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CurrentandEmergingIssuesandChallenges
European Region
Chapter10UnitedKingdom
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter11France
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentIssuesinHealthcare
Chapter12Germany
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem Quality
Access
CurrentandEmergingIssuesandChallenges
Chapter13Ireland
CountryDescription
BriefHistoryoftheHealthcareSystem EvaluationoftheHealthcareSystem
Chapter14Russia
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthSystem CurrentandEmergingIssuesandChallenges
Middle East and Africa
Chapter15Turkey
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthSystem EmergingChallenges
Chapter16Jordan
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter17Israel
CountryDescription
HistoryofCountry
SizeandGeography GovernmentandPoliticalSystem
Macroeconomics
Demographics
HealthcareSysteminIsrael:Organization,Financing,andDelivery EmergingChallengesandOpportunities
AnIntegratedHealthcareSystem IsraeliLeadershipinGlobalHealth
Summary
Chapter18Ghana
CountryDescription
BriefHistoryoftheHealthcareSystem
DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter19Nigeria
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheCurrentHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter20Botswana
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingChallenges
Asia and Pacific Region
Chapter21Bangladesh
CountryDescription
BriefHistoryoftheHealthcareSystem
Chapter22India
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingChallengesandOpportunities
Chapter23China
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheCurrentHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter24Japan
CountryDescription
BriefHistoryoftheHealthcareSystem DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter25Korea
CountryDescription
Introduction
BriefHistoryoftheHealthcareSystem
DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem CurrentandEmergingIssuesandChallenges
Chapter26Australia
CountryDescription
BriefHistoryoftheHealthcareSystem
DescriptionoftheCurrentHealthcareSystem EvaluationoftheHealthcareSystem
CurrentandEmergingIssuesandChallenges
PARTIIIChallenges,Innovations,andOpportunities
Chapter27SmallCountryInnovations
Introduction
Cuba
Singapore
Taiwan
TheNetherlands
CostaRica
ConcludingCommentary
Chapter28HealthSystemsinCrisisandDisaster
Introduction
GeophysicalDisasters
BiologicalEvents
ClimateEvents
HealthSystemsResponse
Conclusion
Chapter29ComparativeGlobalChallengesandOpportunities
Introduction
InternationalHealthPolicy,Globalization,andPrivatization
Decentralization
HealthCareasanIncreasingPortionofGDP
InjuriesandViolence
MentalIllness
AgingPopulation
EnvironmentalImpact/ClimateChange
Refugees,DisplacedPeople,andHumanitarianCrises
GlossaryofHealthSystemsTerms
Index
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Acknowledgments
Wewouldliketothankalloftheauthorsfromaroundtheworldfortheirinvaluableandinsightful contributionstothisbook WealsowanttothankDanielleBessetteforherexceptionaljobandhardwork asassociateeditor Daniellebroughtherownperspectivesandmuchappreciatedprofessionalismtothis project,oftenservinginthevaluedroleoffourtheditor WealsowanttothankGeorgeJacobandAthena Lakrifortheirvaluableandskillfulinput Additionally,wethankMichaelBrownofJones&Bartlett Learningforhissupportasweworkedourwaythroughthismultifacetedinternationalundertaking
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Foreword
Drs David and Kathleen Jordan
Aswewritethisforeword,weareviewingaworldwithglobalclimatechange,incomeinequalities,gapsin educationalopportunitiesforgirls,societalunrest,andanunprecedentednumberofrefugeeswhoare seekingpersonalandeconomicsafetyfromwar-tornregionsfromaroundourworld Anyofthesesocial determinantshasadirecteffectuponthehealthofindividualsineverycorneroftheglobe fromthe
remotesteppesofMongoliatothebourgeoningurbansettingsinSouthAmericaandAsia.Healthcareis nolongeralocalorevenanationalphenomenon;itisaglobalnetworkofdisparategroupingsof practitioners,systems,facilities,governmentalfundingapproaches,non-governmentalorganizations, shamans,midwives,technologicalwonders,andculturalbeliefs Toattempttounderstandthemyriad aspectsofglobalhealthcareisakintounravelingtheuntoldmysteriesofhumanDNAandthevery essenceofwhatmakesushuman
