1. Dr. Shahram Yazdani Health System Structure and Function Shahid Beheshti University of Medical Sciences School of Medical Education Strategic Policy Sessions: 22

2. Dr. Shahram Yazdani Health Related Activities Health Sector Health System Healthcare System PHC

3. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system

4. Dr. Shahram Yazdani Goodness and Fairness: Both Level and Distribution Matters A good health system, above all, contributes to good health. But it is not always satisfactory to protect or improve the average health of the population, if at the same time inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health.

5. Dr. Shahram Yazdani Goodness and Fairness: Both Level and Distribution Matters Objective of good health is really twofold: 1. The best attainable average level: goodness 2. The smallest feasible differences among individuals and groups: fairness

6. Dr. Shahram Yazdani Level and Distribution of Responsiveness The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated. The distribution of responsiveness matters, just as the distribution of health does.

7. Dr. Shahram Yazdani Measuring Goal Achievement The overall level of health; The distribution of health in the population; The overall level of responsiveness; The distribution of responsiveness; The distribution of financial contribution.

8. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system

9. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system Stewardship (oversight) Oversight Policy Setting; Information, Disclosure & Advocacy; Developing Partnerships; Regulation & Standard Setting; Monitoring & Evaluation; Strategic Incentives

10. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system Financing Revenue Generation and Collection Pooling Allocation & Purchasing Financing (collecting, pooling And purchasing)

11. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system Input Management Human Resources; Knowledge; Pharmaceuticals; Technology; Consumables Capital Creating resources (investment And training)

12. Dr. Shahram Yazdani Relations between functions and objectives of a health system Stewardship (oversight) Financing (collecting, pooling And purchasing) Creating resources (investment And training) Delivering services (provision) Responsiveness (to non-medical expectations) Fair (financial) contribution Health Functions the system performsObjectives of the system Service Delivery Public Health Services Ambulatory Care Inpatient Care Delivering services (provision)

13. Dr. Shahram Yazdani Performance on level of health (disability-adjusted life expectancy) relative to health expenditure per capita, 191 Member States, 1999

14. Dr. Shahram Yazdani The situation for I.R. Iran (2000) The overall level of health: 96 The distribution of health in the population: 113 The overall level of responsiveness: 100 The distribution of responsiveness: 94 The distribution of financial contribution: 113 Overall goal attainment: 114 Health Expenditure Per Capita: 94 Performance on level of health: 58 Overall health system performance: 93

15. Dr. Shahram Yazdani The Situation Low and middle income countries account for only 18% of world income and 11% of global health spending ($250 billion or 4% of GDP In those countries). Yet 84% of the world’s population live in these countries and they bear 93% of the world’s disease burden

16. Dr. Shahram Yazdani How much cost for health is rational? If a car worth $10000 would cost $15,000 to repair after an accident, an insurer would only pay $10,000. The impossibility of replacing the body, and the consequent absence of a market value for it, precluded any such ceiling on health costs.

17. Dr. Shahram Yazdani ….Why Health Systems Matter There is an enormous gap between the apparent potential of public spending to improve health status and the actual performance Many deaths of children under 5 years of age could be averted for $10 or less, but the average actual expenditure in poor countries per death prevented as estimated from the overall relation between spending and mortality is $50,000 or more

18. Dr. Shahram Yazdani In the USA between 1966 and 1979 the introduction of safety features in automobile design ( laminated windshield, collapsible steering column, interior padding, lap and shoulder belts, side marker lights, head restraints, leak resistant fuel systems, stronger bumpers, increased side door strength and better brakes ) reduce the vehicle accident fatality rate per mile traveled by 40%. only three of these innovations added more than $10 to the price of a car and in total they accounted for only 2% of the average price increase during 1975-1979. From 1975 to 1998, seat belts saved an estimated 112,000 lives in USA

