Session 2
Health Systems in Context
Why Health Systems Matter?
Health Systems Science & Health Systems
The definition of health system science as a field of study shifts and adapts in response to changes in its object of its study, the health system itself.
The World Health Organisation (WHO) who describe a health system “as comprising at the organisations, institutions and resources that are devoted to producing health actions. A health actions is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health” (WHO, 2000: xi). Or simply put, a health system consists of “all the organizations, people, and actions whose primary intent is to promote, restore, or maintain health” (WHO).
It takes account of the different roles and responsibilities of providers and consumers of health services. It also addresses inequalities in health systems and how they affect people's expectations and the degree to which they impact people’s rights, dignity and freedoms.
Progress towards WHO’s three national health systems’ performance indexes depends on how well health systems carry out four vital functions. Namely, 1) service provision,2) resource generation, 3) financing, 4) and stewardship.
Though the overall goal of health systems is to improve health outcomes, this goal should be based on ethical practice. In WHO’s reference to goodness (alignment to consumers’ expectations) and fairness (equitability), they point to key dimensions of health systems which include quality, access, equity, equality and justice. In addition to the provision of health services, the four vital functions identified by the WHO are important as well as the importance of factoring the determinants of health in relation to the services that are provided within health systems.
To avoid definition of health systems that may be too reductionist, Frenk (2010) identifies four areas of consideration:
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Health systems should not only be expressed and understood in terms of their components but also the interrelationships of those components.
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Health systems are not only made up of the institutional or supply side of health but also the consumer or population.
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Health systems must be seen in terms of their goals, which not only include improving health outcomes but also equity, responsiveness to legitimate expectations, respect of dignity, and fair financing, among others.
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Health systems must also be defined in terms of their functions, which include the direct provision of services, whether they are medical or public health services, and "other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
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One of our challenges as systems scientists is to find a balance between specificity and generalisability, avoiding a reductionist framing of health systems while still being focused and specific. For this reason, we should consider our personal constructions of HSS as a field of study within a shifting, adaptable, and complex health environment.
Health Systems Science & Health Systems
The definition of health system science as a field of study shifts and adapts in response to changes in its object of its study, the health system itself.
The World Health Organisation (WHO) who describe a health system “as comprising at the organisations, institutions and resources that are devoted to producing health actions. A health actions is defined as any effort, whether in personal health care, public health services or through intersectoral initiatives, whose primary purpose is to improve health” (WHO, 2000: xi). Or simply put, a health system consists of “all the organizations, people, and actions whose primary intent is to promote, restore, or maintain health” (WHO).
It takes account of the different roles and responsibilities of providers and consumers of health services. It also addresses inequalities in health systems and how they affect people's expectations and the degree to which they impact people’s rights, dignity and freedoms.
Progress towards WHO’s three national health systems’ performance indexes depends on how well health systems carry out four vital functions. Namely, 1) service provision,2) resource generation, 3) financing, 4) and stewardship.
Though the overall goal of health systems is to improve health outcomes, this goal should be based on ethical practice. In WHO’s reference to goodness (alignment to consumers’ expectations) and fairness (equitability), they point to key dimensions of health systems which include quality, access, equity, equality and justice. In addition to the provision of health services, the four vital functions identified by the WHO are important as well as the importance of factoring the determinants of health in relation to the services that are provided within health systems.
To avoid definition of health systems that may be too reductionist, Frenk (2010) identifies four areas of consideration:
-
Health systems should not only be expressed and understood in terms of their components but also the interrelationships of those components.
-
Health systems are not only made up of the institutional or supply side of health but also the consumer or population.
-
Health systems must be seen in terms of their goals, which not only include improving health outcomes but also equity, responsiveness to legitimate expectations, respect of dignity, and fair financing, among others.
-
Health systems must also be defined in terms of their functions, which include the direct provision of services, whether they are medical or public health services, and "other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
​
One of our challenges as systems scientists is to find a balance between specificity and generalisability, avoiding a reductionist framing of health systems while still being focused and specific. For this reason, we should consider our personal constructions of HSS as a field of study within a shifting, adaptable, and complex health environment.
Why Health Systems Matter?
Health systems continue to evolve rapidly in the face of significant challenges. “It is not just that the players, rules, and equipment in the health care game are new - more importantly, they are constantly changing and evolving”. In the last two decades, foundational science along with diagnostic and therapeutic options have expanded dramatically in range and complexity. The understanding of the biopsychosocial-environmental model of health and disease has also progressed dramatically. All the while societal, economic, and political pressures have emerged as significant influencers. This has all been supported by innovations in data and information systems.