Understandingglobalhealthsystems,outcomes,andpracticesisacomplexandmultidimensional exerciseworthyofsocialscientistscapableofgraspingboththebalconyviewsandtheground-level realitiesofthesocialdeterminantsthataffectthehealthoftheworld’s74billionmen,women,and children Dr JamesJohnsonisonesuchindividualwhohasspentalifetimeattemptingtomakesenseof themultiplemetricswhichcontributetoourunderstandingofglobalhealthsystems Thislatesteditionof Comparative Health Systems providesanimportantreferenceforpractitioners,scholars,academics, researchers,andstudentswhoseworkrestsinunderstandingglobalhealthcare
Wearesocialentrepreneurs,collegeeducators,andhealthandhumanserviceexecutivesandaredeeply investedinaddressingeconomic,social,andhealthcareoutcomesinunderresourcedcountriesaround theworld Weworkinareasofthedevelopingworldwherenaturalandchildmortalityratesare frustratinglyhigh
Thesecondeditionof Comparative Health Systems,editedbyJamesJohnson,CarleenStoskopf,and LeiyuShi,offersoneofthefewcomprehensivesourcesofbothstatisticalinformationandanecdotal narrativebehindthedata Thisneweditionwillreplaceourcurrentdogged-earedcopyofthefirstedition andwillgainitsnewplaceinourlibrarybookshelfintheyearstocome Itis muchlikeJameshimself a treasuretousboth.Hehasbeenaninvaluablementor,formerprofessor,andtrustedfriendoverthe years
Ifyouareastudenttryingtobroadenyourunderstandingofglobalhealth,apractitionerresearching informationonacountryinwhichyoumaywork,oraresearcherattemptingtounderstandthedynamics associatedwithhealthcarearoundtheglobe,thisisthetextyouneedinyourbackpack,youroffice,orin thehandsofyourstudents
Dr.DavidA.JordanandDr.KathleenM.Jordan Founder/President(David)and ExecutiveVicePresident(Kathleen) SevenHillsFoundation
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Foreword
Dr Ted Karpf
Thisisamosttimelybook.Drs.Johnson,Stoskopf,andShihaveanticipatedanddocumentedthecore concernsfacedbynations Healthandhealthcareareattheforefrontofinternationalconcern,especially inatimeofglobalfinancialturmoilandinsecurity Thisbookisabsolutelyessentialtounderstanding what’satstakeandtochartingapaththroughthemazeofissuesconfrontinghealthcareplannersand
healthcarerecipients,healthcareprofessionalsandfinancingmanagers,politicians,andbureaucrats.It’s morethanamatterofsystemsandapproaches;itisaboutthesecurityoftheglobalcommunity
AccordingtoDr MargaretChan,director-generaloftheWorldHealthOrganization:
Healthyhumancapitalistheveryfoundationforproductivityandprosperity Equitabledistributionofhealthcareandequityinthe healthstatusofpopulationsisthefoundationforsocialcohesion Socialcohesionisourbestprotectionagainstsocialunrest, nationallyandinternationally Healthy,productive,andstablepopulationsarealwaysanassetbuttheymustespeciallybesoduring atimeofcrisis
Therecipientsofhealthcaremustbeheardabovethedinofcompetingclaimsofequityand effectiveness:
Thepeoplehavetherightanddutytoparticipateindividuallyandcollectivelyintheplanningandimplementationoftheirhealthcare Primaryhealthcare requiresandpromotesmaximumcommunityandindividualself-relianceandparticipationintheplanning, organization,operation,andcontrolofprimaryhealthcare,makingfullestuseoflocal,national,andotheravailableresources;and tothisenddevelopsthroughappropriateeducationtheabilityofcommunitiestoparticipate”(DeclarationofAlma-AtaInternational ConferenceonPrimaryHealthCare,ArticlesIVandVII,Alma-Ata,Khazakhstan,USSR,September6–12,1978)
Obtainingdecentcare,whichacknowledgesthevoiceofthepeoplethroughthevaluesofagencyand dignity,interdependenceandsolidarity,subsidiarityandsustainability,raisestheanteabithigher Politicalandhealthcareleaders,financialmanagers,andmedicalandhealthcareprofessionalsmustbe remindedamidstthepolicydebatethatwhenthepeopleareinvestedintheirowncare,theformulasfor successandsustainabilitychange Whenthepeopleareengagedindeterminingthelevelsandresource allocationsforcare,thereisalsomoredecisionlatitudethanthosechargedwithdeterminingformulascan imagine
Thehealthcaredebatemustfinallyfactorinthepeoplewhoitclaimsaretobeservedandsustainedwith improvedhealth Thenthevariousfinancialmodelsandhealthcaresystemswillstillnotbringusthelongneededsatisfactionandsupportweneedtoday NobelLaureateandformerUS presidentBarack Obamastatedrepeatedlythat“healthcareisaright”Thisnotion,enshrinedthreedecadesagoatAlmaAta,changestherulesandreorganizesthelinesofaccountabilityalongwithourthinkingand expectations Wherehealthisaright,socialresponsibilitywillleadtoanenhancedcommitmentto improvedhealth Theformulaceasestobeabout“thosepeople”or“theirproblems”andbecomesabout us!
Asweproceedthroughthesepagesitwillbeimportanttoaskhowthisapproachwillhelpensurethatthe peopleareheardandheeded.
