Introduction and frameworks

Reinhard Busse, Prof. Dr. med. MPH FFPH FG Management im Gesundheitswesen, Technische Universität Berlin (WHO Collaborating Centre for Health Systems Research and Management) & European Observatory on Health Systems and Policies

21 November 2017 Introduction and frameworks 1 Outline of the course- Week 1 Topic Date Lecturer Introduction and Outline of the course 20.11.2017 Wilm Quentin and Daniel Opoku 15-17 Uhr Introduction and frameworks 21.11.2017 Reinhard Busse 09-12 Uhr Financing I: Raising Resources 13.30-17 Uhr Wilm Quentin Seminar on health system relevant 22.11.2017 Anne Spranger databases and information for term paper 10-12 Uhr (H8173/74) Financing II: Pooling and re-allocation 13.30-17 Uhr Reinhard Busse Financing III: Purchasing and payment 23.11.2017 Wilm Quentin systems 09-12 Uhr Leadership and Governance + Care 13.30-17 Uhr Reinhard Busse Delivery Workforce 24.11.2017 Claudia Maier 9-10.30 Uhr Introduction to group exercise 10.30-12 Uhr Anne Spranger Medical products 13.30-17 Uhr Reinhard Busse 21 November 2017 Introduction and frameworks 2 Outline of the course - Week 2 Topic Date Lecturer Preliminary Summary of building blocks 27.11.2017 Reinhard Busse 09-10.30 Uhr Presentation by GIZ on health system 10.30-12 Uhr Ursula Bürger, Fachplanerin related German development cooperation Kompetenz-Center Gesundheit und Soziale Sicherung, GIZ Access and Coverage 13.30-17 Uhr Reinhard Busse

Quality and Safety 28.11.2017 Reinhard Busse 09-12 Uhr Financial and social risk protection 13.30-17 Uhr Wilm Quentin Improved Health 29.11.2017 Wilm Quentin 13.30-17 Uhr Efficiency and Responsiveness 30.11.2017 Reinhard Busse 09-12 Uhr Summary of Health System Performance 13.30-17 Uhr Reinhard Busse Assessment Group Presentations and Wrap-up 01.12.2017 Reinhard Busse or Wilm Quentin

21 November 2017 Introduction 09and -frameworks12 Uhr 3 Organisational matters 13.30 onwards WHO building blocks 30 Nov/1 Dec 21 Nov 27 Nov

23 Nov

24 Nov 29 Nov 27 Nov 22 Nov (seminar) 30 Nov Week 8

24 Nov 28 Nov 28 Nov 21 to 23 Nov 30 Nov

23 Nov

WHO 2007

21 November 2017 Introduction and frameworks 4 What is a health system?

People, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.

European Observatory for Health Systems and Policies (2007)

21 November 2017 Introduction and frameworks 5 A starting point: 2000 World Health Report

This report sets out to analyse the role of health systems and suggest how to make them more efficient and, most importantly, more accessible and responsive….

21 November 2017 Introduction and frameworks 6 The first health system framework = strategy behind World Health Report 2000

2000 (WHR)

21 November 2017 Introduction and frameworks 7 2000 World Health Report

• First attempt to rank performance of 191 national health systems • Identifies and measures performance of member states on ‘key health system objectives’ • Examines whether each health system is performing as well as it can, given existing resources • Based on Murray & Frank framework (2000)

21 November 2017 Introduction and frameworks 8 And the winner was…

21 November 2017 Introduction and frameworks 9 … but not everyone agreed

21 November 2017 Introduction and frameworks 10 Health system frameworks I (an adapted version of the original from 2000)

Source: World Health Organization (WHO). (2007) Everybody’s business: Strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva: WHO Document Production Services.

21 November 2017 Introduction and frameworks 11 Health system frameworks II

Control Knobs

Roberts et al. 2004

21 November 2017 Introduction and frameworks 12 Health system frameworks III

Atun et al.

Atun 2008

21 November 2017 Introduction and frameworks 13 A Q

R

21 November 2017 14 Introduction and frameworks Health system framework V (a further WHO development)

WHO building blocks Week 14 Week 1

Week 5

Week 4 Week 9 Week 11

Week 7 (seminar) Week 13 Week 8

Week 6 Week 12 Week 10 Week 2 + 3 Week 13

Week 7 (lecture)

WHO 2007

21 November 2017 Introduction and frameworks 15 Health system frameworks VI

WHO systems thinking

“Building blocks do not constitute a system …. It is the multiple relationships and interactions among the blocks …. that convert these blocks into a system”

De Savigny and Adam 2009: Systems thinking for health systems strengthening

21 November 2017 Introduction and frameworks 16 Overview: frameworks 1. Boundaries of the system 2. Architecture/functions 3. Goals/ objectives

+ focus on HSPA

21 November 2017 Introduction and frameworks 17 What are the Health system boundaries?

Source: Murray, CL. and Evans, DB. (2003) Health systems performance assessment: Debates, Methods and Empiricism. Geneva: World Health Organization.

