Faculty of Medicine Public Health 31505291 Lecture 19

Faculty of Medicine Public Health (31505291) ﺍﻟﺼﺤﺔ ﺍﻟﻌﺎﻣﺔ Lecture 19 Healthcare service delivery in developed and developing countries By Hatim Jaber MD MPH JBCM Ph. D 6 - 8 -2018 1

1. The global health impact of mental health and mental diseases. Drug abuse and Addictive substances 1. 2. 3. 4. Global overview of communicable diseases Global overview Non- Communicable Diseases(NCDs) The global health impact of Hepatitis, Tuberculosis and HIV/AIDS The global health impact of Cardiovascular Diseases , Diabetes and Obesity 1. 2. Health policy and management, Health priorities Health policies and management within a global health perspective 4. 5. Healthcare systems and financing Quality of care and effectiveness in different health services systems 1. 2. Violence and Injuries Migration and Travelers' health 3. Healthcare service delivery in developed and developing countries

Presentation outline Time Introduction of concepts : General Concepts in Management Sciences 09: 15 to 09: 25 Health Care Delivery and System 09: 25 to 09: 35 Health system In Jordan 09: 35 to 09: 40 Health system In Low income countries 09: 40 to 09: 50 Health system In High income countries 09: 50 to 10: 15

MODEL OF HEALTH CARE SERVICES q The model of health care delivery is adopted from Steven’s System Model (1952) general system theory is used to accomplish the purpose. • Health status or health problems • resources Health care inputs systems services • • Curative Preventive Promotive Restorative • • Public Primary Indigenous Voluntary outputs • Changes in health status

What is a System? • System: “a set or arrangement of things connected or related to form a unity or organic whole”. • System: “a collection of components organized to accomplish a specific function or a set of functions”. 5

What is a Health Care System? • A Health Care System: “the complete network of agencies, facilities, and all providers of health care in a specified geographic area. ” (Mosby's Medical Dictionary, 8 th edition. © 2009, Elsevier. ) “an organized plan of health services. ” Every country has a health care system, however fragmented it may be among different organizations or however 6

Health Care Systems • Health care systems are designed to meet the health care needs of target populations. In some countries, the health care system has evolved and has not been planned, whereas in others efforts have been made by: • governments, • trade unions, charities, religious, • or other coordinated bodies to deliver planned health care services targeted to the populations they serve. 7

Goals of a Health Care System The goals for health systems, according to the World Health Report (WHO, 2000), are: 1. Good health for the population 2. Responsiveness to the needs and expectations of the population 3. Fair financial contribution to the health care system 4. Efficient to achieve the best outcomes possible given available resources and circumstances 8

FUNCTIONS OF HEALTH CARE SYSTEM: promote health education and health services 1 - To • To promote quality of life and life expectancy • To promote maternal and child health, family planning, adolescent health 2 - To prevent and control locally endemic diseases Eg: dengue fever, filariasis etc • To provide immunization services • To prevent, control and manage common diseases and injuries Eg: ARI, diarrhoea, malnutrition etc.

What is a Health Care Delivery System? Three major components that make up the Health Care Delivery System are: 1. Facilities 2. Practitioners 3. Entities 10

Three major components that make up the Health Care Delivery: Facilities • Hospitals: acute and sub-acute care, primary care, and tertiary care (medical education and complex cases) • Health Centers or Ambulatory Surgery (outpatient) • Physician offices (GP, s and specialists) • Skilled Nursing Facilities • Home Health Agencies: nursing care at home • Freestanding Substance Abuse Facilities: inpatient • Hospice: care for terminally ill patients • End-stage Renal Disease Centers 11

Three major components that make up the Health Care Delivery Practitioners Physicians • Medical Doctors (MD’s) Nurses • Nurse Practitioners • Registered Nurse (RN) Physician Assistants (Pas) Therapists • Physiotherapist (PT) • Occupational therapist (OT) • Speech therapist (ST) 12

Three major components that make up the Health Care Delivery Entities Provide the financial and regulatory functions for the facilities and practitioners, e. g. government. Governmental Health Care Functions: 1. Direct Services (hospitals, health care centers) 2. Financing 3. Information 4. Policy Setting 13

Elements of a health care system (1) Personal health care services for individuals and families, available at hospitals, clinics, neighborhood centers, and in physicians' offices, etc…… . (2) Public health services needed to maintain a healthy environment, such as control of water and food supplies, regulation of drugs, and safety regulations. (3) Teaching and research activities related to the prevention, detection, and treatment of disease. (4) Third party (health insurance, pharmaceutical companies) of system services. 14