Dr TedKarpf Internationalhealthadvocate(retired), WorldHealthOrganization,andauthorof thebook Restoring Hope: Decent Care in the Midst of HIV/AIDS
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Preface
Dr James A Johnson
Overthepasttwodecades,IhavetakengraduatestudentstoGeneva,Switzerland,eachsummerto studyglobalhealth Whilethere,wealwaysspendtimeattheWorldHealthOrganization(WHO),whichis receivingupdatesonglobalhealthandinteractingwithseniorscientists,healthpractitioners,andleaders inthemissionof“healthforall”Inadditiontobeingspellboundbydescriptionsofthemanyinitiativesand
greatsuccessesoftheWHO,werepeatedlyhearofonemajorlimitationthatcontinuestoimpedeeven thegreaterprogress Thatisthepoorstateofhealthsystemsinmanypartsoftheworld Thereare modelsofsuccessaswellasmodelsoffailure Mosthealthsystemsareorientedtowarddiseasecare, andmanyareunderfundedandunderstaffed,whereassomecountriesexpendlargeportionsoftheir nationalresourcesonhealth Somehealthsystemsareoperatedbygovernments,andothersaremore involvedintheprivatesector Regardlessofscopeorscale,everyprogram,everyinitiative,everypolicy, andeverycourseoftreatmentareimbeddedwithinaparticularcountry-specifichealthsystem
Severalyearsago,myfriendandcolleagueDr CarleenStoskopfjoinedmeononeofthetripsto Geneva Whilethere,wediscussedtheneedforabookthatwoulddescribearangeofhealthsystemsso thatstudentscouldbetterunderstandthelimitationsandopportunitiesofferedinthediversitythatwehad eachseeninourowninternationalwork Wefeltthatoneofthebestwaysforstudentstolearnaboutthe rangeofsystemswouldbethroughcomparativestudy Aswithmanyinvigoratingsidewalkcafé conversationsinEurope(andelsewhere),wesetthisideaasideandreturnedtothebusyactivitiesofour academicpositionsatthetime Carleen,adepartmentchairattheSchoolofPublicHealthatthe UniversityofSouthCarolinainColumbia,SouthCarolina,andmyself,adepartmentchairattheMedical UniversityofSouthCarolinainCharleston.Afewyearslater,however,atameetingoftheAmerican PublicHealthAssociationinBoston,inaconversationwithpublisherMichaelBrown,thetopiccameback upandmomentumforsuchabookgrewquickly.
Weconceptualizedthebookasatexttobeusedincoursesininternationalhealth,comparativestudies, globalhealth,internationalaffairs,healthadministration,andpublichealth.Inanincreasingly interconnectedandinterdependentworldcomprisedofwidevariationsinhealthdeliverysystems, practices,andpolicy,thebookwasdevelopedtoofferstudentssomeunderstandingthroughcomparative study
Inseekingtoachievethisgoal,weenlistedcontributorsfrommanycountriestowriteaboutthesystems thattheyhadworkedinandwerefamiliarwith Thus,everychapterthatdescribesahealthsystemis writtenbyatleastonepersonfromthatcountry.ChaptersalsoendeduphavingU.S.-basedcoauthors becauseweusedourownprofessionalnetworksinschoolsofpublichealth,medicine,administration, andpolicytoidentifychaptercontributors.Needlesstosay,thebookprojectemergedasasignificant multiculturalundertakinginvolvingauthorsfromeverycontinentandfromthelargestpossiblerangeof healthsystemtypes.Thisledtothepublicationofthefirsteditionof Comparative Health Systems: Global Perspectives in2010
Overfiveyearslater,wewereaskedbythepublishertowritethe Second Edition.Forthisundertaking,I askedanotherfriendandcolleaguethatgoesbacktoourSouthCarolinadaystojoinCarleenandme ThisthirdeditorisLeiyuShi,nowatJohnsHopkinsUniversity.Hebroughthisusualhighenergyand globalviewpointtotheproject
Followingtheconceptualstructureofthe First Edition,wecontinuedtousetheframeworkCarleenandI hadpreviouslydeveloped Thisframeworkforeachchapterallowsstudentstocompareandcontrastsuch divergentsystemsasCanada,India,Japan,Nigeria,Germany,Australia,Mexico,andmanyothers.The frameworkusedtodevelopeachchaptercountryfocusedincludesthefollowing:
Country Description
History
Sizeandgeography
Governmentandpoliticalsystem
Macroeconomics(GDP,OECD)
Demographics(includingreligion,gender,andpoverty)
Brief History of the Healthcare System
Descriptionofhealthcaresystem
Facilities
Workforce
Technologyandequipment
Evaluation of the Healthcare System
Cost Quality
Access
Currentinnovationsandemergingchallenges
