Chapter 1: Health Care System Components PDF

# Chapter 1 ## Health Care System Components - Healthcare delivery system is the organized response of a society to the health problems and needs of the population. - Countries differ considerably by the levels of income and economic potential, diversity of health problems and needs, the way they...

# Chapter 1 ## Health Care System Components - Healthcare delivery system is the organized response of a society to the health problems and needs of the population. - Countries differ considerably by the levels of income and economic potential, diversity of health problems and needs, the way they organize their response, as well as in the degree of central management, sources of financing and control of their health care system regarding coordination, planning and organization. - The quality of healthcare system is expressed through coverage, access, equity, but also efficiency in use of resources, and financing. - Substantial changes in the health systems are necessary to be implemented with greater role of the primary health care, increasing the efficiency by market forces and the use of economic incentives for providers of health care. ### What is the Healthcare System? - A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health. This includes efforts to influence determinants of health as well as more direct health improvement activities. - The health system providing preventive, promotive, curative and rehabilitative interventions through a combination of public health actions and the pyramid of health care facilities that deliver personal health care - The actions of the health system should be responsive and financially fair, while treating people respectably. - Healthcare system needs staff, funds, information, supplies, transport, communications and overall guidance and direction to function. Strengthening health systems thus means addressing key constraints in each of these areas. ### Functions of the overall health care system: - **Health services**: Environmental, health promotion, prevention of diseases and injuries, primary care, specialist medicine, hospital services, services for specific groups, self-help. - **Production of health resources**: Construction and maintenance of health facilities, production and distribution of medicines, production, distribution and maintenance of instruments and equipment. - **Education and training of health manpower**: Undergraduate training, postgraduate training. - **Research and development**: Health research, technology development, assessment and transfer, quality control. - **Management of a National Health System**: health policy and strategy development and its implementation by action plans, information, coordination with other sectors, regulation of activities and utilization of health manpower, physical resources and environmental health services. - **Financing health care**: mobilization of funds, allocation of finances. ## Characteristics of good health system: - Good service delivery is a vital element of any health system. It is a fundamental input to population health status. The network of service delivery should have the following key characteristics: - **Comprehensiveness**: A comprehensive range of health services is provided appropriate to the needs of the target population, including preventative, curative, palliative and rehabilitative services and health promotion activities. - **Accessibility**: Services are directly and permanently accessible with no undue barriers of cost, language, culture, or geography. Services may be provided in the home, the community, the workplace, or health facilities as appropriate. - **Coverage**: Service delivery is designed so that all people in a defined target population are covered by adequacy of financing with cost and efficient use of resources. - **Continuity**: Service delivery is organized to provide an individual with continuity of care across the network of services, health conditions, levels of care, and over the life-cycle. - **Quality**: Health services are of high quality, i.e. they are effective, safe, centered on the patient’s needs and given in a timely fashion. - **Coordination**: Local area health service networks are actively coordinated, across types of provider, types of care, levels of service delivery, and for both routine and emergency preparedness. - **Accountability and efficiency**: Health services are well managed so as to achieve the core elements described above with a minimum wastage of resources. Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and results. Assessment includes appropriate mechanisms for the participation of the target population and civil society. - **Continuous improvement in health status indicators** - **Consumer satisfaction** - **Well-developed information and monitoring systems** - **Promotion of standards of professional education, training and research** ## Who are the Stakeholders of Healthcare and their definition ? - Stakeholders in most healthcare organizations are government, political groups, financial bodies, customers, advocacy groups for customers' rights, suppliers and competitors. - Healthcare is a complex system have multiple stakeholders with diverse interests and ethical conditions, which leads to increased difficulty in achieving quality improvement. | Stakeholder | Definition | |---|---| | Patients | Individuals with existing or previous disease or pain, members of family or informal caregivers, or members of support associations that represent caregivers or patients. | | Clinicians | Healthcare providers in a clinical setting, including, for example, medical doctor, nurse, physician’s assistant, rehabilitation professional, druggist, and an organization of professional serving clinicians.