciated with having to pay for them
Leadership/Governance
must ensure strategic policy frameworks exist and are combined with effective oversight, coalition building, the provision of appropriate regulation and incentives, have attention to system design, and have accountability.
How much we spend and how we spend it determines…
improved health
social and financial risk protection
improved efficiency
Total Expenditures on Health
all the $ spent in a country in 1 yr
Total expenditures as a % of GDP
how big a piece of the economic pie is healthcare?
Government expenditures on health as a % of total government expenditures
what % does the government spend on health as a % of all its spending
Per capita expenditure on health
total health expenditures divided by the population
What is the us spend per capita on health per year?
8,000
Where do global preventable deaths take place?
in the places with the lowest per capita spending
What are the sources of US spending on health?
Social health insurance (payroll taxes and private health insurance)
Direct expenditures (VA system)
Taxes
how are OOPP good?
discourages overuse of services
how are OOPP bad?
prevents the poor from getting essential care
Where are OOPP lowest?
IN high income countries…. ironically oopp drop as countries get wealthier, but the poor are the ones who need more help.
What is the range of OOPP as a % of total health spending?
70% down to 15%
What is the goal for OOPP?
to limit financial hardship, should be <20% of total health expenditures
what is NOT included in OOPP?
health insurance premiums.
What is the r^2 of weath and per capita expenditures?
95% - very highly correlated.
When did health services begin to be organized?
19th century
What were hospitals like in the 19th century?
they were places of last resort, where people went to die, or were refuges for the crippled/insane.
see same thing in africa today….go to the hospital, get Ebola.
Health care spending per capita for low-income countries
$24
Health care spending per capita for lower-middle income countries
$91
health care spending per capita for upper-middle income countries
$342
Health care spending per capita for high income countries
$3810
What did Germany do to start their HS?
in 1883, enacted a law requiring worker premium contributions to ensure health coverage (pool $ and provide HC in a systematic way)
What were the next 3 countries post Germany to work on creating a health care system?
Belgium, Norway, Britain
What was Russia’s basic health care system?
They created a tax-funded network of clinics and hospitals where treatment was free in the late 1800s.
By 1911, free crae was mandatory (were looking to improve the health of the farmers)
Bismark System
Social security system where employers and workers contriubte to health funds; generally progressive (although can me mildly regressive if there are ceilings on income contributions).
More you make the more you give.
Large pool of money from many workers.
Government kicks in money for unemployed
Nations that follow the bismark system:
Japan, Germany, US for employer sponsored HC
Participation in bismark system
mandatory, but wealthy can have option to opt out at times (Germany, Netherlands)
Who are the payers in the Bismark System?
The social insurance funds (multi-payer).
can be geographic, political, or religiously based
are not-for profit
are regulated by the state and require same comprehensive benefits for all members
can negotiate directly with providers and pharma
What is the choice option in Bismark systems?
have choice of providers and sometimes of sickness funds
Beveridge Model
Tax based insurance (income, sales, etc.)
Is progressive as long as the taxes are progressive
is portable since not tied to a job
directly pays the providers
Who participates in beveridge model
everyone, is mandatory
risk and contribution are spread over a large base
Promotes equity (as contributions are not based on health need) and solidarity
Payers in beveridge
single payer model
country examples of beveridge
canada, UK, US for veterans
What is the impact of the beveridge model on costs?
tends to have low cost per capita due to purchasing power and economies of scale
Semashko
tax funded, centralized planning, with universal coverage, free service, salaried workers, little or no private sector participation
What countries use semashko?
cuba, formerly eastern europe
Mixed model
USA
majority of health systems belong in this category
combination of tax based, social insurance and out of pocket funding for health care
Risk Rated premiums
Little risk transfer/pooling
Community Rated premiums
risk transfer between sick and healthy
Income Rated
Risk transfer between sick/healthy and rich/poor
What is the main underlying factor in health system formation?
societal values
What are the basic principles of government financed health systems?
comprehensiveness universality solidarity/equity portability accessibility/affordability choice of providers
Law of Inverse care - who and what?
julian tudor hart
availability of medical care varies inversely with need…this variability is much more potent when medical care is a marketplace, and is much less so when it its not
How does the US compare with everyone else wrt public spending?
its on par with many other countries but our costs are so high that OOPP is still super high in comparison
Challenges to Bevridge system
Assumes political support for redistribution
lessens accountabilty of providers to patient (sinced salaried from state)?
Lessens focus on personal responsibility?
Private Model
- Mandatory or Voluntary
- Premiums may be risk rated, community rated, or income rated (ACA made risk rating illegal)
- Can be for or not for profit
- Principle Coverage (US non poor, under age 65) or Supplementary (Canada to get dental care coverage)
Tax Based Insurance Countires
ANNI’S DUC
UK Canada Denmark Italy Australia New Zealand Norway Sweden
Social Insurance based Countries
GI FLAN
Germany France Austria Netherlands Luxembourg Israel
Mixed Countries
US
United States
Switzerland
US per capita vs others
8k vs next closest of 5k (denmark)
US as a % of gdp vs others
18% vs next closest of 12%
is US sicker?
no, younger than average, and have less smokers
Does the US have too many doctors?
no we have 2.4/1000 pop vs 3/1000 pop on avg
Do US citizens go to the doctor too much?