Althoughthesechaptersweredevelopedbyin-countryauthorsandtheircollaborators,additionally, workingwithcolleagues,wedevelopedotherchaptersthatareoverarching.Thisincludesachapterthat describeshealthsystemsandonethatprovidesanoverviewofdisease Dr WalterJonescontributeda veryusefulchapterdiscussinghealthpolicyandeconomics.Myson,Dr.AllenJohnson,andcoauthors contributedachapterdescribingtheroleofnon-governmentalorganizations(NGOs)asanimportant, thoughsometimesoverlooked,componenttohealthsystemsandglobalhealth Dr CarenRossowandI alsoaddedachapteronhealthsystemsincrisisanddisasterresponse Additionally,CarleenandI includedachapterthatoutlinesfuturechallenges Thereisalsoaglossaryofhealthsystemstermsthat shouldbeusefultostudentsandprofessors
Havingworkedinortraveledtoover45countriesmyself,Icansaywithgreatconfidencethatthisbook willservetobroadenthereader’sunderstanding Itwillalsolikelychangetheirperspectivesonglobal health Theywilllearnthatalthoughhighlydevelopedcountriescontinuetoofferprofoundbreakthroughs inmedicalscienceandtechnology,aswellasreformandcontinuousimprovementofhealthsystems,the bestsolutionsdonotalwaysemergeinthewealthiestcountries Inthe Harvard International Review,Dr VanessaKerry,founderandCEOofSeedGlobalHealth,stated“Ithinkthemostimportantthingisfor peopletorealizethattobeinglobalhealth,youcancomefromanyfieldorbackground Inordertohave animpactonglobalhealth,weneedto,again,realizethatthereisafundamentalbreakdownofthe systemonanynumberoflevelsindifferentcountries”
AsstatedbyDr BarryBloom,formerdeanoftheHarvardSchoolofPublicHealth,thehugedisparitiesin healththatexistbetweencountriesremainsomeofthegreatmoralandintellectualproblemsofourtime Thisbookcanserveasonetoolamongmanythatwillbeneededtoempowerstudentstobecome changeagentsinthisongoingchallenge
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Contributors
MusahSugriAlhassan,MSA
GhanaNationalAssociationofTeachers GNAT
Tamale,Ghana
StephanieBaiyasi,DVM
UniversityofDenver
Denver,Colorado,UnitedStates
AntonioPiresBarbosa,PhD,MD UniversidadeNovedeJulho SãoPaulo,Brazil
StevenD Berkshire,EdD,MHA,FACHE CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
RaulChiquiyauri,MD,MPH,PhD CentrodeInvestigacióndeEnfermedadesTropicles InstitutoNacionaldeSalud SedeIquitos,Peru
OmurCinarElci,MD,PhD St George’sUniversitySchoolofMedicine TrueBlue,Grenada
MariaCreavin,RD,SM,MAS CentralMichiganUniversity MountPleasant,Michigan,UnitedStates
MarkAnthonyCwiek,JD,MHA CentralMichiganUniversity MountPleasant,Michigan,UnitedStates
GaryE Day,DHSM,MHM,RN,EM,FGLF,FCHSM SchoolofMedicine,GriffithUniversity Southport,Queensland,Australia
JoséDelacerda-Gastelum,PhD,MILR ITESOUniversity Guadalajara,Mexico
LindaF Dennard,PhD AuburnUniversityMontgomery Montgomery,Alabama,UnitedStates
JamesE DotherowIV,MPA SoTheyCan(NGO) Babati,Tanzania
MazwellDroznin,BA RollinsCollege WinterPark,Florida,UnitedStates
R.PaulDuncan,PhD,MS,BA UniversityofFlorida Gainesville,Florida,UnitedStates
SharonR.Elefant,DHAc, CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
HarryFlaster,MD UniversityofWashingtonMedicalCenter Seattle,Washington,UnitedStates
LeonardFriedman,PhD,FACHE GeorgeWashingtonUniversity Washington,DC,UnitedStates
LesegoGabaitiri,PhD,ScM,MSc,BA UniversityofBotswana Gaborone,Botswana
SheynaGifford,MD,MSc,MA,MBA St LouisScienceCenter St Louis,Missouri,UnitedStates
OctavioGomez-Dantés,MD,MPHA CarsoHealthInstitute MexicoCity,Mexico
MikiyasuHakoyama,PhD CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
WhiejongM Han,PhD UniversityofSouthCarolina Columbia,SouthCarolina,UnitedStates
UmarHaruna,PhD,MPhil UniversityforDevelopmentStudies UpperWest,Ghana
Kuo-CherhHuang,DrPH,MBA TaipeiMedicalUniversity Taipei,Taiwan
ManzoorHussain,MBBS,FRCP,FRCPCH BangladeshInstituteofChildHealth Dhaka,Bangladesh
StynM Jamu,DHA,MPA SteppingStonesInternational Gaborone,Botswana
AllenJohnson,DrPH,MPH RollinsCollege WinterPark,Florida,UntiedStates
WalterJ.Jones,PhD,MHSA,MA MedicalUniversityofSouthCarolina Charleston,SouthCarolina,UnitedStates
KaluKalu,PhD,MBA AuburnUniversityMontgomery Montgomery,Alabama,UnitedStates
BernardJ KerrJr,MHA,MBA,MPH,MIM,EdD,FACHE CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
SophieKobouloff,DHA,MBA,EDHECMBA SaddleImplantTechnologies Geneva,Switzerland
HailunLiang,MS JohnsHopkinsSchoolofPublicHealth Baltimore,Maryland,UnitedStates
