1. Health System Jagrati Jani, MD, PhD

2. Provide a broad overview of health system Highlight Health System Domains Health systems in context of Developing countries Outline

3. Health is” a state of complete physical, mental and social well-being. WHO 1946 Disease as an organic-level disorder confined to the individual (scientific medicine). Merson et al 2006 Illness as a subjective state of dysfunction from the disorder at the individual level. Merson et al 2006 Ill health is an umbrella used to refer to the experience of disease plus illness. Naiodoo and Wills 2000 Sickness as a social dysfunction within society that goes beyond the individual. Merson et al 2006 What is health?

4. The PRECEDE-PROCEED Model by Green and Kreteur, 1999:35)

5. Determinants of health Political Environment Economic social Living conditionsDiseasesHealth Systems Death Disability Recovery Dahlgren and Whitehead 1991 WHO framework for action 2007

6. Source: Good Health at Low Cost 25 Years on What make a successful health system?

7. Source: Good Health at Low Cost 25 Years on What make a successful health system?

8. Political commitment to health as a social goal Societal values of equity, political participation and community involvement in health Investments on PHC or other community based services Widespread education (women) Intersectoral linkege for health Factors contributing to good health?

9. Social and political factors supporting good health at low cost Political commitment to health as a social goal Legislation Government expenditure on health Establishment of health facilities Cultural influences Social welfarePreventive orientation Support for basic necessities Education program Political process participationPolitical engagement Decentralization Community involvement Equity oriented servicesHealth, education, nutrition status (Women, minorities etc) Income asset distribution Intersetoral collaborationRecognition that health is socially determinate

10. Health promotion an preventative work is more than health care Health Care Education Work Personal Lifestyle Family and network Social security Shelter Societal conditions ETC Health Promotion & Preventative Work The 10-90 rule (Wildavsky 1977) 10% 90%

11. Conceptual framework of Health System WHO def: All organizations, people and actions to promote, restore or maintain health.  This includes efforts to influence determinants of health  And health improving activities through public, private non profit organizations)

12. Service availability Health system is not only Health Facility or hospitals Health facility Curative care Preventive care vaccination Outreach program Supplementary vacc program Health facility

13. India administrative structure Village 500 - 5000 Block 1 – 200.000 District 1 – 2 million State 38 – 180 million MoH

14. Health System Domains Determinants of Health H.S. inputs Policy Financing H.R. Organization Supplies H.S. outputs Plans, # vaccines,# train staff HIS Service availability Quality of Care H.S. Outcomes Service utilization Target pop receiving intervention (coverage) Health Status Disease incid Morbidity Disability Mortality Cure SustainabilityEfficiencyEffectivenessImpact

15. Life expectancy and GDP per capita in USD, 2005 Source: Good Health at Low Cost 25 Years on What make a successful health system?

16. Source: Good Health at Low Cost 25 Years on What make a successful health system?

17. FinancedHealth Care delivery PublicPrivate Public sectorNational Health Service (UK, Cuba, spain, Norway) National Health Insurance (South Korea, Canada, Thailand) PrivateNAPluralistic – private with some public (US, Ghana) What shapes Health Care System policy? Financial mechanisms, coverage and methods of health care deliver

18. Challenges Chronic communicable and NCD Food security Injuries accidents and obesity Multi professional and cross levels care Global structure of the programs Horz vertical programs

19. HR Africa carries 25% of the world's disease burden yet has only 3% of the world's health workers and 1% of the world's economic resources. Human resources Quantity inequity of distribution Brain drain or migration of local health workers Quality knowledge poor working conditions (multi-task) misdistribution of personnel within and between countries Health tourism Challenges The lancet. 2008 Volume 371, Issue 9613:623Volume 371, Issue 9613

20. Countries with a Critical Shortage of Health Care Providers. N. Engl. J.Med 2007, 2564-67

21. Challenges Only 22% of 68 count down countries met minimum threshold of 23 physicians, nurses, midwives per 10,000 people necessary to deliver essential health services Interventions include: - education of more health workers, strategies for motivation and retention, substitution of roles/task shifting

22. Source: Health Policy. Vol 371 February 23, 2008 Figure 2: Monthly income for health workers in Zambia (US$)

23. Increased recognition of role of Community Health workers

24. Human resources

25. Financing Private Public partnerships Private Public partnerships for child health - Global Alliance for Vaccine Initiatives, Global Fund for Malaria - Increased resources for new vaccines – Hib, Pneumocaccal vaccine - New technologies – autodisable syringes - Push to minimise missed opportunities and reach every child - Vaccination campaigns as part of polio eradication, measles elimination Health financing mechanisms to increase access for vulnerable group- increase risk pooling schemes and minimise out of pocket payments. EX JSY Scheme in India

26. Population covered Infrastructure Logistic and management Challenges in output

27. Rajasthan State depot Zonal depot (total 7) District depot Private hospitals Blokk level N= 14 36 lak pop NGOs Primary Health Care N=72 30.000 pop Community Health Centres (CHC) N=24 1 lak population Subcenter - ANM N= 375 5000 pop Anganwali center 1000 pop Anganwali center 1000 pop Anganwali center 1000 pop

28. Health Information ◦Birth registration ◦Death audits Interest in mobile technologies Challenges of current health information systems and need for Electronic systems

29. Take home messages... Health System is more than point of care Have huge challenges Demand inovative approach Urgent need for strengthening health systems to provide better health for all