Definition of Health System World Health Organization definition : • "A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health including the efforts to influence determinants of health as well as more direct health-improving activities. • A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, – – – – Mother caring for a sick child at home; Private providers; Behavior change programs; Vector-control campaigns; Health insurance organizations; Occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education,

PRINCIPLES OF HEALTH CARE DELIVERY SYSTEM: • • • It supports a coordinated, cohesive health care services It opposes the concept that fee-forpractice It supports the concept of pre-paid group practice It supports the establishment of community based, community controlled health care system It urges an emphasis to be placed on development of primary care It emphasizes on quality assurance of the care It supports health care as a basic human right for all people It supports individuals unrestricted access to the provider, clinic or hospitals It urges that in the establishment of priorities for health care funding, resources should be allocated to maintain services for the economically deprived.

PRINCIPLES OF HEALTH CARE DELIVERY SYSTEM: …. • It supports the efforts to eliminate unnecessary health care expenditures and voluntary efforts to limit increase in health costs • It endorses to provide special health maintenance to old age • It supports public and private funding • It condemns health care funds • It supports the establishment of a national health care budget • It supports universal health insurance

Service delivery • Just as the principal objective of a health system is to improve people's health, the chief function the system needs to perform is to deliver health services.

Growing recognition • Overall there is a growing recognition that to maintain and improve the health of the world’s people governments must shape sound, efficient health systems that provide effective disease prevention and treatment to all women, men and children, no matter who they are or where they live.

Health system In Jordan Health system governance in Jordan has been characterized by a stable political system which seeks to identify and allocate responsibilities between the public and private sectors. The government is responsible for supervising, monitoring and enacting laws for the protection of public rights and justice between the citizens. 20

The health sector in Jordan consists of: Service providers (public, private, international and charity sectors) and councils and institutions working on the development of health policy. The public sector includes the: Ministry of Health, the Royal Medical Services and university hospitals (University of Jordan Hospital, King Abdullah University hospital) and the centre for diabetes and Endocrinology and Genetics. The private sector includes private hospitals and diagnostic and therapeutic centers in addition to hundreds of private clinics. 21

The international sector and charitable sectors provide services through: - UNRWA clinics for Palestinian refugees and the UNHCR and - King Hussein Cancer Center and charity association clinics. Drawing the general policy for health sector in Jordan is done mainly through: the Higher Health Council pursuant to law No. 9 of 1999. Other institutions in the health sector involved in health policy, such as the Jordanian Medical Council, the Supreme Council of the population, the Jordanian Nursing Council, the National Council for Family Affairs, Jordan Food and Drug Administration and the Joint procurement Department 22

Major components of health sector in Jordan 23

The most important challenges facing the health system governance 1. Poor cooperation and coordination between the various components of the health sector 2. Adoption of the central system 3. weakness in the training process on management and strategic planning 4. Overlapping and duplication in some health laws 5. Poor application of strategies to contain costs 6. Inactivated monitoring and evaluation systems of institutional performance in the public sector 7. Weak oversight systems on the private sector 8. Weak empowerment of citizens to gain support for their own interests and to hold local governments accountable 9. Weak commitment to implement national strategies and plans and weak monitoring and evaluation systems.

Health Services Delivery: PHC

Secondary and Tertiary Health Services

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Health services in Low and Medium Countries

Middle income and especially low-income countries face a overabundance of constraints in their healthcare systems. These countries face a • severe lack of human and physical resources, • as well as some of the largest burdens of disease, • extreme poverty, and • large population growth rates. Additionally, healthcare access to all reaches of society is generally low in these countries.

The WHO notes an extreme deficit within the global healthcare workforce. The WHO notes critical healthcare workforce shortages in 57 countries—most of which are characterized as developing countries—and a global deficit of 2. 4 million doctors, nurses, and midwives.

The WHO, in a study of the healthcare workforce in 12 countries of Africa, finds an average density of physicians, nurses and midwives per 1000 population of 0. 64. The density of the same metric is four times as high in the United States, at 2. 6.

The burden of disease is additionally much higher in low - and middle-income countries than high-income countries. The burden of disease, measured in disability-adjusted life year (DALY), which can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability, is about five times higher in Africa than in high-income countries.

In addition, low- and middle-income countries are forced to face the burdens of both extreme poverty and the growing incidence of chronic diseases, such as diabetes and heart disease.

Considering poor infrastructure and low human resources, the WHO notes that the healthcare workforce in sub-Saharan Africa would need to be scaled up by as much as 140% to attain international health development targets such as those in the Millennium Declaration.

Health and development The link between health and development can be found in three of the Millennium Development Goals (MDGs), as set forth by the United Nations Millennium Declaration in 2000. The MDGs that specifically address health include reducing child mortality; improving maternal health; combating HIV and AIDS, malaria, and other diseases; and increasing access to safe drinking water.