GeraldLedlow,PhD,MHA,FACHE UniversityofTexasHealthScienceCenterNortheast Tyler,Texas,UnitedStates
OsnatLevtzion-Korach,MD,MHA HadassahMedicalCenter Jerusalem,Israel
MarcusLongley,PhD WelshInstituteforHealthandSocialCare UniversityofSouthWales Pontypridd,Wales,UnitedKingdom
JohnLopes,Jr.,DHSc,PA-C CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
NingLu,PhD,MPH GovernorsStateUniversity UniversityPark,Illinois,UnitedStates
HalaMadanat,PhD,MS SanDiegoStateUniversity SanDiego,California,UnitedStates
LindaA McCarey,MS,BSN,RN Haliburton,Kawartha,PineRidgeHealthUnit Haliburton,Ontario,Canada
JohnE McDonough,DrPH,MPA HarvardUniversity Cambridge,Massachusetts,UnitedStates
HaniMichelSamawi,PhD,MS GeorgiaSouthernUniversity Statesboro,Georgia,UnitedStates
AmalK.Mitra,MD,MPH,DrPH JacksonStateUniversity Jackson,Mississippi,UnitedStates
MichaelE.Morris,PhD,MPH,MPA UniversityofFlorida Gainesville,Florida,UnitedStates
AdrienneNevola,MPH UniversityofArkansas Fayetteville,Arkansas,UnitedStates
MarciaCristinaZagoNovaretti,PhD,MD UniversidadeNovedeJulho SãoPaulo,Brazil
QwolabiOgunneye,MD,FRCP,FASN CovenantHealthcare Saginaw,Michigan,UnitedStates
YetundeOgunneye,MD,DHAc,MPH CentralMichiganUniversity Mt Pleasant,Michigan,UnitedStates
ElenaA Platonova,PhD,MHA UniversityofNorthCarolina,Charlotte Charlotte,NorthCarolina,UnitedStates
HugoRodriguez,MD,MPH HospitalIquitos Iquitos,Peru
CarenRossow,DHA,MSA,RN,FACHE IndianaUniversity SouthBend,Indiana,UnitedStates
AlexanderV Sergeev,MD,PhD,MPH OhioUniversityDepartmentofSocialandPublicHealth Athens,Ohio,UnitedStates
NeelamSharma,MD Newark-WayneCommunityHospital Newark,NewJersey,UnitedStates
HaticeSimsek,MD,PhD DokuzEylülUniversitySchoolofMedicine İzmir,Turkey
DouglasA Singh,PhD IndianaUniversity,SouthBend SouthBend,Indiana,UnitedStates
JamesH Stephens,DHA,MHA GeorgiaSouthernUniversity Statesboro,Georgia,UnitedStates
ReyhanUcku,MD,MPH DokuzEylülUniversitySchoolofMedicine Izmir,Turkey
StalinVilcarromero,MD,MPHc NavalMedicalResearch Iquitos,Peru
MatthewW Walker,DrPH,MPH US FoodandDrugAdministration SilverSpring,Maryland,UnitedStates
SudhaXirasagar,PhD,MBBS
UniversityofSouthCarolina
Columbia,SouthCarolina,UnitedStates
KapilYadav,MD
TulaneUniversity
NewOrleans,Louisiana,UnitedStates
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AbouttheEditors
JamesA Johnson,PhD,MPA,MSc,isamedicalsocialscientistandprofessorofhealthadministration andinternationalhealthattheDowCollegeofHealthProfessions,CentralMichiganUniversity,and visitingprofessoratSt George’sUniversity,Grenada,WestIndies Hewaspreviouslychairmanofthe DepartmentofHealthAdministrationandPolicyattheMedicalUniversityofSouthCarolina Dr Johnson teachescoursesinhealthorganizationdevelopment,internationalhealth,systemsthinking,and comparativehealthsystems Hispublicationsincludeover100journalarticles,mostofwhicharepeer
reviewed,and15booksonawiderangeofhealthcareandorganizationalissues.Hismostrecentbooks include Public Health Administration: Principles of Population-Based Management; Introduction to Public Health Management, Organizations, and Policy; Multisector Casebook in Health Administration, Leadership, and Management;and Organizations: Theory, Behavior, and Development Heisalso coeditorofthewidelyused Handbook of Health Administration and Policy Dr Johnsonhasalsoserved aseditorofthe Journal of Healthcare Management,publishedbytheAmericanCollegeofHealthcare Executives;editorofthe Journal of Management Practice;andfoundingeditorofthe Carolina Health Services and Policy Review Heisacontributingeditorforthe Journal of Health and Human Services Administration HehasservedontheBoardofDirectorsfortheAssociationofUniversityProgramsin HealthAdministrationandtheScientificAdvisoryBoardoftheNationalDiabetesTrustFoundation Dr Johnsonhasworkedandtraveledin45countries,includingTanzania,Zimbabwe,SouthAfrica,Nepal, China,Belize,Peru,Ethiopia,Turkey,andMexicoandhaslecturedatOxfordUniversity(England), UniversityofDublin(Ireland),BeijingUniversity(China),andUniversityofColima(Mexico) Healsoworks onprojectswiththeWHOandtheBelize-basedNGO,HearttoHeartandisactiveintheOrganization DevelopmentInstitute HecompletedhisPhDin1987attheAskewSchoolofPublicPolicyand AdministrationatFloridaStateUniversityandhisMPAinhealthadministrationatAuburnUniversity.