Health systems find themselves needing to provide care to an ever-expanding and diverse population. This includes marginalised and rural communities, South Africa’s quadruple burden of disease environmental enablers and other comorbid conditions. Concurrently, there are social, political and economic factors are significant aspects of healthcare transformation. There are other challenges also face South Africa’s healthcare system. The successful alignment of these factors with our goals for quality healthcare transformation (and all its characteristics like equitability, transparency, etc) will require health professionals to engage in a new paradigm.
This goal also requires us to interweave a range of skills, attitudes and knowledge domains that have been previously overlooked (marginalized) or assumed (the book lists some of these competencies)
Relying on medical science and clinical science is not enough to achieve the desired outcomes in healthcare. Optimal contemporary healthcare requires the expertise and integration of multiple domains of health systems science. It is no longer enough to know why and how biological systems operate, or implement the latest and best medical or surgical therapy. Health professionals are required to factor in the “multiple complexities of social, environmental, economic, and technical systems” and translate this paradigm shift into their care of individuals and populations.
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What is health systems science?
Health systems science is defined as the study of how healthcare is delivered, how healthcare workers can work together to deliver that care, and how the healthcare system can enhance patient care and healthcare delivery. Health systems science provides a comprehensive and holistic perspective of topics, subjects, and competencies for individuals training and providing care within healthcare systems. This “third medical science” should intertwine with, synergize and complement with the core content and concepts of traditional basic science and clinical science. From a person-centered paradigm, basic and clinical science cannot be considerably applied to patient care in the absence of health systems science. This integration provides the necessary context for the care of individual patients and achieving desired health outcomes.
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George Engel’s biopsychosocial model emphasized the importance of physicians understanding their patients in multiple dimensions, both diagnostically and personally. He asserted that physicians should appreciate that illness manifests at various levels of patient and systems-related factors in addition to disease pathology and that physicians cannot only focus on one component of the organised whole, they need to adopt a holistic approach to achieve the greatest health outcome impacts. This model is based on general systems theory, which proposes that every level of organisation – from molecular to societal or biospheric – affects every other level. Through systems theory, both the organised whole and the components can be studied and therefore supply the basis for health systems science. The health systems science curricular framework and definition are an expansion of the sociological domain.
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Health systems science curricular domains
Core functional domains:
1. Patient, family, community: This includes issues related to the experience of care, the patients values in relation to their health, and the patient’s behaviours and motivation for engaging in health care as well as the contextual influence of the patients’ families and communities.
2. Healthcare structures and processes: This includes all elements of how healthcare is provided such as the organization of professionals, institutions, resources and processes for delivery to meet the needs of patients and populations, including processes of collaboration and coordination.
3. Healthcare policy and economics: This domain deals with issues related to the decisions, plans, and actions undertaken to achieve specific healthcare goals and issues related to the efficiency, effectiveness, value, and behaviour in the production and consumption of healthcare.
4. Clinical information and health technology: This domain includes issues related to the implementation of informatics and information technology to deliver healthcare services (including clinical decision support, documentation, technology, and tools) and the utilization of data to improve health.
5. Population, public, and social determinants of health: This includes issues related to traditional public health and preventative medicine, the social determinants of health in regards to an entire population, the improvement of strategies at the population level to address gaps in care.
6. Value in healthcare: This deals with issues related to the performance of the healthcare system in terms of quality of care delivery, cost, and waste. The content also includes all issues related to the cost of health care, waste components, and service requirements. Finally, the content includes understanding the epidemiology of, as well as seeing and classifying, gaps in care and care delivery.
7. Health system improvement: The health system improvement domain includes all content related to processes of identifying, analysing, or implementing changes in policy, health care delivery, or any other function of the health care system to improve the performance of any component of the health care system. Issues herein include quantifying and closing gaps (action), variation/measurement (specifically related to quantifying and closing gaps, not to health care measures in general), analysis of data, interventions, and innovation and scholarship. Specific curricular examples in this domain include (1) selecting a quality indicator and developing an improvement plan, (2) drafting a Plan-Do-Study-Act worksheet that outlines a test of change, and (3) developing the ability to adapt to different improvement challenges with different evidence-based methodologies.
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Linking Domain: Systems Thinking.
Health systems thinking in the curriculum equips individuals with a comprehensive and holistic approach to medical care and healthcare issues. It deals with attention to a complex web of interdependencies, an appreciation of the whole and not just the parts, and the ability to recognise multi-directional cause-and-effect relationships with all causes emerging as an effect of other system dynamics.
The intersection of these domains requires us to realize that they are not discrete and separate categories but considerably overlap and interrelate as they comprise the integrated whole of health systems science.