| | Researcher | Conductors of the clinical study, as well as funders of the study and organizations representing the community of research | | Purchasers | Providers of health benefits for workers and their families, including individual companies in addition to groups of domestic and national businesses, and health coalitions. | | Hospitals/Health Systems | Organizations that provide medical care, such as public and private hospitals, medical clinics, and their associations. | | Policy-makers | Persons responsible for creating public policy at any level of government such as federal and local government units and organizations that represent policymakers. | | Payers | Those who work in the healthcare system as financial intermediaries, for example, private and public insurers, and groups representing insurers. | | Industry | Firms that design, invest in, or produce diagnostics, devices, medicines, and systems of electronic records. | | Training Institutions | Organizations that provide health professional education such as universities and colleges, and associations representing these organizations, groups, and persons. | Source: Patient-Centered Outcomes Research Institute (2014) ## Healthcare System Challenges: - In recent years, significant progress has been achieved in delivering health-related interventions that are designed to achieve goals relating to improving maternal and child health, and reducing mortality and ill- health due to HIV/AIDS, tuberculosis, malaria and many endemic diseases. - Healthcare systems are facing new challenges, among them are aging of the population, widespread lifestyle risk-factors and growing burden of non-communicable diseases, new medical technology, innovations, increasing costs, lack of community involvement and intersectoral cooperation and actions. - The progress in healthcare delivery is not neither universal nor sufficiently broad-based and sustainable. - Health systems that can deliver services equitably and efficiently are critical for achieving improved health status. - Hospital patients suffer from avoidable injury, medication errors, or medical mismanagement - Absence of a competent monitoring strategy that enables decision-makers to accurately track health progress and performance, evaluate impact, and ensure accountability at country and global levels will compromise sustainability of the health services. - Information is needed to track how health systems respond to increased inputs and improved processes, and the impact they have on improved healthcare. - The Data on population access to essential services are limited, inaccurate or out of date - Lack of Effective communication between patient and healthcare provider, which is an important tool to reduce negative perceptions. ## Health systems framework and objectives: - World Health Organization (WHO) has been used a framework that describes health systemsin terms of six core components or "building blocks": - Providing Health Services, - health workforce, - health information systems, - access to essential medicines, - financing, and - leadership/governance ### The WHO Health Systems Framework | System Building Blocks | Overall Goals / Outcomes | |---|---| | Providing Health Services | ACCESS COVERAGE | | Health Workforce | Improved Health (Level And Responsiveness | | Health Information Systems | Social And Financial Risk | | Access To Essential Medicines | QUALITY SAFETY | | Financing | Improved Efficiency | | Leadership / Governance | | #### The Six Building Blocks Of A Health System: Aims And Levels of organization in healthcare systems (Doncho Donev et al., 2013) - All models of health care systems are imperfect and there is no one model which is the best and broadly accepted and recommended. There are big differences among countries in relation to the goals, structure, organization, finance and the other characteristics of the health care systems. - These differences are influenced by history, traditions, social-cultural, economic, political and other factors. But, regardless of all present differences, there are same common characteristics, typical for all organized health care systems. - "levels of health care' are classified according to the size of the population served, and specific diseases and conditions that are treated at certain level. However, It is possible to recognize four levels of the health care system. ### First Level: Self-care level, which is non-professional care. - It is performed within the family, and the population group counts from one to 10 persons. - Self-care implies largely unorganized health activities and health-related decision-making carried out by individuals, families, neighbors, friends and workmates. - These include the maintenance of health, prevention of disease, self-diagnosis, self-treatment, including self-medication, and self-applied follow-up care and social support to the sick and weak members of the family before or after contact with the health services. - By community involvement and participation, individuals and families accept responsibility for their, and the community’s health and welfare and develop the capability to contribute to their own and the community’s development. - This type of care has its own long tradition and it is a part of all cultures. WHO has shown interest and pointed out that traditional and alternative medicine consist big potential, which might be useful for improvement of the health status of the population. - Health promotion advice on important lifestyle issues such as nutrition, exercise, consumption of alcohol and cessation of smoking is most effective if it is persistent, consistent and continuous, and if it is offered to families and communities at all levels. ### Second Level: Primary professional (medical) care - Is a care of the "first contact" of the individual with the health care service, which is provided in ambulatory settings by qualified health professionals (general practitioner-GP, family doctor, or nurse) when a patient came, usually for the first time, with certain symptoms or signs of disease. - The primary professional level of care includes a doctor and members of its team: nurse, birth attendant, home visiting nurse, social worker, and sometimes a