CarleenH.Stoskopf,ScD,MS,isProfessorofHealthManagementandPolicyandDivisionHeadinthe GraduateSchoolofPublicHealthatSanDiegoStateUniversity,whereshealsoservedasSchool Directorfor7years Dr StoskopfheldacademicappointmentsattheArnoldSchoolofPublicHealthat theUniversityofSouthCarolinafor19years,advancingtoChairoftheDepartmentofHealthServices PolicyandManagement Dr StoskopfhasservedasaFellowoftheCommissiononAccreditationof HealthManagementEducationandservedasasitevisitorfortheCouncilonEducationinPublicHealth reaccreditationprocess Herareasofteachingincludefinance,healthinsurance,andreimbursement At theUniversityofSouthCarolina,shewasDirectorofDoctoralProgramsanddevelopedtwoadditional doctoralprogramsinTaiwanandSouthKorea Priortoenteringhercareerinacademics,Dr Stoskopf servedintheU.S.NavyasanEnvironmentalHealthOfficewiththeThirdMarineAircraftWingatElToro, CaliforniaandasChiefofthePreventiveMedicineServiceattheNavalRegionalMedicalCenterin Okinawa,Japan.ShewashonorablydischargedasaLieutenant,USN,MSCin1982.Shewasalsoa RegisteredSanitarianwiththeStateofCalifornia
Internationally,Dr.StoskopfhasworkedextensivelyforUSAIDandavarietyofagenciesincountries suchasHaiti,Kenya,SouthAfrica,theUnitedArabEmirates,Oman,Kuwait,Jordan,People’sRepublic ofChina,theRepublicofChina,RepublicofSouthKorea,RepublicofGeorgia,Kazakhstan,Ukraine,and Russia Dr Stoskopf’sactivitieshaverangedfromlecturing,providinghealthcaremanagementtraining, healthcaremanagementcurricularreviewsanddevelopment,policyandcurriculumconsultationswith newschoolsofpublichealth,publichealthassessments,HIV/AIDSresearch,andhospitalmanagement consultations
Dr Stoskopfhasbeenanactiveresearcherconductingstudiesinaccess,utilization,andoutcomesof healthcareservices Specificareasofresearchincludedisparitiesinvulnerablepopulationssuchas personslivingwithHIV/AIDS,livingwithmentalillness,inpoverty,olderpersons,andAfricanAmericans livinginthesouthernUnitedStates Dr Stoskopf’sresearchhasbeenfundedfromsuchsourcesasthe NationalInstitutesofHealth,CentersforDiseaseControlandPrevention,theHealthResourcesand ServicesAdministration,aswellasanumberofstateandlocalagenciesandfoundations Dr Stoskopf hasauthoredorco-authoredover50peer-reviewedpublicationsinacademicjournals Shecompletedher doctorofscience(ScD)degreefromTheJohnsHopkinsUniversityBloombergSchoolofPublicHealthin 1989intheDepartmentofHealthPolicyandManagement,andearnedherMSdegreefromthe UniversityofMinnesotaSchoolofPublicHealthin1977inenvironmentalhealthbiology
LeiyuShi,DrPH,MBA,MPA,isprofessorofhealthpolicyandhealthservicesresearchinthe DepartmentofHealthPolicyandManagement,BloombergSchoolofPublicHealthatJohnsHopkins University.HeisalsodirectorofTheJohnsHopkinsPrimaryCarePolicyCenter.Priortohisacademic positions,Dr Shiworkedinthepublichealthfieldfocusingoncommunity-basedprimarycareand vulnerablepopulations.HereceivedhisdoctoraleducationfromtheUniversityofCalifornia,Berkeley,
majoringinhealthpolicyandservicesresearch.Healsohasamaster’sinbusinessadministration focusingonfinance Dr Shi’sresearchfocusesonprimarycare,healthdisparities,andvulnerable populations Hehasconductedextensivestudiesabouttheassociationbetweenprimarycareandhealth outcomes,particularlyontheroleofprimarycareinmediatingtheadverseimpactofincomeinequalityon healthoutcomes Dr Shiisalsowellknownforhisextensiveresearchonthenation’svulnerable populations,inparticularcommunityhealthcentersthatservevulnerablepopulations,includingtheir sustainability,providerrecruitmentandretentionexperiences,financialperformance,experienceunder managedcare,andqualityofcare Dr Shiistheauthorof9textbooksandmorethan150scientific journalarticles
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PARTI GlobalHealthandHealthSystems
CHAPTER1IntroductiontoHealthSystems
CHAPTER2GlobalHealthandDisease
CHAPTER3GlobalHealthSystemsPolitics,Economics,andPolicy
CHAPTER4RoleofInternationalOrganizationsinHealthSystems
©MatvienkoVladimir/Shutterstock
JamesA JohnsonandCarleenH Stoskopf
healthsystemasdescribedbytheWorldHealthOrganization(WHO)isthesumtotalofallthe
Aorganizations,institutions,andresourceswhoseprimarypurposeistoimprovehealth.Ahealth systemneedsstaff,funds,information,supplies,transport,communications,andoverallguidanceand direction Furthermore,itneedstoprovideservicesthatareresponsiveandfinanciallyfair,while treatingpeopledecently1
Withinthisdefinition,thereareseveralconceptsthatneedtobeunderstoodbeforeoneembarksonthe taskofstudyinghealthsystems.Firstandforemost,anagreed-ondefinitionofhealthisparamount. Healthistoooftenseenasaconceptthatappliesonlytophysicalwell-beingortheabsenceofdisease; however,themostwidelyaccepteddefinitionofhealthistheonefirstpublishedbytheWHOin1948.