No, we average 3.9x/yr vs 6.3x/yr avg
Does the us have too many hospital beds?
No, we have 2.7 beds/1000 population vs oecd average of 3.2/1000 population
does the us have too many high tech surgeries?
no for some (hip replacements), yes for others (knee replacements)… not suepr clear this is the reason
Why this are US costs so high?
At the end of the day we just pay more per service than any other nation
Us on hospital discharge per capita costs
18k vs 6k median (and canada is #2 at 13k)
What is the median price of the top 100 drugs vs what the US pays?
43%
Office visits US vs others
$60 in us vs $43 average
Orthopetic fees
avg is 1000, but our private fees are way higher $3900
Cs doctors rates
on average just earn more than anywehre else in whe world
US Life Expectancy
below OECD median
Quality of Life - first 3 rankings
New Zealand, Canada, US (but maybe we’re just mroe optimistic, culturally, bc its self-rated rankings)
5 yr surival rate on select cancers - us vs others?
US is marginally better on 5 yr survival rate averages for select cancers (but not justified given how much more we spend on care)
US asthma mortality
0.4 vs OECD averge of 0.09… very bad!
diabetes mortality
32.9 vs 9.9 in oecd average
stroke
not as bad… 3.0 vs 4.9 oecd average
heart attack
same as stroke…4.3 vs 4.6 oecd average
asthma hospital admissions
us at 120.6 admissions per 100k population vs 51.8 per 100k admission Oecd average
COPD hospital admissions
US at 230 admissions per 100k population vs 198/100k population for oecd median
What percent of americans prior to the aca had health related cost-access problems?
1/3
How many americans were unable to or had problems paying medical bills in last year?
20% vs 9% at second closest country
how many americans spent more than $1000 out of pocket?
41% vs next closest country at 25%
Inequity in the US rich vs poor view on if you’d receive most-effective care if sick?
82% vs 62%
What % of the us thought the us health care system should be rebuilt completely in 2010?
1/3
What percent of Us docs were happy with the healthcare system?
<20%
5 Mechanisms to Control Costs
Control Prices LImit Service Volume Institute Budget Caps for Hospitals Share Costs with Patients Improve Efficiency
How can you control prices?
fee schedules
price setting by state
How can you Limit Service Volume
capitation, waiting lists, limits on choice of provider, physician supply policies
How do you share costs with patients?
copays, deductibles, uninsured services
How do you improve efficiency?
electronic medical records, competition, pay for performance
Low Income Countries per capita income averages
$1025 or less
Low-Middle Contries average Income
$1026-$4035
Upper Middle Income Countries Average Incomes
$4036 to $12475
High Income Countries Average
$12,476+
BRIC countries tend to be
upper middle income
Middle income countries tend to be
heterogeneous - large range in life expectancy, U5MR, MMR, TFR, HIV
What relatively rich country has the shortest life expectancy?
South Africa due to aids and inequity
What does low literacy rates impact and where do you see them?
impacts MMR and U5MR, as well as TFR –> pakistan
Range in health expenditure per capita in LMIC
very little to 1000
Range in health expenditure per capita in HMIC
200 to 1000
What is the Health Spending as a % of gdp on average for middle income countries?
6%
Universal Health Care
Included in replacement goals for MDGs
Definied as the ability of people to get good quality of health care services when they need it without financial hardship
Tradeoffs in attempt to move toward UHC
population - who is covered
services - what is covered
proportion of costs covered - how much?
Pooled funds
the fudns you collect in advance
Options of what to do with pooled funds (as need to tradeoff items, unless government puts more money in)
Extend to Uncovered
REduce cost-sharing and fees (to make more affordable to more people)
INclude other services
What will NOT result in UHC?
- expanding voluntary private insurance (us prior to ACA)
- providing only catastropic insurance (china tried, costs skyrocketed, and people got sicker)
- providing terrible services (peopel wont go)
How to extend services to cover poor from the start
1) cover everyone but narrow benefit package
2) cover larger package with co-payments from which the poor are exempt (rwanda today), or cover poor selectively (thailand before UHC)
Progressive universalism
planning to ensure the poor benefit from the start
Health System Prorities in HIC
Building Block: Financing
Goal: Equity, Responsiveness, Efficiency
Health System Priorities in Middle Income Countries
Improved Health
Social and Financial Risk Protection
What is the only low-income country in the Americas?
Haiti
How di the health system develop in sub-saharan africa?
- originally established by colonial powers designed for europeans, w/ 2nd tier for africans
- health infrastructure was concentrated in cities
- medical and nursing training was based on european models
- Health care provisoin in rural areas was priimarily in hands of local providers and NGOs
- after independence, countries struggled to maintain infrastructure and health workers
- Countries relied on commodity exports and loans to pay for health systems (agri was largest industry)
- Still much of rural population had little or no access to health care
How long after colonialization ended did Alma Ata Happen?