physiotherapist, too. - The administration/ territorial unit for this type of care is a local community, and the population size vary from 2000 persons per one GP or family doctor to 10.000-50.000 inhabitants per health facility within the community (health center). - Beside medical care (diagnostics, treatment and rehabilitation) the primary professional care team performs various activities toward maintenance and improvement of the health and prevention of diseases. - The most common role of the physician is "gate keeper", which means that the doctor is motivated and empowered to treat and cure broader scope of illnesses and conditions (up to 85% of health care problems in a community without recourse to specialist), and to select and refer patients to higher levels of the health care system when necessary. ### Secondary or intermediate level of care - It is a general specialist care, provided by "general specialist doctor" for more complex conditions, which couldn't be resolved by the general practitioner or primary professional care level. General specialists (surgeons, internal medicine specialists, gynecologists, psychiatrists etc.) usually provide this type of care through specialized services of district or provincial "general hospitals". - The administrative unit for secondary level of care is a district, and the population size is from 100.000 to 500.000 inhabitants. - Usually patient is directed by the general practitioner from primary professional level to the secondary level as the first referral level of care through referral. | Dimension | Definition | |---|---| | Safety | The degree to which the healthcare intervention minimizes risks of adverse outcome for both, patient and provider | | Effectiveness | The provision of healthcare should be based on scientific knowledge and evidence, avoiding both underuse and overuse of the best available techniques to achieve the desired out come | | Efficiency | The system of healthcare and service should be cost efficient, and the waste of equipment, supplies, ideas, time, and energy should be removed constantly from the system. | | Timeliness | Patient waiting periods and delays in receiving healthcare services should be minimized. | | Patient Centered | The system of healthcare should center on the patient; be respectful and responsive to individual patient’s preferences, needs, and values; and put the patient in control. Patients should play an active role in making decisions about their own care. | | Equitability | The system should provide and deliver healthcare to all individuals equally, regardless of individual characteristics, such as gender, race, education, disability, or income. | | Appropriateness | The care and services provided should be relevant to patient’s needs | | Availability | The appropriate care and services should be accessible qand obtainable to meet the patient’s needs | | Continuity of care | The coordination of needed healthcare services for coherent unbroken succession of services | | Respect and Caring | The provider should respect the patient’s needs expectation and individuals differences | ### Third level: Tertiary or central level of care - It is sub-specialist care including highly specific services, which might be provided in specialized institutions or by highly specialized health professionals - Sub-specialists i.e. neurosurgeons, plastic surgeons, nephrologists or cardiologists - The specialized institutions, which provide this type of care are, also, educational institutions for health manpower (university hospitals, university clinics, etc.). - Secondary and tertiary care support primary health care by providing technologically-based diagnosis, treatment and rehabilitation. ## What are the Dimensions of Quality in Healthcare? - Quality plays a significant role in attracting more customers for any service. It has been defined in multiple ways by many different persons and from different perspectives, anticipations and objectives. May mean "zero defects", meeting expectations of consumers or conformance to specification ## Requirements for Healthcare Quality ### Standards: - A Standard: is defined as a statement of quality expected. - Standards of care: are General statement about what is expected to be provided to ensure high quality healthcare. Each standard has been carefully defined and each is considered essential to provide quality service. - The standard is SMART (Specific, Measurable, Applicable, Realistic, time bounded). Also Valid, Clear, Current and Evidence Based - **Intent of standard should:** - Explain the full meaning of the standard. - Describes the purpose and rationale of the standard, - Providing an explanation of how the standard fits into the overall program, - Sets parameters for the requirement(s), and otherwise "paints a picture" of the requirements and goals. ### General service standard includes: - Physical facilities. - Staffing - Client flow - Support service - Operating procedures - Client satisfaction. ### Measurable Elements (MEs) - Measurable elements (MEs) of a standard indicate what is reviewed and give a score. - The MEs for each standard identify the requirements for full compliance with the standard. - The MEs are intended to bring clarity to the standards to help educate leaders and health care workers about the standards ### Key Performance Indicators (KPI) - A healthcare KPI is a well-defined performance measurement that is used to monitor, analyze and optimize all relevant healthcare processes to increase patient satisfaction. ### Quality Assurance - It a set of activities that are planned for, carried out systematically or in an orderly manner and continuously to improve quality of care. - It involves: - Setting of standards - Monitoring to see if there is a gap between what is being done now and what is expected; and addressing the gap on a regular basis (quality improvement). ### Quality Control - It is a process through which a healthcare organization (facility) seeks to ensure that health quality is maintained