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Chapter 12: Understanding and organizing health care systems
What is a health care system?
-Within the health sector, the element that most affect health are public health
activities such as water supply and sanitation, food inspection, vector insect
control, disease surveillance, reduction of industrial pollution, and regulation of
pharmaceuticals. But many don’t take these into account.
-The organization of the health care system in each country is a reflection of its
political trajectory and societal ideas/values. It is also influenced by the
international political and economic order.
-Roemer says: A health care system is the “a combination of resources,
organization, financing, and management that culminate in the delivery of
health services to the pop”.
oHealth care systems tend to focus on medicalized care, at the expense of
community-based, integrative services. Closely related to this is the fact
that HC systems tend to privilege biomedical and behavioural models over
the other ones.
-W/in every country, there is an entity, usually a ministry of health. They may be
the dominant provider of medical care, or its main function may be to supervise
and regulate the work of other organization.
-Health policy is usually focused on curative, medicalized care and
underemphasizes community, preventive, and integrated services.
-A bona fide health policy would focus on a range of societal determinants of
health, many of which are outside of the direct influence of ministries of health
-**An important characteristic of health care systems according to Donald Light
is their relation to a society’s cultural and political values:
o1) mutual aid values; underlying aim of health system is to help fellow
members of society and their families when they are ill
o2) societal/state values; main goal of health system is to strengthen the
nation through a vigorous, healthy population
o3) professional values; purpose of the health system is to provide the best
possible care to every sick patient
o4) Corporatist values: the role of the health care system is to join buyers
and sellers, providers and patients, who then decide on the range and cost
of services to be provided.
-Health care systems are further shaped by the extent to which health is viewed as
a public good & human right as opposed to a commodity or privilege
Table 12-1:Public vs Private Financing & delivery
-no health systems that are privately financed & publicly delivered
-Korea, Canada, New Zealand, Thailand largely publicly financed, mix of
private/ public delivery
-US privately financed & privately delivered (except public financing for
seniors, disabled, military)
-United kingdom, Cuba, Spain Publicly financed & delivered
Health system typologies
Political economy of health system
-*Simplest way of classifying health systems is two variables.
o1) the financing and delivery of health care services
o2) whether each of these occurs in the public or private sector.
-Financing comes from income from state-owned enterprises, taxes, user fees, etc.
-Delivery is the means by which HC is provided. -Public means: hospitals are
owned by the government, medical practitioners are employed, contracted,
subsidised by gov't. -Private means: that hospitals and practitioners operate
outside of the government
oCritiques: -few countries fit neatly into a single category - the typology
doesn’t explain how the differences in HC systems come about - Navarro:
capitalism governs financing and delivery of health services.
oNavarro's Alternative P-E Approach to Health Systems Analysis
considers: political system & distribution of political power; ownership
and social structure of production; distribution of income & resources;
-The political economy approach to health analysis seeks to take into account: 1)
the political system and distribution of political power, 2) the ownership and
social structure of production, 3) distribution of income and resources, 3)
*Roemer’s typology: economic level and health care policy.
-Milton Roemer’s classification of health care systems is perhaps the best known
and mostly widely replicated typology. 2 key points:
o1) The level of economic development of a country (GNP/capita)
o2) the degree to which the market and/or the state influence the
distribution of health care goods and services.
-Roemer’s typology distinguishes among 4 different types of health care policies,
based on the level of state protection against market forces. 12-2
oCritiques: - doesn't consider changing nature of pol, econ and social
systems (USSR, China have undergone huge changes) - many countries
have a mixture of priv and publ financing and delivery - private systems
might not be for-profit
-Roemer’s typology might be enhanced by distinguishing further among the
various arrangements of state, marker, and family or household in capitalist
o1) liberal welfare state: (US) which provide only a min safety net,
o2) wage earner welfare states: (employment-based rather than citizen-
based benefits) which are more generous than liberal states and provide
largely employment based (rather than citizen based; Australia) benefits,
o3) conservative corporatist welfare state: (Italy) which are more generous
than wage earner states and provide health and social services based on
religious affiliation, union membership, or residence,
o4) social democratic welfare states: (the Nordic states) which are the most
redistributive, providing universal benefits to all residents.
Comparison without a typology: resources spend on health
-Many international comparisons of health system do not employ typologies at all,
but rather list measurable health care system attributes.
-Higher percentage of GDP spent on health care does not = better health status of
-Why doesn't health spending lead to health?
o1) the distribution of health resources may not relate to need. Rich people
get more then poor ppl even though they don’t need it.
o2) access to resources such as clean water, housing, sanitation, maternal
education, wages and many other societal factors also affect health,
o3) medical care (spending) is unable to correct for overall inequalities in
-The proportion of GDP spent on health care continues to spiral upward in
-In some low income countries, the % of GDP spent on health care may appear to
be relatively high, but the actual per capita monetary expenditure is often
-Also, the high cost of purchasing drugs and medical equipment can squeeze out
spending on primary health care.
-At an extreme, excessive spending on health services may prevent societies from
marshalling resources to other key determinant of health, such as adequate
housing and occupational health measures.
-In many countries, out-of-pocket expenditures dwarf private health insurance
Ranking health systems: The world health report 2000
-In 2000, WHO developed a new typology based on measurable performance
indicators of health care systems. Countries ranked according to 5 variable:
o1) overall level of health,
o2) distribution of health in the population,
o3) overall level of responsiveness,