1 May 2010
Key components of a well functioning health system
A well functioning health system responds in a balanced way to a population’s needs and expectations by:
- improving the health status of individuals, families and communities
- defending the population against what threatens its health
- protecting people against the financial consequences of ill-health
- providing equitable access to people-centred care
- making it possible for people to participate in decisions affecting their health and health system.
Without strong policies and leadership, health systems do not spontaneously provide balanced responses to these challenges, nor do they make the most efficient use of their resources. As most health leaders know, health systems are subject to powerful forces and influences that often override rational policy making. These forces include disproportionate focus on specialist curative care, fragmentation in a multiplicity of competing programs, projects and institutions, and the pervasive commercialization of health care delivery in poorly regulated systems. Keeping health systems on track requires a strong sense of direction, and coherent investment in the various building blocks of the health system, so as to provide the kind of services that produce results.
THE WHO HEALTH SYSTEMS FRAMEWORK
Leadership and governance
Each country’s specific context and history shapes the way leadership and governance is exercised, but common ingredients of good practice in leadership and governance can be identified. These include:
- Ensuring that health authorities take responsibility for steering the entire health sector (not merely public sector service delivery); and for dealing with future challenges (including unanticipated events or disasters) as well as with current problems
- Defining, through transparent and inclusive processes, national health policies, strategy and plan that set a clear direction for the health sector, with:
- A formulation of the country’s commitment to high level policy goals (health equity, people-centeredness, sound public health polices, effective and accountable governance)
- A strategy for translating these policy goals into its implications for financing, human resources, pharmaceuticals, technology, infrastructure and service delivery, with relevant guidelines, plans and targets
- Mechanisms for accountability and adaptation to evolving needs
- Effective regulation through a combination of guidelines, mandates, and incentives, backed up by legal measures and enforcement mechanisms;
- Effective policy dialogue with other sectors;
- Mechanisms and institutional arrangements to channel donor funding and align it to country priorities.
Health information systems
Good governance is only possible with good information on health challenges, on the broader environment in which the health system operates, and on the performance of the health system. This specifically includes timely intelligence on:
- Progress in meeting health challenges and social objectives (particularly equity), including but not limited to household surveys, civil registration systems and epidemiological surveillance
- Health financing, including through national health accounts and an analysis of financial catastrophes and of financial and other barriers to health services for the poor and vulnerable
- Trends and needs for HRH; on consumption of and access to pharmaceuticals; on appropriateness and cost of technology; on distribution and adequacy of infrastructure
- Access to care and on the quality of services provided.
This, in turn, requires a variety of institutional mechanisms:
- A national monitoring and evaluation plan that specifies core indicators (with targets), data collection and management, analyses and communication and use
- Arrangements to make information accessible to all involved, including communities, civil society, health professionals and politicians
Health financing can be a key policy instrument to improve health and reduce health inequalities if its primary objective is to facilitate universal coverage by removing financial barriers to access and preventing financial hardship and catastrophic expenditure. The following can facilitate these outcomes:
- A system to raise sufficient funds for health fairly
- A system to pool financial resources across population groups to share financial risks
- A financing governance system supported by relevant legislation, financial audit and public expenditure reviews, and clear operational rules to ensure efficient use of funds
Human resources for health
The health workforce is central to achieving health. A well performing workforce is one that is responsive to the needs and expectations of people, is fair and efficient to achieve the best outcomes possible given available resources and circumstances. Countries are at different stages of development of their health workforce but common concerns include improving recruitment, education, training and distribution; enhancing productivity and performance; and improving retention. This requires:
- Arrangements for achieving sufficient numbers of the right mix (numbers, diversity and competencies)
- Payment systems that produce the right kind of incentives
- Regulatory mechanisms to ensure system wide deployment and distribution in accordance with needs
- Establishment of job related norms, deployment of support systems and enabling work environments
- Mechanisms to ensure cooperation of all stakeholders (such as health worker advisory groups, donor coordination groups, private sector, professional associations, communities, client/consumer groups).
Essential medical products and technologies
Universal access to health care is heavily dependent on access to affordable essential medicines, vaccines, diagnostics and health technologies of assured quality, which are used in a scientifically sound and cost-effective way. Economically, medical products are the second largest component of most health budgets (after salaries) and the largest component of private health expenditure in low and middle income countries. Key components of a functioning system are:
- A medical products regulatory system for marketing authorization and safety monitoring, supported by relevant legislation, enforcement mechanisms, an inspectorate and access to a medical products quality control laboratory
- National lists of essential medical products, national diagnostic and treatment protocols, and standardized equipment per levels of care, to guide procurement, reimbursement and training
- A supply and distribution system to ensure universal access to essential medical products and health technologies through public and private channels, with focus on the poor and disadvantaged
- A national medical products availability and price monitoring system
- A national programme to promote rational prescribing.
Health systems are only as effective as the services they provide. These critically depend on:
- Networks of close-to-client primary care, organized as health districts or local area networks with the back-up of specialized and hospital services, responsible for defined populations
- Provision of a package of benefits with a comprehensive and integrated range of clinical and public health interventions, that respond to the full range of health problems of their populations, including those targeted by the Millennium Development Goals
- Standards, norms and guidance to ensure access and essential dimensions of quality: safety, effectiveness, integration, continuity, and people -centeredness
- Mechanisms to hold providers accountable for access and quality and to ensure consumer voice.