or improved. ## Steps for Access to Care & Continuity of care (application) ### 1) Known organization: - Healthcare facility is known to the public - Practice is accessible by public transportation - Patients and their relatives are able to reach directly to the facility when needed (24 hrs./d, 7 days/wk, 52 wks/yr.) - The practice is physically accessible and meets public requirements. ### 2) Patient Admission: - There is a process patients with emergent or immediate needs are given priority for assessment and treatment - There is a priority process for patient needs preventive, palliative, curative and rehabilitative services based on patient condition at the time of admission as inpatient to the facility - At inpatient admission, patients and families received information on the proposed care, expected outcomes of that care and any expected cost - Reduce physical, language or cultural barriers to provide high quality services. ### 3) Continuity of care: - Maintenance of comprehensive central record that contains all patient information - Providing continuous care and planning for transfer/ or discharge by a qualified identified profession as responsible for the patient care ### 4) Discharge, Referral and follow up: - There is a policy for patient referral or discharge - Appropriate referral with written acceptance letter - Clinical record and discharge summary with all known significant diagnosis, drug allergy, current medications - Discharge summary of inpatient is complete - Discharge prescription. Patient and his family understand follow-up instructions ### 5) Transfer of patients - Patients are transferred to other organization based on his status - Effective communication of the referring organization determines that the receiving organization can meet the patient's continuing needs - Transfer written summary of the patient's clinical condition and the interventions is provided by the referring organization - During direct transfer, a qualified staff member monitor the patient's condition - Transfer process is documented in the patient's record ### 6) Transportation of the patient: - During the process for referring, transferring or patient discharge where ever in patient or out patient, planning is needed to meet patients requirements during transportation. ## Accreditation of healthcare organization (facility) - Accreditation الإعتماد( is a process by which a separate, distinct non-governmental non-profit organization, assesses the healthcare facility to determine if it meets a set of requirements (standards) designed to improve the safety and quality of care. ### Benefits of accreditation: - Improve public trust - Provides a safe and efficient work environment - Maximize achievable standards - Respect patients and their families rights and sharing them in decision making in care process - Enhance quality culture and continuous improvement ### National and international Accreditation organizations - There is a wide list of national and international healthcare accreditation organizations. These organizations are responsible for the accreditation of hospitals and other healthcare services. - **National accreditation organization:** Most countries have their own accreditation organization system. - **In Egypt The General Authority for Healthcare Accreditation & Regulation (GAHAR)** is the organization responsible for accreditation of hospitals and any healthcare facility - **International Healthcare accreditation organizations** - ISO 9001: - International Society for the Quality in Healthcare (ISQua) - Joint Commission international (JCI) in USA: is one of the most widely used accreditation organizations. - Accreditation Canada International, as well as accreditation organizations in the United Kingdom and Australia Many countries have either voluntary or mandatory accreditation requirements. ### Accreditation process is composed of four main sections: - Section 1: Requirements for application - Section 2: Identification of patient centered standards which are assuring, - International patient safety Goals (IPSG) - Accesses to care and continuity of care (ACC) - Patient and family rights (PFR) - Patient and family Education (PFE) - Assessment of Patients (AOP) - Anesthesia and surgical care (ASC) - Medication Management and Use (MMU) - Section 3: Assessment of the standards management: - Quality Improvement and patient safety (QPS) - Prevention and control of infections (PCI) - Governance (الحوكمة), leadership and direction (GLD) - Facility management and safety (FMS) - Staff qualification and education (SQE) - Information management system (IMS) - Section 4: Academic medical center standard - Medical profession education (MPE) - Human subjects research program (HRP) ## Health System in Egypt and challenges (by Egypt Service Provision Assessment (ESPA) survey). - Egyptian health care system faces multiple challenges in improving and ensuring the health and wellbeing of the Egyptian people. - The system faces not only the burden of combating illnesses associated with poverty and lack of education, but it must also respond to emerging diseases and illnesses associated with modern, urban lifestyle. - Emerging access to global communications and commerce is raising the expectations of the population for more and better care and for advanced health care technology. - A high birth rate combined with a longer life expectancy is increasing the population pressure on the Egyptian health system. By the year 2020 it is estimated that the population of Egypt will have grown to about 92 million people. (Now 105 Million) ### General organization of the health system - Egypt has a highly pluralistic (متشابك health care system, with many different public and private providers and financing agents. Health services in Egypt are currently managed, financed, and provided by agencies in all three sectors of the economy- government, parastatal, and private. - The government sector represents activities of ministries that receive funding from the Ministry