Healthisastateofcompletephysical,mental,andsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity2
Thiscomprehensiveconceptofhealthistheoneusedinthisbookandservestoinformdiscussionson healthsystems
Theotherkeywordthatneedstobeexploredhereistheword“system”Thehumanbodyisasystem composedofmanyphysiologicalsubsystemsthatareinterconnectedinaholisticway Thesubsystems, includingrespiratory,circulatory,neurological,endocrine,andmusculoskeletalsystems,communicate andareinterdependent Theyworktogetherforthepurposesofsurvival,adaptation,growth,and development.Theyalsointeractwiththeenvironmentandrespondtofeedbackfromwithinandoutside thesystem Inmanyways,theinterconnectivityofthevarioussubsystemsanditsextensionasawhole intotheenvironmentformthebuildingblocksoflargersystems,suchasfamily,community,andnation. Thusanatural(biological)system,suchasahumanbeing,isalsoaparticipantinandacreatoroflarger socialsystems.Thehuman-createdsystemshavemanyofthesameattributesofbiologicalsystems. Additionally,itcanbesaidthattheselargersystemsarecharacterizedby
Astructurethatisdefinedbyitspartsandprocesses
Generalizationsofreality
Atendencytofunctioninthesameway,involvingtheinputs(material,humanresources,finances,etc)andoutputs(products andservices)thatarethenprocessed,causingthemtochangeinsomeway
Asystem’svariousparts,whichhavefunctionalaswellasstructuralrelationships Human-createdsystemscanbesmall,asinthethree-personfamily,orquitelarge,asinanation-state suchasIndiawithabillionpeople Themostwidelydispersedhuman-createdsystemsareorganizations Aswiththeotherexamplesdescribedpreviously,organizationssharethesameattributesandadapt accordinglytotheirenvironments Infact,organizationsarecomplexhumansystemsthathaveevolved overtimeandcontinuetodoso.3Thenaturalemergenceofhuman-createdsystems,suchas organizationsandcommunities,probablygrewoutofinstinctforsurvival Inthehostileworldofearly humankind,food,shelter,andsafetyneedsusuallyrequiredcooperativeefforts Inturn,cooperative effortstypicallyrequiresomeformoforganization4Thisisnolesstrueinthecaseofprovidinghealth In ordertomeetthecriteriaofhealthasastateofcompletephysical,mental,andsocialwell-being, individuals,communities,organizations,andnation-stateshaveworkedtogethertoformelaborateand diversehealthsystemsthroughouttheworld
Aswithanysystem,ahealthsystemhasinputs.Theseincludefinancial,material,andhumanresources thatdifferentiateonehealthsystemfromanother ThedatainTABLE1-1clearlydemonstratesomeof thesedifferences.
Countrywithhighestgovernmentspendingperpersonperyearonhealth
Countrywithlowestgovernmentspendingperpersonperyearonhealth Myanmar($2)
Countrywithhighestannualout-of-pockethouseholdspendingonhealth
Countrywithlowestannualout-of-pockethouseholdspendingonhealth
AverageamountspentperpersonperyearonhealthincountriesbelongingtotheOrganisationforEconomicCooperationandDevelopment(OECD)
WHOestimateofminimumspendingperpersonperyearneededtoprovidebasic,life-savingservices
Countrieswheretotalhealthspendingwaslowerthan$50perpersonperyear
Countrieswherehealthspendingwaslowerthan$20perpersonperyear
DatafromWorldHealthOrganization (2014)
Kiribati($002)
Oneofthemajor“inputs”intoanyhealthcaresystemispatients Patientspresentwithavarietyof symptoms/diseases/injuries;however,theyalsocomewithamyriadofcharacteristics,suchas personality,lifeexperiences,knowledge,attitudes,culturalnorms,educationlevel,incomelevel,intellect, prejudice,religiousandotherbeliefsystems,emotions,biologicalstrengthsandweaknesses,andgenetic makeup Inaddition,patientsmayormaynotbepluggedintosociety’sinfrastructure,suchashaving accesstotransportation,childcare,orhealthinsurance Thecomplexitythesemanyfactorscreatecannot beoverlookedbyhealthcaresystemsnorshouldtheybeoverlookedbyhealthpolicymakers Ithasbeen wellestablishedthatincomeisperhapsoneofthebestpredictorsofhealth Theincomegradientwithina populationishighlyassociatedwithhealthstatusofindividualsorgroupsinthatpopulation,andtheper capitaincomesandtheGDPofnationsarealsohighlycorrelatedwiththehealthstatusofthatcountry’s population Takenfromthisperspective,healthpolicymakesusalsobeconcernedwithpovertyandlifting populationsoutofpovertythroughsocialpoliciesdesignedtoimproveeducation,housing,infrastructure, jobcreation,andtheenvironment
Healthsystemsarisewithinasocial,cultural,political,andeconomiccontext Aswithallhuman constructedsystems,thereisconsiderablediversityinsize,scope,andform Asaresult,healthsystems havestructure,processes,andoutcomesthatvaryconsiderably TABLE1-2showssomeofthevariation alongthesethreedimensionsforthecountriesselectedforthisbook.Asyouwillseehereandin subsequentchapters,financialandhumanresourceinputsdointerrelatewithhealthoutcomes