A progress report published in 2006 indicates that childhood immunization and deliveries by skilled birth attendants are on the rise, while many regions continue to struggle to achieve reductions in the prevalence of the diseases of poverty including malaria, HIV and AIDS and tuberculosis.

The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services.

A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.

providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment.

Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care.

“Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

There is a need for improved health services for the 2. 6 billion people living on less than $2 a day. The poor experience considerable barriers to health care such as limited purchasing power and health insurance, low health literacy, and residence in slums or remote rural areas which are frequently underserved.

These barriers must be considered in the way services are marketed, financed and delivered to this group to ensure that quality care is made available and affordable to the poor. In part due to gaps in public health services, the private provision of health care has grown. The presence of private health providers in low- and middleincome countries (LMIC) is significant.

Recent estimates suggest that poor people seek care in the private sector for 35 -95% of cases of childhood diarrheal and respiratory illnesses across a wide range of countries. Private provision of care is not without its critics. The main concerns about private health care delivery are the under provision of public goods in free markets, lack of access to care for the poor, and the potential for providers to induce demand for unnecessary services to generate profit.

However, since public health services are not always available or in some cases perceived to be of poor quality, private health care delivery has been widely used in LMIC. One area where the private sector may contribute is as a source of "disruptive innovators" - organizations who develop simpler and cheaper services that enable the participation of new sets of consumers previously excluded from conventional markets.

Providers in the private sector may operate on a for -profit or a not-for-profit basis but there is a growing number of social enterprises which aim to develop models of pattern-breaking social change that can scale up easily, which can include novel financial strategies. These social capitalists attempt to improve the affordability, availability or quality of care for the poor.

There is not a great deal of mystery as to why poor people in low income countries suffer from high rates of illness particularly infectious diseases and malnutrition: little food, unclean water, low level of sanitation and shelter, failure to deal with the environments that lead to high exposure to infectious agents and lack of appropriate medical care.

Similarly there is a great deal of knowledge of the causes of non-communicable diseases that represent the major burden of disease for people at the lower end of the social gradient in middle income and high income countries. The World Health Organization global burden of disease study identified underweight, overweight, smoking, alcohol, hypertension, and sexual behaviour as major causes of morbidity and mortality.

These health inequities are the result of a complex system operating at global, national and local levels which shapes the way society at the national and local levels organizes its affairs and embodies different forms of social position and social hierarchy.

Although inequities in health result from the social conditions that lead to illness, the high burden of illness particularly amongst socially disadvantaged populations creates a pressing need to make health systems responsive to population needs. International, national and locals systems of disease control and health services provision are both determinants of health inequities and powerful mechanisms for empowerment.

Out-of-pocket expenses for health care discourage poorer people from using services leading to untreated morbidity. Such expenditure can lead to further impoverishment. The larger the proportion of health care that is paid out of pocket, the larger the proportion of households that are faced with catastrophic health expenditures.

Health Insurance have proved to be unsustainable and failed to deliver on the promise of equity. Therefore currently investigating and proposing to introduce a broader prepayment scheme for health care, in the form of Social Health Insurance.

Health Systems in Developed Countries Dr.

Overview of the U. S. Health Care System INTRODUCTION o America has arguably the “best health care system in the world”, pointing to the available medical technology and state-of-the-art facilities o Understanding of these two diametrically opposed viewpoints requires a basic understanding of the o Structure of the U. S. health care system. o Organization and Financing of the system.

Health Care System - Challenges The multiple players involved in the health care system maintain key roles and face distinct challenges in the provision of care. These range from ; § Financing and technological issues facing facilities like hospitals and clinics; § Supply and educational challenges facing providers such as doctors, nurses, and other health care professionals; § The shifting role of government in financing and regulating the delivery system. § The two overarching challenges before all segments of the health care system in the U. S. are § improving the quality of health care and § Checking the rapid rate of growth in health care costs.

Health spending and financing in USA • The United States spent 15% of its GDP on health care in 2003, the highest percentage in the OECD (an organization of industrialized countries). • The average % GDP spent on health care in OECD countries was 8. 6%. • In the United States, 44% of health spending is funded by government, well below the average of 72% in OECD countries. • In the United States, private insurance accounts for 37% of total health spending, by far the largest share among OECD countries.

ORGANIZATION OF U. S. HEALTH CARE SYSTEM • Health Care is not universally available to populations • America has both private and public insurers in the health care system. • U. S. system is unique in the world with the dominance of the private element over the public element.