10 years, it took place in 1978
What did Alma Ata Do?
Health for all by 2000. attempted to put basic health care services foward as the stragey of health for all
What happened in Africa as a result?
- africa thought HFA was the right thing to do; trained workers in primary care and focused on rural areas
- Thought community should run w/ HC so ended era of faith based medicine…negative, bc that was free, so costs jumped
- Referral systems to higher care were ignored bc they erroneously thought that primary care would cure all ills
- Since it was given to the communities, some governments thought that meant they were absolved of responsibility
What caused debt service obligations for LIC’s to becomde unmanagable?
- global economic crisis in 1980s led to inflation and rise of debt
- commodity export prices fell
- drought, civil war, and poor leadership slowed down economy
- got to the point that even though they were borrowing at low rates, service payments out became more than loans in
- led to IMF and World Bank giving structural adjustment loans
What did structural adjustment entail?
- trade liberalization
- devaluation
- removal of subsidies and price controls
- cost recovery in health and education (user fees)
- reducing civil service rolls
- privatization
What happened to spending on HC during Structural Adjustment Era?
50% reduction, saw health as an expenditure, not an investment
What did the reduction on spending result in?
loss of health workers
collapse of drug supply & distribution programs
underinvestment in infrastructure
and
AIDS was discovered!
What are health systems in most lmic characterized by?
Underfunding and understaffing
Fragmentation in Care (verticle initiatives, disconnect between primary and higher level care)
Poor regulation of the private sector
What do these aspects of HS in LMIC result in?
limited access to services
poor quality of care in many health facilities
large inequities to access and quality
financial burden for health care (except wehn it isnt high bc there isnt even care to spend $ on if you wanted to)
experience of exclusion and voicelessness by the poorest
How many of the MDGs is health included in?
3 - reduce child mortality, improve maternal health,a nd combat hiv/aids, tb, and malaria
What happened to spending during MDG era?
health spending doubled and got a lot more complicated
bilateral development spending increased
more ngo involvement
but money wsnt spent on developing health systems, was rather spent on verticle programs which led to perverse incentives
What has no low income country achieved (health metric)
MMR<50.
Successes of LIC’s
vitamin A supplementation, Complementary Feeding, Immunizaitons
Failures of LICs
Contraception, Malaria
Progress being made in LIC’s
child mortality improvement
Less progress being made
maternal health and stopping spread of HIV/AIDS
What is one of the main health sytem constraints?
shortage and maldistribution of health workers
4 tiers of health workers
professionals, community workers, informal and traditional workers, family workers
HRH inclues all the categories of health workers…what does the data normally represent?
just doctors, nurses, and midwives
Relationship between health workers per capita and gdp
strong positive linear relationship between the two
How many doctors are we short globally?
4mm if we want good health worldwide
How many workers must sub saharan africa add to reach MDG’s?
triple curent number (or add 1mm)
Health worker dynamics: inflow
- train your own
- bring them in
- huge regional disparities in graduating classes (all of africa is equivalent to NY, CA, TX, IL combind)
Health worker dynamics: Production
Not enoguh to have a body in a given country, person must be competent, knowledgable, and in the right are
Health worker dyamics: outflow
retirement, disability/death, brain drain
Geography - where are they located in each country?
strongly skewed toward urban settings
approaches to maldistribution
bonding
incentives for rural practice
pool of locum physicians for temporary service
recruitment of students from rural communities
task shifting
Brain Drain - pull factors
aging populations in developing counries
controls on medical schools
higher salaries
recruiting efforts
Brain Drain - Push Factors
low salaries high work burdens (HIV/AIDS) poor working conditions professional dissatisfaction poor quality of life opportunities for famillies
How many Africans professionals emigrate each year to the west?
20,000
What % of US medical graduates are from low-income countries?
60%
What % of UK healthcare work force is from outside the UK?
1/3
What two regions have the greatest flight of physicians?
India and SubSaharan Africa (and ironically they’re the areas that need them the most).
What is task shifting?
the name now given to the process by which specific tastks are moved, where appropriate, to health workers with shorter training and fewer qualifications
fragile states are
states in conflict, recovering from conflict, in chronic political crisis, and those with chronically poor governance
often governmental regulation cant happen becuse htere isnta government TO regulate
According to the World Bank, fragile states have:
1/3 of thsoe living in absolute poverty
1/3 of maternal deaths each year in developing countries
Nearly 1/2 of children dying under the age of 5
1/3 of those living with HIV/AIDS
1/3 of those living in fragile states are undernourished
What is most death in post and low-intensity conflict due to?
preventable and treatable conditions that come about as a result of the collapse of internal health systems and infrastructure
What % of deaths in the democratic republic of congo are attributable to fever, malaria, diarrhea, respiratory infections, and malnutrition
50%; and those under 5 accounted for 45.4% of all deaths even thogh they made up only 18.7% of the sample
What happens with HS post conflict?
in the transition phase out of conflict…
- transition from humanitarian assistance to development is challenging
- may be funding gaps as ngos leave
- health policies and systems may not be first priority of rebuilding
- cant allow NGO removal to cripple a country