21 November 2017 Introduction and frameworks 18 Different definitions of boundaries ...

– WHO: “The resources, actors and institutions related to the financing, regulation and provision of health actions. Where health actions are any set of activities whose primary intent is to improve or maintain health”. (Murray & Frenk 2000) – Commonwealth Fund: “The way in which health care services are financed organized and delivered to meet societal goals for health. It includes the people, institutions, and organizations that interact to meet the goals, as well as the processes and structures that guide these interactions”. (Commonwealth Fund 2006) – OECD (old!): “The health care system, not including public health activities or other wider issues”. (Hurst & Hughes 2001) WHO Commonwealth Fund OECD

21 November 2017 Introduction and frameworks 19 21 November 2017 Introduction and frameworks 20 What are health system functions?

Framework Health System Functions WHO (2000) • Resource Generation • Financing • Service Provision • Stewardship In summary: WHO (2007) • Service Delivery 1. Leadership/ • Health Workforce • Information governance/ • Medical products, vaccines and technologies organization/ • Financing regulation • Leadership and Governance 2. Resource Control Knobs • Financing (2003) • Payment generation/ • Organization financing/payment • Regulation 3. Human/ • Behaviour technological Atun (2008) • Financing • Organization and Regulation resources • Resource Allocation 4. Service provision 21 November 2017 • Provision Introduction and frameworks 21 What are health system objectives?

Framework Intermediate Ultimate Objectives Objectives WHO (2000; 2007) • Access • Level and distribution of health • Coverage • Level and distribution of responsiveness • Quality • Fairness in financing • Safety In summary: • Efficiency 1. Health (level and Commonwealth • High quality care • Long Healthy and Fund (2004) • Efficient care Productive Lives distribution • Access 2. Responsiveness/ • System and workforce innovation and consumer improvement satisfation (level Control Knobs • Efficiency • Health status and distribution) (2003) • Quality • Consumer satisfaction • Access • Risk protection 3. Financial Atun (2008) • Equity • Health protection (level • Choice • Financial risk protection • Efficiency • Consumer satisfaction and distribution) • Effectiveness 4. Efficiency

21 November 2017 Introduction and frameworks 22 So why bother with a framework?

Health system framework • understand • describe • compare • analyze

Health Systems Performance Assessment framework • Much more contentious 21 November 2017 Introduction and frameworks 23 The European Observatory

Activities: • Country- monitoring (HiTs) • Studies • Dissemination (Publications, 21 November 2017 dialogues,Introduction etc.) and frameworks 24 Observatory‘s approach to country-monitoring = Health Systems in Transition (HiT)

. Describe and analyze a country’s health system and key reform initiatives

. Based on a common set of questions and follow the same structure, enabling easy cross-country comparisons ( next slide)

. Seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe and beyond

21 November 2017 Introduction and frameworks 25

Observatory‘s approach to country-monitoring

1. Context 2. Organization and governance 3. Financing 4. Physical and human resources 5. Provision of services 6. Principal health reforms 7. Assessement of the health system 8. Conclusions 9. Appendices

European Observatory 2010

21 November 2017 Introduction and frameworks 26 Chapter 7: Assessment of the health system

WHO goals

21 November 2017 Introduction and frameworks 27 Country Monitoring: HSPM

21 November 2017 Introduction and frameworks 28 Similar initiative in Africa

21 November 2017 Introduction and frameworks 29 … and in Asia

21 November 2017 Introduction and frameworks 30 Group Work

21 November 2017 Introduction and frameworks 31 Group Work

• 4 Groups of 5 students each • 30 minutes group work – Discuss/answer to questions on boundaries of health systems and health system goals • 25 minutes presentation/discussion of results (5 minutes per group) • 5 min summary/wrap-up

21 November 2017 Introduction and frameworks 32 Questions for group work

Please discuss the following questions 1. Boundaries of health systems: • What are advantages and disadvantages of different definitions of health systems‘ boundaries? • Decide as group: How should the boundary of a health system be defined? 2. Goals of health systems: • What are the most important goals of health systems? • Please rank health systems‘ goals and add weights to each goal.

21 November 2017 Introduction and frameworks 33 Grenzen von Gesundheitssystemen

21 November 2017 Introduction and frameworks 34 What are health system objectives?

Framework Intermediate Ultimate Objectives Objectives WHO (2000; 2007) • Access • Level and distribution of health • Coverage • Level and distribution of responsiveness • Quality • Fairness in financing • Safety In summary: • Efficiency 1. Health (level and Commonwealth • High quality care • Long Healthy and Fund (2004) • Efficient care Productive Lives distribution • Access 2. Responsiveness/ • System and workforce innovation and consumer improvement satisfation (level Control Knobs • Efficiency • Health status and distribution) (2003) • Quality • Consumer satisfaction • Access • Risk protection 3. Financial Atun (2008) • Equity • Health protection (level • Choice • Financial risk protection • Efficiency • Consumer satisfaction and distribution) • Effectiveness 4. Efficiency

21 November 2017 Introduction and frameworks 35 Ziele von Gesundheitssystemen

21 November 2017 Introduction and frameworks 36 Conclusions

• Health systems can be defined with different boundaries and different goals • Goals usually include (1) Health (level and distribution), (2) Responsiveness/consumer satisfaction (level and distribution), (3) Financial protection (level and distribution), and (4) Efficiency

21 November 2017 Introduction and frameworks 37