DatafromWorldHealthOrganization Violenceandinjuryprevention:Countryprofiles http://www.who.int/violence injury prevention/road safety status/country profiles/en/ nd;CentralIntelligenceAgency The WorldFactBook,2016 https://www.cia.gov/library/publications/resources/the-world-factbook/
BuildingBlocksofHealthSystems
Eventhougheveryhealthsystemisuniqueinitsgivensocialandculturalenvironment,allhealthsystems havecommonelementsthatarenecessaryforfunctionality Thesebuildingblocksnotonlyhelpusto understandinghealthsystemsbetterbuttheyalsoprovideopportunitiesforsystemimprovement.The WHO,theWorldBank,andvariousgovernmentsaroundtheworldhaveacommonunderstandingof thesekeyelements.Somewoulddescribethemascriticalsuccessfactorsthatareessentialtoahealth system’ssurvival(TABLE1-3)
TABLE1-3HealthSystemsBuildingBlocks(CriticalSuccessFactors)
Goodhealthservicesarethosethatdelivereffective,safe,quality personalandnon-personalhealthinterventionstothosewhoneed them,whenandwhereneeded,withminimumwasteofresources
Healthworkforce
Awell-performinghealthworkforceisonethatworksinwaysthat areresponsive,fair,andefficienttoachievethebesthealth outcomespossible,givenavailableresourcesandcircumstances (ie,therearesufficientstaff,fairlydistributed;theyarecompetent, responsive,andproductive)
Healthinformation
Awell-functioninghealthinformationsystemisonethatensures theproduction,analysis,dissemination,useofreliableandtimely
Awell-functioninghealthsystemensuresequitableaccessto essentialmedicalproducts,drugs,vaccines,andtechnologiesof assuredquality,safety,efficacy,andtheirscientificallysoundand cost-effectiveuse
Healthfinancing
Agoodhealthfinancingsystemraisesadequatefundsforhealth, inwaysthatensurepeoplecanuseneededservicesandare protectedfromfinancialcatastropheorimpoverishment associatedwithhavingtopayforthem;itprovidesincentivesfor providersanduserstobeefficient
Leadershipandgovernance
Leadershipandgovernanceinvolveensuringthatstrategicpolicy frameworksexistandarecombinedwitheffectiveoversight,
informationonhealthdeterminants,healthsystemperformance, andhealthstatusimprovements
coalitionbuilding,regulation,attentiontosystemdesign,and accountability
DatafromWorldHealthOrganization TheWHOHealthSystemsFramework http://wwwwprowhoint/health services/health systems framework/en/ 2016
Onewidelyacceptedwayofmeasuringthebuildingblocksortheoverallfunctioningofahealthsystemis throughthelensofcost,quality,andaccess Thecost,quality,accesstriangleisshowninFIGURE1-1
FIGURE1-1TheCost,Quality,AccessTriangle
Intheeraofrapidglobalizationandchange,itisbecomingincreasinglyprudenttoaddafourth dimension,innovation Thisresultsinacost,quality,access,innovationdiamondasshowninFIGURE12.
Furthermore,asshowninBOX1-1countriesmustembracethenotionofincorporatinghealthinallpolicy arenas,suchastransportation,agriculture,education,andothers.Thereisconsiderableoverlapof interestandpurposethatcanbenefitsocieties
FIGURE1-2TheCost,Quality,Access,InnovationDiamond
BOX1-1HealthinAllPolicies
Health in All Policies isanapproachtopublicpoliciesacrosssectorsthatsystematicallytakesintoaccountthehealthimplicationsof decisions,seekssynergies,andavoidsharmfulhealthimpactsinordertoimprovepopulationhealthandhealthequity Itimproves accountabilityofpolicymakersforhealthimpactsatalllevelsofpolicymaking Itincludesanemphasisontheconsequencesofpublic policiesonhealthsystems,determinantsofhealthandwell-being
ReproducedfromWorldHealthOrganization Healthinallpolicies:Trainingmanual Geneva:Author;2015 s
HealthSystemsWithinLargerSocialSystems
In2013attheHelsinkiConference,theWHOadoptedandbegantopromulgateaHealthinAllPolicies approach.Thisisbasedontheunderstandingthatallsectorsofasocietymustworktogethertopromote healthandsupportthehealthsystem Thestatementofthisapproachfollows
RonAndersenproposedamodelinthe1960sthatsoughttoidentifysomeofthefactorsthatinfluence whetherapatientevenaccesseshealthcareservices5Hismodelidentifiesthreemaincomponents: predisposingfactors,enablingfactors,andneedfactors Predisposingfactorsincludefamily characteristics,socialstructure,andhealthbeliefs Enablingfactorsincludefamilyresourcesand communityresources Needfactorsincludeillnessandtheresponsetoillness Thisworkwasexpanded intotheBehavioralModelforVulnerablePopulations.ThismodelispresentedinFIGURE1-3. Understandingthecharacteristicsofthepopulationthatahealthsystemservesiskeytodesigningthe systemprocesses,providingadequateandappropriateresources,andhavingclearexpectationsforthe rightoutcomes