• Public Health Insurance 1. Medicare • Medicare is a federal program that covers individuals aged 65 and over, as well as some disabled individuals. • Medicare is a single-payer program administered by the government which perform the function of reimbursement. . 2. Medicaid • Medicaid program is designed for the low-income and disabled. • Under federal law, states must cover very poor pregnant women, children, elderly, disabled, and parents. Childless adults are uncovered, • Medicaid offers a fairly comprehensive set of benefits, including prescription drugs.

3. Other public insurance systems • The State Children’s Health Insurance Program (S-CHIP) designed in 1997 to cover children whose families do not qualify for Medicaid but fail to buy pvt. health insurance. • S-CHIP and Medicaid often share similar administrative and financing structures. • The Veteran’s Administration (VA) is a federally administered program for veterans of the military.

Private Health Insurance 1. Employer-sponsored insurance • Employer-sponsored insurance is the most common for Americans health insurance. Employers provide health insurance as package for employees. • Insurance plans are administered by private companies, both for-profit (e. g. Aetna, Cigna) and non-for-profit (e. g. Blue Cross/Blue Shield). • Employer-sponsored insurance is financed both through employers (who usually pay the majority of the premium) and employees (who pay the remainder of the premium). In 2005,

Private non-group - individual Insurance • The individual market covers part of the population that is self-employed or retired and covers some people who are unable to obtain insurance through their employer. • The plans are administered by private insurance companies.

FINANCING OF THE U. S. HEALTH CARE SYSTEM § The United States practices a “multi-payer” system. § The financing of health care centers around two streams of money : § The collection of money for health care (money - in) § The reimbursement of health service providers for health care (money - out). § In the United States, the responsibility for these two functions is shared by private insurance companies as well as the government, § Both of which are known in policy terms as “payers. ”

World Health System Ranking § The World Health Organization (WHO) ranked the health systems of its 191 member states in its World Health Report 2000. § Report provided a framework and measurement approach to examine and compare aspects of health systems around the world. § WHO developed a series of performance indicators to assess the overall level of the health systems. It was the organization's first ever analysis of the world's health systems. The WHO abandoned ranking processes due to academic criticism regarding the methodology and validity of rankings. [ § Distribution of health in the populations, § Health equality § Responsiveness equality and § Financing of health care services.

Country Ranking 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 France Italy San Marino Andorra Malta Singapore Spain Oman Austria Japan Norway Portugal Monaco Greece Iceland Luxembourg Netherlands United Kingdom Ireland Switzerland Belgium Colombia Sweden Cyprus Germany Expenditure Per Capita Ranking 4 11 21 23 37 37 24 62 6 13 16 27 12 30 14 5 9 26 25 2 15 49 7 39 3 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Country Saudi Arabia United Arab Emirates Israel Morocco Canada Finland Australia Chile Argentina Denmark Dominica Costa Rica United States Slovenia Cuba Brunei New Zealand Bahrain Croatia Qatar Kuwait Barbados Thailand Czech Republic Malaysia Expenditure Per Capita 63 35 19 99 10 18 17 44 15 8 70 50 1 29 118 32 20 48 56 27 41 36 64 40 93

The UK Health Care System Who is covered ? § Coverage is universal for all citizens. § All those ‘ordinarily resident’ in the United Kingdom are entitled to health care that is largely free at the point of use. What Services are covered ? Publicly-funded National Health Service (NHS) covers ; § Preventative services; § Inpatient and outpatient (ambulatory) § Hospital (specialist) care; § Physician (general practitioner) services; § Inpatient and outpatient drugs; § Dental care; mental health care; § Learning disabilities; and rehabilitation.

What is being done to ensure quality of care? Quality of care is a key focus of the NHS. Quality issues are addressed in a range of ways including: 1. Regulatory bodies: § A number of bodies monitor and assess the quality of health services provided by public and private providers. § This involves regular assessment of all providers, investigation of individual providers where an issue has been drawn to the attention of the regulatory body, and consideration of key areas of provision in order to recommend best practice. § The three bodies primarily responsible for regulation in England § Healthcare Commission, § Commission for Social Care Inspection and § Mental Health Act Commission. 2. Targets: § Targets have been set by the government for a range of variables that reflect the quality of care delivered. § Some of these targets are monitored by the regulatory bodies mentioned above; § others are monitored on a regular basis either by the Department of Health or its regional organizations. .

How are costs controlled? • The government sets the budget for the NHS on a threeyear cycle. To control utilization and costs, the government sets a capped overall budget for PCTs. • NHS trusts and PCTs are expected to achieve financial balance each year. • The centralized administrative system tends to result in lower overhead costs. • Other mechanisms that contribute to improved value for money include arrangements for the systematic appraisal of new technologies through the National Institute for Health and Clinical Excellence (NICE).