19. Dr. Shahram Yazdani Health Care Systems (Field, 1989) Type1: Emergent Type2: Pluralistic Type3: Insurance/Social Security Type4: National Health Service Type5: Socialized

20. Dr. Shahram Yazdani Emergent HCS Health care viewed as item of personal consumption Physician operates as solo entrepreneur Professional associations powerful Private ownership of facilities Direct payment to physicians Minimal role in health care for the state

21. Dr. Shahram Yazdani Pluralistic HCS Health care viewed mainly as consumer good Physician operates as solo entrepreneur and in organized groups Professional organization very powerful Private and public ownership of facilities Payments for services direct and indirect State’s role in health care minimal and indirect Example: USA

22. Dr. Shahram Yazdani Insurance/Social Security HCS Health care as an insured/guaranteed consumer good or service Physicians operate as solo entrepreneurs and members of medical organizations Professional organizations strong Private and public ownership of facilities Payments for services mostly indirect State’s role in health care central but indirect Example: France

23. Dr. Shahram Yazdani National Health Service Health care as state-supported service Physicians solo entrepreneurs and members of medical organizations Professional organizations fairly strong Facilities mainly publicly owned Payments for services indirect State’s role in health care central and direct Example: UK

24. Dr. Shahram Yazdani Socialized HCS Health care a state provided public service Physicians are state employees Professional organizations weak or non-existent Facilities wholly publicly owned Payment for services entirely indirect State’s role in health care is total Example: Former Soviet Union

25. Dr. Shahram Yazdani France HCS: Finance About ¾ of health care costs are funded by the state social security fund, raised by levies on employers and employees. For certain illnesses like cancer the state funds 100% of the cost. In other cases individuals pay the balance of care costs, usually financed by subscriptions to non-profit making insurance societies. The scale of medical fees is negotiated between the profession and the health ministry

26. Dr. Shahram Yazdani France HCS: Ownership About 2/3 of hospital beds are in publicly owned hospitals under the responsibility of the health ministry, the remainder are in private hospitals. Private hospitals tend to be smaller and outnumber public hospitals by about 2:1. Most hospital physicians are salaried but family doctors are independent. In all over half the doctors in France are private practitioners

27. Dr. Shahram Yazdani France HCS: Reform Introducing new taxes on income and expenditure to raise revenue Tighter regulation of medical fees Nationwide computerization to reduce administrative costs New system of hospital management Encouraging referral networks Clinical guidelines New system of record-keeping

28. Dr. Shahram Yazdani USA HCS: Finance The state operates two main scheme: Medicaid for the poor and Medicare for the elderly and disabled A further two third of the population is insured privately the majority as part of their employment package A proportion of the privately insured (1/4 of the total population) are enrolled with HMOs This leaves around 16% of the population (40 million people) without health insurance Limited free care is provided by the public hospitals and some private hospitals cross- subsidize patient who cannot pay

29. Dr. Shahram Yazdani USA HCS: Ownership ¾ of hospitals are privately owned, of which a minority are operated for profit. Involvement of for profit corporations in the financing and provision of health care is increasing progressively The remaining hospitals are run by local or state authorities Traditionally the majority of the medical profession has taken the form of independent private practitioners charging a fee for services provided. But increasing numbers are employed directly by hospitals and by third party organizations such as HMOs

30. Dr. Shahram Yazdani USA HCS: Reform After election of president Clinton in 1992 he announced plans to create a managed market in health care, while guaranteeing health insurance to all citizens. Regional alliances would be established to manage enrolment on insurance plans, negotiate fees and premiums, monitor the quality of health plans, and means test low income subscribers In spite of initial support from the general public, big business, large insurers and from parts of the medical profession, the proposals were defeated. But individual states and health insurance market move in the direction set by Clinton plan. Increasingly hospital doctors and doctors are forming provider networks to negotiate fees with purchasing pools formed by employers

31. Dr. Shahram Yazdani Thank You ! Any Question ?

32. Dr. Shahram Yazdani Thank You ! Any Question ?