보건의료체계 Health System 김창엽 ( 서울대학교 보건대학원 )

순서 정의 (Definition) 보건의료체계의 중요성 (Significance and Implication) 구성요소 (Components) 평가 (Evaluation) 유형 (Typology)

체계 (system)? Educational system, administration system, transportation system, subway system, nervous system… Institution, policy, administration, management, governance… Government, public, state…

Characteristics of System Organization Interaction Interdependence Integration Central objective

Terms and Concepts 건강 (health) 보건 보건의료 의료 의학 Health Health care (healthcare) Medicine Medical care Public health

Similarities and Differences Health system Healthcare system Public health system Public health (healthcare) sector

Why Health System? - Examples Determinants of individual health and health care utilization Providers’ behaviors: NHS vs. private Health expenses Quality of health care Equity

What Is a Health System All the activities whose primary purpose is to promote, restore or maintain health - WHR

SOCIAL GOALS AND SYSTEMS SOCIAL SYSTEMS SOCIAL GOALS EducationHealth Economic PoliticalCultural Other Education Health Consumption Democratic participation Knowledge Other Responsiveness Fair financing

Goals of a Health System Good health Responsiveness to the expectations of the population Fairness of financial contribution

HEALTH SYSTEM GOALS Health Responsiveness Fairness in Financial Contribution LEVELDISTRIBUTION QualityEquity * * * * * Efficiency

Responsiveness: Conceptual Framework Focus on measuring what happens when health system and person interact Also interested in person’s perception of what happens Differs from patient satisfaction –Reduces role of expectations –Addresses legitimate levels of expectation

Components of Responsiveness Respect for persons  Dignity  Confidentiality  Autonomy Communication Client Orientation  Prompt attention  Access to social support networks  Quality of basic amenities  Choice of provider

Functions of a Health System Service provision Resource generation Financing Stewardship

Structure and Functional Relationship of a National Health System

Major Components of a National Health System Infrastructure

Relationship between Functions and Objectives of a Health System (WHO, 2000)

(WHO, 2007)

Health Resources Development Manpower Facilities Equipment and supplies Knowledge

Organized Arrangement of Resources National Health Authorities Health Insurance Program Other governmental agencies Private sector

Delivery of Health Care Primary, secondary, tertiary Health promotion, prevention, treatment, rehabilitation, social care

Economic Support Public sources Employer Organized voluntary agencies Local community effort Foreign aid Private household

Management Leadership Decision-making  Planning  Implementation and realization  Monitoring and evaluation  Information support Regulation

Limitations of Current Approaches Too technical Closed vs. open systems Whose perspectives? Where is people?

Attainment and Performance (Efficiency)  Attainment = achievement of goals single and composite attainment e.g. Human development index  Performance (Efficiency) attainment related to resources available and other non-health system inputs to the production of health system outcomes

B M A a b Health system goal inputs attainment = b efficiency = b/(b+c) c L

Typology of National Health Systems (1) Health systems Kleczkowski et al. 1984

Typology of National Health Systems (2) Financing

Typology of National Health Systems (3) Socio-political systems Health as a societal value Collectivism as opposed to individualism Distributional responsibility

Typology of National Health Systems (4) Welfare systems (Esping-Andersen) Liberal Corporatist Social democratic

Typology of National Health Systems (5) Health systems Market oriented/Liberal Corporatism/Social insurance Universalism