of Finance (MOF). - It is an integrated delivery system in which the financing and provider functions are included under the same organizational structure. - Government providers are permitted to generate their own income through various means, including charging user fees in special units or departments known as economic departments. Income from these non-budgetary sources is classified as "self-funding." - The private sector includes for-profit and non-profit organizations and covers everything from traditional midwives, private pharmacies, private doctors, and private hospitals of all sizes. Also in this sector are a large number of non-governmental organizations (NGOs) providing services, including religiously affiliated clinics and other charitable organizations, all of which are registered with the Ministry of Social Affairs (MOSA). ### Organization of the Ministry of Health and Population - The organizational structure of the MOHP consists of two functional structures: the administrative structure and the service delivery structure. - **Administrative Structure** - The administrative organization of the MOHP comprises the central headquarters and the governorate level health directorates. The main functions of the central headquarters include planning, supervision, and program management. The population portfolio, which was previously an independent Ministry, was merged into the Ministry of Health in 1995. - All functions of the central headquarters are divided into five broad sector divisions: - central administration for the minister’s office, - curative health services, - population and family planning, - basic and preventive health services, - administration and finance. - There are 13 offices of undersecretaries (وكلاء الوزارة in charge of various functions reporting to the minister. The responsibilities of these undersecretaries include preventive care, laboratories, primary health care, endemic diseases, curative care, research and development, pharmaceuticals, dentistry, family planning, and nursing. - **Service Delivery Structure** - The MOHP is currently the major provider of primary, preventive, and curative care in Egypt, with around 5,000 health facilities and more than 80,000 beds spread nationwide. - The MOHP service delivery units are organized along a number of different dimensions. These include geographic (rural and urban), structural (health units, health centers, and hospitals), functional (maternal child health centers), or programmatic (immunization, and diarrheal disease control). - The MOHP is the largest institutional provider of inpatient health care services in Egypt. It has about 1,048 inpatient facilities, accounting for more than 80,000 beds. ### Hospital services are provided through the following types of facilities. - **Integrated hospitals**: are small, 20- to 60-bed hospitals providing primary health care and specialized medical services in the rural areas. Integrated hospitals contain well-equipped surgical theatres, X-ray equipment, and laboratories and are responsible for serving a catchment population of between 10,000 and 25,000 people. - **District hospitals**: are 100- to 200-bed hospitals that provide more specialized medical services and are available in every district which is responsible for serving a population between 50,000 to 100,000 people in the urban district area. - **General hospitals**: contain more than 200 beds and contain all medical specialties. General hospitals are available in every capital of a governorate. - **Specialty hospitals**: are located in urban areas and include specialties such as eye, psychiatric, chest (34), fever (88), heart, ophthalmology (31), tumors, and gynecology and obstetrics. Specialty hospitals are available in all governorates. Fever hospitals were the only type of specialty hospital included in the ESPA. - The private sector has 2,024 inpatient facilities, with a total of about 22,647 beds. This accounts for approximately 16 percent of the total inpatient bed capacity in Egypt. ### MOHP Public Health Programs - The MOHP has attempted to target many health priorities in Egypt through vertical programs that rely heavily on donor assistance. These programs include the following: - **Population, Reproductive Health, and Family Planning Program** - **Control of Diarrheal Diseases (CDD) and Acute Respiratory Infections (ARI) Programs** ### Expanded Program on Immunization (EPI) - The Expanded Program on Immunization (EPI) is probably the most accessible, available, and utilized of all public health programs in Egypt. The program has been quite effective in reducing the incidence of some vaccine-preventable diseases, such as diphtheria and poliomyelitis. ### Maternal Health - The government of Egypt has demonstrated continued political commitment to improving maternal and child health, with focus on reducing maternal mortality. ### Health Sector Reform Strategy: (Health Sector Reform Program (HSRP). - The government of Egypt has articulated as its long-term goal the achievement of universal coverage of basic health services for all of its citizens. It has also stated the importance of targeting the most vulnerable population groups as its priority. #### Major components of the strategy include - Expanding the social health insurance coverage of the population to universal coverage based on the "family" as the basic unit. - Reorganizing services so that they are provided through a holistic family health approach. - The MOHP service provision management will be decentralized to the district level (the district management approach), in the transition period until the MOHP phases out its service delivery function. - Strengthening management systems and developing a regulatory framework and institutional relationships to ensure quality of care and to support the reform of the health sector. - Developing the domestic pharmaceutical industry and reducing government involvement in the production of pharmaceuticals while strengthening its role as a financier.